fsnau technical series report post gu 2012 nutrition analysis

FSNAU Technical Series Report No. VI 47Issued September 26, 2012

Nutrition Analysis Post Gu ‘12

September 26, 2012Technical Series Report No VI. 47

Food Security and Nutrition Analysis Unit - Somalia

Information for Better Livelihood

Swiss Agency for Development and Cooperation SDC

Funding AgenciesTechnical Partners

FSNAU Technical Series Report No. VI 47 Issued September 26, 2012

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Acknowledgements

FSNAU would like to thank all our 24 partner agencies for their participation and support in the Deyr 2011 seasonal nutrition assessments and analysis.

From April through July 2012, a total of 46 nutrition surveys were conducted based on standard SMART methodology. Seventeen of the nutrition surveys were conducted in the south. Additionally, nutrition data from about 130 health and nutrition facilities was reviewed. Without the support and expertise of the 8 local NGOs, 3 International NGOs, 3 Local Authorities, 8 line Ministries and 2 UN agencies, this would not have been possible. Special thanks to UNICEF, for financial and/or technical support.A sincere note of appreciation also goes to the FSNAU nutrition team based in Somalia who work under such difficult conditions yet continue to produce such high quality professional work.

Participating Partners - north central regions only

United Nations Children’s Fund (UNICEF), World Food Programme (WFP), Ministry of Health (MOH Somaliland), Ministry of Agriculture (Somaliland), Ministry of environment and rural development, and NERAD (Somaliland); Ministry of Health (Puntland), Ministry of Women Development and Family Affairs (MoWDFA), Ministry of Wildlife, Tourism and Environment (Puntland), Puntland State of Water and Energy (PSWEN), Medair, Somalia Red Crescent Society (SRCS), CAFDARO and Elberde Primary Health Care organization (EPHCO).

Mahad Sanid


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TABLE OF CONTENTS1 ExEcutivE SuMMAry 1

2 cASES of AcutEly MAlnouriShEd childrEn in SoMAliA 103 nutrition AnAlySiS in SoMAliA 134. rEGionAl nutrition AnAlySiS 164.1 GEDO REGION 164.2 MIDDLE AND LOWER JUbA REGIONS 204.3 bAy AND bAkOOL REGIONS 274.4 MIDDLE AND LOWER SHAbELLE REGIONS 344.5 HIRAN REGION 394.6 CENTRAL SOMALIA: GALGADUD AND MUDUG REGIONS 424.7 NORTHEAST REGIONS 484.8 NORTHWEST REGIONS 585 urbAn SuMMAry findinGS 676 PlAuSibility chEckS 697 APPEndicES 737.1 Progression Of Estimated Nutrition Situation Gu ‘12 757.2 Nutrition Assessment Tools Post Gu ‘12 777.3 Nutrition Assessment Household Questionnaire, May 2012 IDP 817.4 Urban Rapid Assessment Record Form - Gu 2012 857.5 Mortality Questionnaire, June 2012 867.6 Field Supervisor– Verbal Autopsy 877.7 Southern IDPs And Urban Questionnaire - July 2012 907.8 Somalia Livelihood Zones 918. Glossary of terms 92

liSt of fiGurES

Figure 1: Global Acute and Severe Acute Malnutrition, (WHZ < 2 and 3 z Scoresor Oedema) April- July 2012 – Somalia 1Figure 2: Retrospective crude and under 5 death rates per 10,000 per day 2Figure 3: Median wasting rates, WHOGS (WAZ<-2 and WAZ <-3) April- July 2012 3Figure 4: Median Stunting rates, WHO GS (HAZ<-2 and HAZ <-3) April- July 2012 3Figure 5: Propotion of Total Cases of Acutely Malnourished Children (WHZ<-Z or Oedema) by Region, September 2012 10Figure 6: Trend in Level of Acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Gedo Region, 2006-2012 16Figure 7: HIS Malnutrition Trends in Gedo Agropastoral MCHs - 2011-12 17Figure 8: Trend in levels of Acute Malnutrition (WHZ <-2Z scores or oedema, WHO 2006), Juba Regions 2007 - 2012 20Figure 9: HIS Malnutrition trends in Juba agro-pastoral MCHs 2010-2011 21Figure 10: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) bakool region, 2002- 2012 27Figure 11: Admissions trends into OTP programmes bakool 2012 28Figure 12: Trend in levels of Acute malnutrition (WHZ< -2 or oedema , WHO 2006) bay Agropastoral, 2002- 2012 28Figure 13: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) bay region, 2002- 2012 30Figure 14: HIS Malnutrition trends in bay Agro-pastoral MCHs,2010-2011 31Figure 15: Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Middle and Lower Shabelle Regions (2007- 2012) 34Figure 16: HIS Malnutrition Trends in Shabelle Reverine MCHs 2010-2011 35Figure 17: HIS Malnutrition Trends in Shabelle Agropastoral MCHs 2010-2011 35Figure 18: Trend in Levels of acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Hiran Region, 2007-2012 39Figure 19: HIS Malnutrition trends in Hiran Riverine MCHs 2011-2012 40Figure 20: Trends in Levels of acute malnutrition (WHZ<-2 or oedema, WHO 2006) Central Regions, 2007-2012 42Figure 21: HIS Malnutrition Trends in Hawd LZ of Central areas(2010-2012) Source: MoH; SRCS 42Figure 22: HIS Malnutrition Trends in Addun L/Z of Central areas (2011-2012) 42Figure 23: HIS Malnutrition Trends in Cowpebelt L/Z (2011-2012) 43Figure 24: HIS Malnutrition Trends in Central Coastal Deeh L/Z (2011-2012) 43Figure 25: Trends in levels of acute malnutrition (WHZ<-2 or oedema, WHO 2006) Northeast regions (2007-2011) 49Figure 26: HIS Malnutrition Trends in Golis/ Karkaar LZ (2010-2012) 49Figure 27: HIS Malnutrition Trends in Sool Plateau LZ (2011-2012) 50Figure 28: HIS Malnutrition Trends in Nugal Valley LZ (2011-2012) 50Figure 29: Trend in Levels of Acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Northeast IDPs (2006-2012) 52Figure 30 : Trends in levels of Acute Malnutrition (WHZ <-2Z scores or oedema, WHO 2006 in North West regions 2006-2011 59Figure 31: HIS Malnutrition Trends in Health Facilities in NW West Golis MCHs - January 2011-June 2012 60Figure 32: HIS Malnutrition Trends in Health Facilities in NW Hawd MCHs - January 2010-June ’12 62Figure 33: Trend in Levels of acute Malnutrition (WHZ<-2 or oedema, WHO 2007)


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in Northwest Regions Region, 2007-2012 65

liSt of tAblES

Table 1: Nutrition Surveys Schedule April-July 2012 3Table 2: Somalia Integrated Food Security Phase Classification, Population Numbers, Aug - Dec 2012 9Table 3: Estimated Cases of Acute Malnutrition in Somalia, by Region, September 2012 10Table 4. The Nutrition Situation Classification Framework, Draft 8, January 2012 14Table 5: Summary of key Nutrition Findings in Gedo Livelihood Zones, May 2012 18Table 6: Summary of key Nutrition Findings in Dowlo IDPs May 2012 19Table 7: Summary of key Nutrition Findings in Juba Livelihood Zones, July 2012 22Table 8: Summary of key Nutrition Findings in kismayo IDPs July 2012 23Table 9: Summary of key Nutrition Findings in bakool Pastoral livelihood zone - July 2012 28Table 10: Summary of key Nutrition Findings in bay Regions-July 2012 32Table 11: Summary of key Nutrition Findings in Mogadishu Town - April- July 2012 35Table 12: Summary of key Nutrition Findings in Mogadishu IDPs - April- July 2012 36Table 13: Proportion of the malnourished women in banadir and Hiran Regions 40 Table 14: Summary of key Nutrition Findings in Hiran region - July 2012 41Table 15: Summary of key Nutrition Findings in Hawd, Addun and Dhusamareb IDPs Central regions 44Table 16: Summary of key Nutrition Findings in Cowpea belt Agro-pastoral and Coastal Deeh Pastoral of Central regions - July 2012 46Table 17: Summary of key Nutrition Findings in Northeast Regions - July 2012 51Table 18: Summary of key Nutrition Findings in Hawd, Addun and Coastal Deeh Northeast Regions 53Table 19: Summary of key Nutrition Findings among Northeast IDPs (bossaso, Qardho, Garowe and Galkayo) May 2012 55Table 20: Summary of Key Nutrition Findings in West Golis/Guban, Nugal Valley and Sool Plateau Livelihood Zones, December 2011 61Table 21: Summary of key Nutrition Findings in Hawd, East Golis and Agro-pastoral Livelihood Zones, July 2012 64Table 22: Summary of key Nutrition Findings for Hargeisa, burao and berbera IDPs, June 2012 66Table 23: Summary of Urban Assessment Findings: Northwest and Northeast Regions – Post Gu ‘12Table 24: Plausibility checks 72Table 25: Summary of Nutrition Assessments (April - July 2012) 73

liSt of MAPS

Map 1: Somalia Nutrition Situation, January 2012 5Map 2 Somalia Nutrition Situation, August 2012 5Map 3: Estimated Nutrition Situation (September-November) 2012 6Map 4: Somalia Acute Food Insecurity Overview, Rural, Urban and IDP Populations, July 2012 8Map 5: Distribution of estimated Cases (%) of Acutely Malnourished Children in Somalia by Region, based on Prevalence, August 2012 11Map 6: Gedo Region Livelihood Zones 16Map 7: Juba Regions Livelihood Zones 20Map 8: bay and bakool Regions Livelihood Zones 27Map 9: Shabelle Livelihood Zones 34Map 10: Hiran Livelihood Zones 39Map 11: Northeast Livelihood Zones 48Map 12: Northwest Livelihood Zones 58

SPEciAl ArticlES

Sustained high levels of acute malnutrition across Somalia and kenya border 24

Case study 1: A family’s experience during a hunger period, in Huddur district 29Case study 2: Increased nutritional vulnerability among the families in the besieged Huddur town, bakool region 33

Nutrition Survey Results in Mataban and beletweyne, Hiran Region Indicate an ExtremelyWorrying Health Situation 38

Food safety and malnutrition in Somalia 47

Strengthening of Infant and young Child Feeding Programming and Planning for Emergency;The Infant and young Child Feeding (IyCF) London Workshop (25-29 June 2012) Preparedness and Response. 69


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liSt of AcronyMS uSEd

AWD Acute Watery DiarrhoeaARI Acute Respiratory Tract InfectionsCDC Center for Disease Control and Prevention, AtlantaCDR Crude Death Rate CHD Child Health DaysCI Confidence IntervalCOSV Co-operatione Di Svillupo InternationalFAO Food and Agricultural Organization of the United NationsFSNAU Food Security and Nutrition Analysis UnitFEWSNET Famine Early Warning System NetworkGAM Global Acute MalnutritionHAZ Height for Age Z ScoresHIS Health Information SystemIDP Internally Displaced personsINGO International Nongovernmental OrganizationLZ Livelihood ZoneMCH Maternal and Child Health CenterMOH Ministry of HealthMT Metric TonMUAC Mid Upper Arm CircumferenceNCHS National Center for Health StatisticsNGO Non Governmental OrganizationOTP Out Patient Therapeutic ProgrammeOPD Out Patient DepartmentPWA Post War AverageR Reliability ScoreRR Relative Risk/Risk RatioSAM Severe Acute MalnutritionSC Stabilization CenterSC-Uk Save the Children - UkSRCS Somalia Red Crescent SocietiesSD Standard DeviationSFP Selective/Supplementary Feeding ProgramTFC Therapeutic Feeding CenterTOT Terms of TradeU5DR Under Five Death RateUNHCR United Nations High Commission for RefugeesUNICEF United Nations Children’s FundWAZ Weight-for-Age Z ScoresWHO World Health Organization of the United NationsWFP World Food Program of the United NationsWHZ Weight for Height Z ScoresWVI World Vision International


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forward

The FSNAU Post Gu 2012 Technical Series report (September 2012) is the seventh edition of the bi-annual nutrition situation technical series launched by the Food Security and Nutrition Analysis Unit (FSNAU) in February 2009. The publication complements the FSNAU bi-annual seasonal technical series reports and provides specific focus on nutrition information for the last 6 months.

The FSNAU Post Gu 2012 Technical Series report was released on September xx, 2012, and is accessible at http://www.fsnau.org/downloads/FSNAU-Post-Deyr-2011-12-Technical-Report.pdf. It provides a detailed analysis of the integrated food security situation, by region and by sector.


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1. ExECuTivE SummAry

nutrition Situation overview

With the exception of the coastal strip of West Golis/Guban, the Coastal Deeh of North and Central, Cowpea belt livelihood zones, bay and parts of Juba regions where the food security situation is of concern, increased purchasing power and improved livestock productivity, and sustained humanitarian support enhanced household access to food and nutrition through the Gu (April-July) 2012 season, and mitigated the nutrition situation across the country. Humanitarian support in terms of cash, food and non-food items strengthened the communities’ purchasing power; while health care and nutrition support enabled control and management of endemic diseases, seasonal outbreaks, and malnutrition, thereby saving lives in these areas. Consequently across the country, levels of acute malnutrition have declined to below the Integrated Phase Classification (IPC) famine threshold of 30%, while crude death rates (CDR) are below the UNICEF emergency threshold of 2/10,000/day.

From April-July 2012, FSNAU in collaboration with partner agencies conducted 46 representative nutrition surveys in Somalia, assessing rural, urban and internally displaced populations (Table 1). Of these, 16 were done in the south; 4 in central rural livelihood zones; 10 in northwest and northeast rural pastoral and agro-pastoral livelihood zones; 8 in IDPs in the north and central regions; and 8 in the urban livelihood zones in the north. Due to security restrictions, updated nutrition and mortality data was not collected in Shabelle regions and the southern parts of Gedo, bakool and Hiran regions. However, indirect information on nutrition trends from health centers and feeding programmes was analysed.

Survey findings (Figures 1 and 2) show significant improvements in the nutrition situation in parts of the southern and northeast regions, and deteriorations in parts of the northwest regions (Maps 1 & 2), since January 2012. Nevertheless, across the South, the situation remains Very Critical except for parts of Juba and Hiran regions in Critical phase. In Central and Northeast regions, the situation is Serious except for the Coastal Deeh and Cowpea belt in Central regions in Critical phase. In the northwest regions, the situation is Serious in all livelihoods apart from the Hawd in Critical, Nugal Valley in Very Critical phases due to high morbidity and disease outbreaks, and West Golis/Guban in Very Critical phase due to deteriorated food security conditions.

based on the Gu 2012 analysis, at national level, an estimated 236,000 (16% of the 1.5 million) Somali children are currently acutely malnourished and in need of specialized nutrition treatment services. of the 236,000 children, 54,000 (3.5% of the 1.5 million Somali children) are severely malnourished requiring immediate lifesaving interventions. Seventy percent of the malnourished are from the southern regions, where there are concerns about their ability to access vital basic services needed for survival. Nevertheless the figures reflect a reducing trend since August 2011, the peak of famine when an estimated 450,000 (30% of the 1.5 million Somali children) of the children were acutely malnourished with 190,000 (13%) in severe state, and January 2012, when 323,000 (or 22%) were acutely malnourished, with 93,000 (6%) in severe state. Despite the improvements therefore, lifesaving humanitarian assistance remains crucial between now and December 2012 to meet immediate nutrition, health and food needs, protect livelihoods and build resilience.

Southern regions • In Bay region and Juba riverine communities, the

situation has improved from Extremely Critical phase with GAM rates in excess of 30% in January 2012, to Very Critical with GAM rates of 20.4% (16.7 – 24.5) in bay, and 21.5% (18.8-24.5) in Juba riverine.

• Juba pastoralists have improved from a Very Critical phase in January 2012 to Critical with the Global Acute Malnutrition (GAM) rate currently at 15.8% (11.8-20.7). CDR is 0.44/10,000/day and within acceptable range.

• For Mogadishu IDPs and urban, the situation has

A calm looking Somali child FSNAU 2011

figure 1: Global Acute and Severe Acute Malnutrition, (WhZ < 2 and 3 z Scoresor oedema) April- July 2012 - Somalia


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improved from Very Critical phase (with GAM of 20-22%) in January 2012 to Serious phase.o Mogadishu IDPs: GAM reate is currently 9.6% (7.1-

13.0) o Mogadishu urban: GAM rate is 10.8% (8.3-13.9)

• Findings from other parts of the south assessed during the Gu 2012 indicate a sustained Very Critical phase with GAM rates between 20-29.9%.

The 90 days retrospective crude death rate (CDR) in bay region, Mogadishu IDPs and urban is in the range of 1- 1.49 /10,000/day indicating a Critical situation, and highest in the country, but nevertheless below UNICEF’s emergency threshold of 2/10,000/day. Across most of the other assessed areas of Southern Somalia, crude death rates are below 0.5/10,000/day and therefore within acceptable levels. For additional findings, refer to Figures 1 & 2, regional information, and the summary table of findings.

northern and central regionsThere are improvements to a Serious nutrition situation from Critical in East Golis of northeast along the Red sea, and in the Hawd of central regions. However, in West Golis/Guban, the Hawd in the northwest, and Nugal Valley livelihood zones, the situation has deteriorated to Critical-Very Critical phases, while global acute malnutrition levels are elevated above seasonal norms of 10-14.9%. • West Golis/Guban: The deterioration is attributed to

declined milk and food access by women and children left behind following rain failure and the out-migration of livestock with men and boys. GAM rate is 21.7% (19.9-26.1).

• The Hawd livelihood zone at the Ethiopian border has deteriorated to Critical from Serious phase mainly due to high morbidity, mainly acute watery diarrhea and measles, in April-July. The GAM rate is 16.7% (11.5-23.5)

• Nugal Valley livelihood zone has deteriorated to Very Critical from Critical phase due to high morbidity and measles outbreaks in the burao and Ainabo districts. The GAM rate is 20.1% (16.5-24.3).

Crude death rates are nevertheless within acceptable levels of <0.5/10,000/day based on UNICEF’s classification. For additional findings, refer to Figures 1 & 2, regional information, and the summary table of findings.

urban livelihoodsIn July 2012, FSNAU and partners undertook 10 nutrition surveys in the urban population of Somalia. Five regional surveys were conducted in northwest regions, two in northeast, two in central regions and one in Mogadishu town.• northwest regions: Gu 2012 survey findings depict Alert

or Serious nutrition situation in urban populations and varied trend since January 2012. o Woq. Galbeed and Sanaag regions: The nutrition situation

remains Alert, with a GAM rates in the 5-9.9% range. o Awdal and Sool regions: The nutrition situation is in

sustained Serious phase with GAM rate of 10-14.9%.o Togdher region: The nutrition situation has deteriorated

from Alert in January 2012 to Serious with a GAM rate of 14.7% (10.5-20.3).

• northeast regions: The nutrition situation among the urban populations in the northeast regions is either sustained or has deteriorated since January 2012. o Bari region: The situation has deteriorated to a Critical

phase from Serious. o Nugal region: The situation is in a sustained Serious

phase

• central regions: The nutrition situation is Critical both in Galgadud and Mudug regions with GAM rate of 15-19.9%. In Mudug, the findings indicate deterioration from Serious phase in December 2011 when GAM and SAM rates of 14.9% (11.7-18.7) and 4.15 (2.4-6.9) respectively were recorded. A survey was not conducted in Galgadud in December 2011.

• Mogadishu urban: The nutrition situation is in Serious phase with GAM rate of 10.8% (8.3-13.9) sustained since April 2012 and an improvement from Very Critical in January 2012,

Due to security reasons, it was not possible to undertake nutrition surveys in the other urban livelihoods zones of the southern regions. Nevertheless the nutrition situation in these regions is likely Very Critical, and consistent with the rural livelihoods and IDP populations with whom there is co-dependence.

figure 2: retrospective crude and under 5 death rates per 10,000 per day


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• Southern regions: o The nutrition situation in Mogadishu IDPs has

improved to Serious with GAM rate of 9.6% (7.1-13.0) from Very Critical phase in January 2012.

o baidoa IDPs face a Critical nutrition situation with GAM rate of 15.8%.

o Dolow, kismayo, Dobley IDPs are faced with a Very Critical with GAM rates in the range of 20-29.9%.

Median levels of malnutritionMedian levels of acute malnutrition have been calculated based on findings from the 46 nutrition surveys conducted across Somalia in Gu 2012. They therefore exclude Shabelle and the southern parts of Gedo, bakool and Hiran regions which could not be accessed due to insecurity. based on the Gu 2012 survey findings, the median GAM rate for the country is 17.2% which is consistent with 16.2%, the median rate for the country based on 220 surveys conducted in Somalia from 2001-2011. The Gu 2012 median rate is 24.3% for IDPs only, and 16.1% for all excluding IDPs, and 21.6% for the south. (Source: FSNAU1 2012).

With regard to stunting, the Gu 2012 median rate for Somalia is 15.6%. This is lower than 23% which is the median rate for the country based on 220 nutrition surveys undertaken in 2001-2011. The difference is of statistical significance. The median stunting rate for IDPs, 22.0% and southern regions, 19.2% are nevertheless consistent with the 10 year median rate. Additional details are provided in the Figures 3 & 4 below.

1 FSNAU 2012: A Meta-analysis report on nutrition surveys undertaken in Somalia in 2001-2011.

internally displaced persons (idPs)Except for Hargeisa and Mogadishu IDPs in Serious phase, findings from nutrition surveys conducted in IDP settlements across Somalia depict a Critical - Very Critical situation with GAM rates above the WHO emergency threshold of 15%. • northwest regions: The nutrition situation is sustained

in Serious phase in Hargeisa IDPs and Critical phase in berbera IDPs, but has improved to Critical from Very Critical phase in burao IDPs, since January 2012.

• northeast and central regions: The nutrition phase has improved to Critical from Very Critical phase in bossaso and Galkayo IDPs; deteriorated to Very Critical from Critical phase in Garowe and Qardho IDPs; and remains Very Critical in Dusamareb since January 2012.

figure 3: Median wasting rates, WhoGS (WAZ<-2 and WAZ <-3) April- July 2012

No. Livelihood Zone (LZ)/Population Group PERIOD1 Agropastoral LZ (Togdheer & Northwest) July 20122 West Golis /GubanPastoral LZ July 2012

3 Sool Plateau LZ (Northwest and Northeast) July 2012

4 Hawd Pastoral LZ (Northwest) July 2012

5 East Golis/Gebbi Pastoral LZ (Northwest) July 2012

6 East Golis/Kakaar Pastoral LZ (Northeast) July 2012

7 Nugal Valley Pastoral LZ (Northwest and Northeast) July 2012

8 Coastal Deeh LZ (Northeast) July 20129 Coastal Deeh LZ (Central) July 2012

10 Hawd Pastoral LZ (Central and Northeast) July 2012

11 Addun Pastoral LZ (Central and Northeast July 2012

12 Sool Region Urban LZ July 201213 Sanaag Region Urban LZ July 201214 Bari Region Urban LZ July 201215 Nugal Region Urban LZ July 201216 Mudug Region Urban LZ July 201217 Awdal Region Uban LZ July 201218 Woq Galbeed Region Urban LZ July 201219 Togdheer Region Urban LZ July 201220 Cowpea Belt (Central) July 201221 Galgadud Region Urban LZ22 Dusamareb IDPs May 201223 Hargeisa IDPs May 201224 Burao IDPs May 201225 Berbera IDPs May 201226 Bossaso IDPs May 201227 Qardho IDPs May 201228 Garowe IDPs May 201229 Galkayo/Margaga IDPs May 201230 Kismayo IDPs July 201231 Dobley IDPs July 201232 Dolo IDPs June 201233 Mogadishu IDPS April 201234 Mogadishu IDPs July 201235 Mogadishu Urban April 201236 Mogadishu Urban July 201237 Juba Pastoral LZ July 201238 Juba Agropastoral LZ July 201239 Juba Riverine LZ July 201240 North Gedo Pastoral LZ June 201241 North Gedo Riverine LZ June 201242 Bakool Pastoralists June 201243 Hiran Region – Beletweyne District July 201244 Hiran Region – Mataban District July 201245 Bay Region July 201246 Baidoa IDPs July 2012

table 1: nutrition Surveys Schedule April-July 2012

figure 4: Median Stunting rates, Who GS (hAZ<-2 and hAZ <-3) April- July 2012


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GenderStatistical analyses for Gu 2012 survey findings show no significant differences between acute malnutrition and • sex of the child, or with • sex of the household head.

Likewise, there are no statistically significant differences between sex of the child with • morbidity status (based on recall) nor with• child feeding practices. However in Sool plateau, there are statistical differences between stunting rate and sex of the child.

Nevertheless, across all the surveyed population groups, a higher proportion of boys than girls tended to be acutely malnourished. This disparity is likely, given the use of the new WHO 2006 sex-differentiated reference standards, which has been observed to discriminatively identify more boys as acutely malnourished. With the new WHO reference standards, a girl of a certain height has to be much lighter than a boy of the same height to meet the

WHZ<-2 threshold for acute malnutrition. A review of data from therapeutic feeding centers (TFC) from 13 African countries found that when children 6-59 months were admitted using UNISEX tables, there was no significant difference in the number of boys and girls admitted and there was no significant difference in the mortality rate2. The review meeting recommended the use of unisex (boys only) reference tables based on the WHO growth standards for children aged 6-59 months in admissions to selective feeding programs.

Discussions are underway to establish the most appropriate way forward with regard to nutrition surveillance and analysis.

2 Golden, M., Grellety, y., Schwartz, H., & Tchibindat, F. (2010). Report of a Meeting to harmonize the criteria for monitoring and evaluation of the treatment of acute malnutrition in West and Central Africa. 30th November – 1st December 2010; Dakar, Senegal. Retrieved February 27, 2012 http://www.ennonline.net/pool/files/ife/consensus-meeting-on-m&e-imam-dakar-2010-eng.pdf

The projected nutrition outlook for September-November 2012 has been derived from the analysis of current situation vis-à-vis historical seasonal trends of nutrition, disease outbreak patterns and its impacts on nutrition, anticipated agricultural production, livestock and milk access, civil insecurity which limits access to imports, and humanitarian assistance.

•Pastoralists and Northwest Agro-pastoralists: Although the current nutrition situation is Serious-Very Critical, improvements are observed across all pastoral livelihood zones associated with increased household food access. This is with the exception for West Golis/Guban livelihood zone. The forecasted moderate El-Nino will bring above-average rains in October to December 2012. This will lead to continued improvements for pastoralists across the country, including West Golis/Guban, in terms of good pasture/water availability; increased livestock holdings; improved milk availability; increased income following livestock demand at the time of the Hajj festivity.

The nutrition situation in pastoral communities, and the northwest agro-pastoralists who are more inclined to pastoralism than farming are therefore likely to improve across the country (Map 3) but unlikely to improve beyond seasonal levels of Serious in the north and central regions, and Critical in the south.

•Agro-pastoralists in south and central regions: The forecasted moderate El-Nino will bring above-average rains in October to December 2012. This is likely to increase cultivation, and with it labor opportunities for the poor.

The carryover food stocks and incme access from the Deyr 2011/12 and the below average Gu 2012 harvests are likely to deplete by October. This is likely to contribute to increased cereal prices and further limit household access. Planned reduction of humanitarian assistance with the end of the 2011 famine, and some moderate flooding anticipated in Juba regions are likely to aggravate the nutrition situation.

In addition, based on historical trends uncontrolled outbreaks of cholera, malaria or measles are expected in October-November 2012. This will further hinder any nutritional gains.

The nutrition situation in the southern/central agro-pastoralists is therefore likely to remain in Critical – Very Critical phases. (Map 3).

• Riverine: The forecasted moderate El-Nino will bring above-average rains in October to December 2012. This is likely to lead to river overflow into the underground storage facilities, contamination of water sources and displacements. Considering that seasonal outbreaks of acute watery diarrhea/suspected cholera are also anticipated in October-November, the more likely scenario is sustained Very Critical phase. (Map 3)

•IDPs: These remain vulnerable due to their dependence on humanitarian assistance, income from petty trade and casual labor opportunities that are closely linked with rural and urban livelihoods. The outlook of their nutrition situation therefore remains of concern, as in the Gu 2012. (Map 3).

The current projection assumption will be reviewed in October 2012 based on updated information on climate performance; cereal price dynamics; humanitarian interventions; insecurity.

considerations for the nutrition outlook for September-november 2012


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Map 3: Estimated nutrition Situation (September-november) 2012


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Food Security Situation Overview

The food security and nutrition data indicate continued improvements in food security in Somalia. During 2011, a famine affected over 4 million people, or more than half of the population of Somalia, leading to tens of thousands of deaths. An estimated 2.12 million people are in crisis for the August to December 2012 period, a 16 percent reduction from the beginning of the year. Therefore humanitarian assistance remains necessary between now and December to help food insecure populations meet immediate food needs, protect livelihoods and build resilience.

Poor rains and below average harvest

According to recent assessment findings, the August/September Gu harvest is significantly below average due to a late start of rains, poor rainfall totals, and pest outbreaks, among other factors. However, food stocks from last season’s exceptional Deyr harvest will help to mitigate this shortfall and overall production for the 2012 calendar year will be average. Low cereal prices, high casual labor wage rates, and high livestock prices over the past six months have also contributed to reduced food insecurity by significantly strengthening the purchasing power of poor agropastoral households. In pastoral areas, households have also benefited from record livestock sales prices, robust livestock exports, and increasing livestock holdings, which have resulted in improved milk availability. This improved access to milk, among a variety of other factors, has driven a 27 percent reduction since January in the number of children requiring nutrition treatment. Currently 236,000 children are severely malnourished, of which 70 percent are in the South.

While conditions have improved considerably since last year, the food security crisis has not ended. In the southern and central agro-pastoral areas, the below average Gu harvest, the continued need for cash to pay down debts, and low livestock holdings are keeping most southern and central agropastoral areas in IPC Phase 3 (Crisis). Other areas of concern include coastal areas and the coastal plains along the Gulf of Aden and the Indian Ocean in the northern and central regions.

outlook A predicted moderate El Niño between now and December 2012, is expected to have positive impacts on Somalia as this phenomenon is associated with average to above average October to December Deyr rains. However, these rains are not always well distributed and therefore, cropping conditions could vary greatly over the rainfed, agro-pastoral areas. In addition, riverine areas are likely to experience flooding as a result of heavy rainfall and increased river levels. During the moderate 2006-07 El Niño, Deyr rains caused flooding, which disrupted production and markets, especially in the Juba Valley.

International food prices have risen and will likely have an impact on prices in Somalia between now and December, especially for wheat and sugar. Over the past three years, wheat and wheat product imports have averaged 73 percent of Somalia’s food imports in grain equivalent terms. Prices for local maize and sorghum, the staple foods consumed by the poor, are likely to rise seasonably over the coming six months, but substantially lower than 2011.

The epicentre of Somalia’s humanitarian crisis remains in the South, largely due to the long-term effects of drought and famine, and the short-term effects of this year’s poor Gu rainy season. Efforts to meet immediate needs are essential to prevent further deterioration of food security. Assistance to help food insecure populations meet immediate food needs, protect their livelihoods, build their resilience, and improve food access remain necessary in Somalia between now and the Deyr harvest in January.


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Map 4: Somalia Acute food insecurity overview, rural, urban and idP Populations, July 2012


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Notes:1 Source: Population Estimates by Region/District, UNDP Somalia, August 1, 2005. FSNAU does not round these population

estimates as they are the official estimates provided by UNDP

2 Estimated numbers are rounded to the nearest five thousand, based on resident population not considering current or anticipated migration, and are inclusive of population in Stressed, Crisis and Emergency

3 Source UN-OCHA/UNHCR: New IDP updated January 18 2012 rounded to the nearest 5,000. Total IDP estimates are based on Population Movement Tracking data which is not designed to collect long-term cumulative IDP data

4 To avoid double counting, only IDPs in Settlements (bossasso, berbera, Galkayo, Hargeisa, Garowe, kismayo, Afgoye, Burao and Mogadishu are considered in the overall population in Crisis. FSNAU does not conduct IDP specific assessments to classify them either in Crisis or Emergency

5. Percent of total population of Somalia estimated at 7,502,654 (UNDP/WHO 2005)

RegionUNDP

2005 Total Population

UNDP 2005

Urban Population

UNDP 2005 Rural Population

Urban in Stressed

Rural in Stressed

Urban in Crisis

Rural in Crisis

Urban in Emergency

Rural in Emergency

Total in Crisis and

Emergency as % of Total population

North

Awdal 305,455 110,942 194,513 35,000 35,000 0 20,000 0 5,000 8

Woqooyi Galbeed 700,345 490,432 209,913 220,000 40,000 0 10,000 0 0 1Togdheer 402,295 123,402 278,893 40,000 65,000 15,000 10,000 0 0 6Sanaag 270,367 56,079 214,288 10,000 25,000 25,000 35,000 5,000 5,000 26

Sool 150,277 39,134 111,143 0 20,000 15,000 10,000 5,000 0 20

Bari 367,638 179,633 188,005 20,000 40,000 60,000 15,000 20,000 0 26

Nugaal 145,341 54,749 90,592 0 20,000 20,000 5,000 5,000 0 21Sub-total 2,341,718 1,054,371 1,287,347 325,000 245,000 135,000 105,000 35,000 10,000 12

Central Mudug 350,099 94,405 255,694 0 60,000 25,000 20,000 5,000 35,000 24Galgaduud 330,057 58,977 271,080 10,000 60,000 15,000 35,000 0 35,000 26

Sub-total 680,156 153,382 526,774 10,000 120,000 40,000 55,000 5,000 70,000 25

South 0

Hiraan 329,811 69,113 260,698 15,000 20,000 15,000 50,000 0 15,000 24

Shabelle Dhexe (Middle) 514,901 95,831 419,070 0 115,000 30,000 25,000 0 45,000 19

Shabelle Hoose (Lower) 850,651 172,714 677,937 0 185,000 70,000 0 0 0 8

Bakool 310,627 61,438 249,189 20,000 110,000 20,000 55,000 5,000 0 26Bay 620,562 126,813 493,749 25,000 145,000 35,000 230,000 0 0 43

Gedo 328,378 81,302 247,076 30,000 70,000 15,000 35,000 0 0 15

Juba Dhexe (Middle) 238,877 54,739 184,138 0 5,000 25,000 45,000 0 0 29

Juba Hoose (Lower) 385,790 124,682 261,108 0 10,000 20,000 45,000 20,000 5,000 23

Sub-total 3,579,597 786,632 2,792,965 90,000 660,000 230,000 485,000 25,000 65,000 22

Banadir 901,183 901,183 - 245,000 - 60,000 - 0 - 7Grand Total 7,502,654 2,895,568 4,607,086 670,000 1,025,000 465,000 645,000 65,000 145,000 18

Assessed and Contingency Population in Crisis and Emergency Number affected

% of Total population

Distribution of populations in

crisisAssessed Urban population in Crisis and Emergency 530,000 7 25%

Assessed Rural population in Crisis and Emergency 790,000 11 37%

IDP in settlements* (out of UNHCR 1.3million) to avoid double counting 800,000 11 38%

Estimated Rural, Urban and IDP population in crisis 2,120,000 28 100%

Table 2: Somalia Integrated Food Security Phase Classification, Population Numbers, Aug - Dec 2012


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ds FSNAU in collaboration with partners conducted a total of 46 representative nutrition surveys throughout Somalia, between April – July 2012. Seventeen of the surveys were done in the South, and the rest in the northern and central regions. With the exception of Shabelle regions and the southern parts of Gedo, bakool and Hiran which were inaccessible for security reasons, all population groups were assessed during this period. Table 3 provides the summary of key findings from these surveys.

Since 2008, FSNAU in collaboration with nutrition cluster partners have illustrated the distribution of cases of the acutely malnourished children in Somalia rather than just presenting the prevailing nutrition situation. The purpose is to draw the attention of response agencies and donors to the needs in different parts of the countries, rather than just focusing on the prevailing situation. In this way, the impact of the population density in determining response needs is manifested.

by extrapolating the prevalence rates of acute malnutrition in each assessed population group to the total under five population during the Gu 2012, cases of acutely malnourished children, based on Weight-for-height Z scores (WHZ) findings, have been estimated. The cumulative total cases at regional level has been obtained by adding the cases from the assessed livelihood and IDP groups. For population groups where representative nutrition survey data for the whole population forms the main reference, reliability of data is high and is ranked as 1 (R=1). For the Shabelle regions and southern parts of Gedo, bakool and Hiran regions where it was not possible to collect nutrition survey data, the median rates for surveys conducted in the Gu season during the period 2001-2010 has been applied. This implies that FSNAU has estimated the current cases of malnourished children on the basis of 100% of the population children aged below 5 years in Somalia. Population figures from the UNDP 2005 settlement survey are used as the standard reference for Somalia. (Table 3). The integrated analysis and overall phase classification of the assessed population is based on the Nutrition Situation Classification Framework. (Table 2).

Analysis of the Post Gu 2012 findings indicates an estimated total of 236,000 children as acutely malnourished. this translates to 16% of the 1.5 million under five population, and implies 1 in 7 Somali children acutely malnourished. This reflects a 27% decrease in numbers at the national level, compared to the Deyr 2011/12 when 323,000 children were estimated to be acutely malnourished. of these, 168,000, or 71% are located in the southern regions.

of the 236,000 children, a total of 54,000 children are severely malnourished. At national level, this translates to 3.5% of all Somali children estimated to be severely malnourished. This reflects a significant decrease at the national level, compared to the Deyr 2011/12 when 93,000 children were estimated to be severely malnourished, and 160,000 in August 2011 at the peak of the famine. of the 54,000 severely malnourished children, 39, 500 (or 72%) are located in the southern regions.

At regional level, these figures are derived by extrapolating the prevalence rate of acute malnutrition to the total under five population. (Table 3). Hence, with regard to cases of acute malnutrition:•Shabelle regions (including Mogadishu IDPs and banadir)

are host to 25% while northwest regions host 21% of all the

acutely malnourished children in Somalia. bay hosts 11%, Lower and Middle Juba region, 11%, Gedo 7% and bakool 6%. (Map 5 and Figure 5).

hence, banadir, Middle and lower Shabelle, bay, Juba, Gedo and bakool regions are host to 60% of all acutely malnourished children in Somalia.

•For cases of severe acute malnutrition, Shabelle regions, bay and Lower Juba, Gedo and bakool regions are host to 63% of the 54,000 children in the country, with Shabelle/Banadir hosting 20%, bay 16%, and Juba regions 12%.

•Likewise, the northwest regions are host to 21% the total acutely malnourished and 18% of the severely malnourished.

This illustrates the implication of population density on caseloads, as Shabelle/Afgoye/Banadir, together with Woqoyi Galbeed are most densely populated areas of Somalia.

In Figure 5, the proportion of cases of acutely malnourished children by region is provided in descending order.

In Map 6, illustrations for (i) the Gu 2012 nutrition situation and (ii) the cases for both total and severe acute malnutrition based on the May-July 2012 nutrition surveys data are provided. For more information please contact [email protected].

2. CASES OF ACuTELy mALNOuriShEd ChiLdrEN iN SOmALiA

Total acutely malnourished

Total severely malnourished

Cases % of total cases Cases % of total

casesbay 25,400 11 8,550 16Lower Shabelle 23,750 10 4,650 9banadir (Mogadishu Town) 22,150 9 3,100 6Woq Galbeed 18,800 8 3,700 7Gedo 17,350 7 4,050 7Lower Juba 16,000 7 3,950 7bakool 13,000 6 4,200 8Middle Shabelle 12,275 5 3,200 6Hiran 11,000 5 2,550 5Togdheer 10,850 5 2,150 4Middle Juba 9,900 4 2,450 5bari 9,000 4 2,600 5Mudug 8,700 4 1,500 3Awdal 8,200 3 1,600 3Galgadud 7,900 3 1,300 2Mogadishu IDP 7,850 3 1,450 3Sanag 7,250 3 1,450 3Sool 4,100 2 800 1Nugal 2,900 1 850 2

236,400 100 54,100 100

table 3: Estimated cases of Acute Malnutrition in Somalia, by region, September 2012

figure 5: Propotion of total cases of Acutely Malnourished children (WhZ<-Z or oedema) by region, September 2012


Map 5: distribution of estimated cases (%) of Acutely Malnourished children in Somalia by region, based on Prevalence, August 2012

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Pregnant and lactating womenThe cumulative total estimate for acutely malnourished pregnant and lac tat ing women based on MUAC measurements < 23cm is 81,000. The severe at risk based on MUAC<21cm is 19, 000. In the Deyr 2011, the cases of acutely malnourished pregnant and lactating women was estimated at 85,000 based on MUAC measurements < 23cm. This indicates a 5% reduction in the cases.

In the Gu 2011, the peak of the famine, the cases of acutely malnourished pregnant and lactating women was estimated at 101,000, based on MUAC measurements < 23cm, hence there is significant progress since then.


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Nutrition Cluster response in 2012

Nutrition treatment servicesIn eight months of service provision, the nutrition cluster response agencies reached 532,615 acutely malnourished children with treatment services (165,129 in stabilization centre/out-patient therapeutic care programme (SC/OTP) and 367,486 in targeted supplementary feeding programme )TSFP). The number reached is above the post dyer caseload of 323,000 acutely malnourished children. The reason for surpassing the estimated caseload maybe due to population figures as well as the incidence rate of 2 which we use. The figure i below shows admission trends for January to August 2012. The low admissions figures for July and August are due to low reporting rate and not necessarily a drastic improvement in the nutrition situation..

Figure ii shows admission trends by zone. The Southern zone of Somalia contributes most of the children reached consistent with the caseloads identified through nutrition surveys.

The table iii shows the prevalence and the cluster targets for July to December 2012. The Cluster aims to reach 142,000 (60%) acute malnourished children ( 109,000 moderate, 33,000 severely malnourished children) from the caseload of 236,000.

Maternal Child Health and Nutrition PrgrammesThe cluster’s response agencies have also reached 1,100,618 targeted beneficiaries of which children 6- 23 months (907,071), pregnant and lactating women (193,547) with a preventive food ratio. From these a total of 983,321 are in the south central Somalia.

Transit IDPsWFP and partners reached 87,849 households with a 5 days High energy Biscuits supplementary ration and 19,605 children 6-59months with a supplementary ration of supplementary plumpy in the transit areas of Gedo and Lower Juba. This project will continue to offer relief to populations in transit in the border areas.

Basic Nutrition Service PackageThe cluster partners have embraced the basic nutrition services package (BSNP-) in programming in an effort to address underlying causes of malnutrition. In this regard, the cluster is sensitizing partners on the incorporation into programming of an innovative approach (home fortification), to deliver micronutrients to young children (6-23 months) so as to improve their micronutrient status and decrease morbidity.

Coordination mechanismsThe cluster membership now stands at 142 partners, an increase by 31 members from last year’s 111 members. This resulted to an increase also of service delivery points from 1650 by the end of 2011 to 2454 currently. Regional coordination has greatly improved in the last quarter of the year in the areas where it had been weak due to poor access such as the Shabelles, Bay and Bakool. It is hoped that there will be a continued improvement in the coordination of services in these and other areas for effective response.

For details, contactNutrition cluster coordinator: Leo MatungaEmail Address: [email protected] cluster Lead: UNICEF

Figure ii: Admissions trends by Zone

Figure i: SC/OTP and TSFP admissions by month

Table iii: Nutrition cluster target figures July to december 2012Zone Prevalence data GAM (60% target) Prevalence data MAM (60% target) Prevalence data SAM (60% target)South Somalia 150,850 90,510 113,700 68,220 37,150 22,290Central Somalia 18,102 10,861 15,106 9,064 2,996 1,798Northern Somalia 66,988 40,193 52,499 31,499 14,489 8,693All Somalia 235,940 141,564 181,305 108,783 54,635 32,781rounded off to 236,000 142,000 181,000 109,000 55,000 33,000


The April-July 2012 (Gu) Nutrition Situation Analysis

Twice per year, in line with the seasonal assessments, post Gu (April – July) and post Deyr (October-December), FSNAU in collaboration with partners undertake a nutrition situation analysis by livelihood, region and IDP settlement. During the April-July 2012 (Gu 2012) season, FSNAU in collaboration with partners undertook 46 representative nutrition surveys aimed at estimating the nutrition situation in the various population groups in Somalia. The survey tools used are provided in the appendices. Data management of the nutrition surveys involved the use of the standard two stage cluster sampling based on SMART recommendations, quality assurance during data collection and entry, and validation of data quality by running frequencies and plausibility checks of core statistical inferences. (Table 24). ENA software was used in the analysis of anthropometric and mortality data, and EpiInfo in the cross tabulations and analysis of non-anthropometric data.

Analysis has been conducted using EpiInfo ENA, and interpretation of findings on specific indicators are based on internationally recognized thresholds, mainly the UN-WHO, UNICEF, Sphere, and FANTA/UNFAO.

• UN-WHO thresholds have been used to determine the cut-offs for anthropometry where available, and to interpret findings on acute malnutrition.

• SPHERE 2011 has been referenced on cut-offs for the mid upper arm circumference for pregnant and lactating women and aided in estimating prevalence and cut off for child imunization status. Nevertheless they are limited in providing thresholds for interpreting the situation.

• FANTA/UNFAO protocols have been referenced on thresholds for dietary intake, however they are limited in guiding on interpretation of the situation.

• The mean WHZ, are based on a “Review of Nutrition and Mortality Indicators for the Integrated Food Security Phase Classification (IPC) by young and Jaspars, 2009.

• The UNICEF 2005 classification has been used to interpret death rates.

The findings for each of analyzed variables are categorized into six different phases based on the recognized thresholds: Acceptable, Alert, Serious, Critical, Very Critical or Extremely Critical. Where internationally recognized interpretation frameworks are not available, for example, MUAC thresholds for the adult non-pregnant women, and the health information system trends, quartile distributions of the meta-data at the FSNAU from 250 nutrition surveys conducted in 2007-2011 has been used.

The Nutrition Situation Analytical Framework

The Nutrition Situation Analytical Framework provides a summary of international thresholds (WHO, UNICEF, Fanta, Unicef) used to interpret findings from the various indicators. Where these are not available, contextually relevant analysis forms the basis. Considering the diversity of indicators collected by FSNAU and partners in Somalia, (acute malnutrition, death rates, proportions at risk based on the mid upper arm circumference, nutrition trends from health facilities and selective feeding programs), the framework forms the basis for integrated analysis of the situation.

The January 2012 version of the analysis framework, used in the Gu 2012 analysis, has three sections: A. Core Outcome Indicators (mainly anthropometry related

information, and mortality. Those from surveys have more weight)

b. Immediate Causes C. Driving/Underlying Factors Where representative nutrit ion surveys have been conducted, the global acute malnutrition (GAM), is the core outcome reference indicator, denoting the prevalence of acute malnutrition. The outcome of the integrated nutrition situation analysis process, the estimated nutrition situation, is based on convergence of the evidence of the findings from the indicators. A minimum of 2 anthropometric indicators (global and severe acute malnutrition rates, for example have been used to make an analysis and classification of the situation into either of the six different phases. Information from the season in progress only is used. However historical data has been used for overall contextual and seasonal trends analysis.

The overall analysis is consolidated into the Estimated Nutrition Situation Map. In the cartographical presentation, reliability of data source is illustrated through solid color (for survey data which is quite reliable, R=1), or through slash marks (when statistically representative data is not available, in which case data reliability is lower and, R=2).

Although FSNAU-led, the framework has been developed over the years through a consultation process involving the WHO, UNICEF, WFP, ACF, CONCERN, SCUk, IMC, WV and more recently, Medair, DIAL and the Nutrition Cluster Support team as well as many nutrition partners in the region. The purpose is to have a tool that helps describe the nutrition situation with contextual analysis, rather than focus on prevalence estimates and thresholds which is traditionally the case in nutrition analysis. The January 2012 version accommodates current research developments, the switch from NCHS 1997 to WHO 2006 growth standards and a category for ‘extremely critical’ or ‘famine’ level nutrition situation where for example global acute malnutrition rate is 30% and above. The analytical framework remains a working document, updated and refined as new information and guidance becomes available.

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Table 4. The Nutrition Situation Classification Framework, Draft 8, January 2012

A. corE outcoME indicAtorS (Anthropometry & Death Rates)

Reference Indicators Acceptable Alert Serious Critical Very Critical Extreme

Global Acute Malnutrition1

(IPC Reference) Reliability (R) =1

<3% 3 to <10%; Usual range and stable

10 to<15% orwhere there is

significant increase from usual/ seasonal trends in last >3 yrs

15 to<20% orwhere there is

significant increase from baseline/

seasonal trends in last >2 yrs

20 to <30%>30%

Mean Weight-for-Height Z (WHZ) scores (R=1)

>-0.40-0.40 to -0.69;Stable/Usual

-0.70 to -0.99;>usual/increasing

<-1.00;>usual/increasing

<-1.5 TBC

SAM2 (WHZ and oedema3)(WHO to advice on thresholds) R=1)

<2.5% 2.5 – 3.4% 3.5 – 4.4% 4.5 – 5.9 6.0-9.9% ≥10%

Crude death rate4/ 10,000/day (R=1)<0.5 <0.5

0.5 to <1 or doubling of rate in preceding phase.

1 to <2 >2 >2

Under five death rates5/10,000/day (R=1)

<1<1 1 to 1.9 2 to 3.9

>4 >4

MUAC6 Children: (% <12.5cm): Ref: FSNAU Estimates 7 (R=2) <2.0%

2.0-5.5% with increase from seasonal trends

5.6-8.0%8.1-11.0 %, or where there is significant increase from seasonal trends

11.1-19. 9%, Or where there is significant

increase from seasonal trends

≥20.0%, Or where there is significant

increase from seasonal

trends

MUAC<11.5cm8 (R=2) <1.0 <1.0 1.0-2.0 2.1-3.0 3.1-5.5 ≥5.5Adult MUAC9 - Pregnant and Lactating(%<23.0cm,Meta Data-FSNAU

<13.5 13.6-21.5 21.6-27.0 27.1-35.0 35.0-49.9 ≥50.0

Adult MUAC - Non-pregnant & non-lactating <18.5cm, Meta data FSNAU)

<0.2 0.2-0.5 0.6-0.8 0.8-1.7 1.8-4.9 ≥5.0

Non Pregnant Maternal10 Undernutrition BMI<18.5

<10% 10.0 to 19.9% 20.0 to 39.9% >40%

Non Pregnant Maternal11 Overnutrition BMI>24.9

TBCTBC TBC TBC

HIS12 Trends of Acutely Malnourished Children(Ref: HIS), (R=3)

V. low (<5%) proportion in the preceding 3mths relative to >2yr seasonal trends

Low proportion (5 to <10%) and stable trend in the preceding 3mths relative to >2yr seasonal trends

Moderate (10 to <15%) and stable or low (5 to <10%) but increasing proportion in the preceding 3mths relative to >2yr seasonal trends

High (> 15%) and stable proportion in the preceding 3mths relative to >2yr seasonal trends

High (> 15%) and increasing proportion in the preceding 3mths relative to >2yr seasonal trends

Sentinel13 Site Trends: levels of children identified as acutely malnourished(WHZ), FSNAU’06 SSS

Very low (<5%) and stable levels

Low levels (5 to <10%)and one round indicating increase, seasonally adjusted

Low (5 to < 10%) & increasing or moderate (10 to <15%) levels based on two rounds (seasonally adjusted)

High levels (> 15%) of malnourished children and stable (seasonally adjusted)

High levels (> 15%) and increasing with increasing trend (seasonally adjusted)

OVERAL NUTRITION SITUATION Acceptable Alert Serious Critical Very Critical Extreme

B. iMMEdiAtE cAuSESReference Indicators Acceptable Alert Serious Critical Very Critical

Poor HH Dietary Diversity(% consuming<4fdgps)

Mean HH dietary diversity Score 13

<5%

TBC

5 – 9.9%

TBC

10-24.9%

TBC

25 – 49.9%

TBC

>50%

TBC

Disease Outbreaks14: (seasonally adjusted). Frequency of reported outbreaks of AWD &, malaria &

measles

• Normal levels, & seasonal trends,

• Review data in

relevant context

-AWD 1 case-Measles 1 case-Malaria–doubling of cases in 2 weeks in hyper endemic areas–using RDT

Outbreak not contained and/or in non endemic area – limited access to treatment:

CFR for AWD >2% ruralCFR for AWD >1% urban

AWD – duration exceed >6 wks

Morbidity Patterns: Proportion of children reported ill in 2wks prior

to survey (R=2)Health facility morbidity trends (R=3) /WHO surveillance (R=1)

TBC

Very low proportion

reportedly sick

TBC

Low & stable proportion of

reportedly sick based on seasonal trends

TBCLow proportion reportedly sick, from previous

months but increasing in >2 mnths based on seasonal trends

TBC

High levels and stable numbers in

>2 months based on seasonal trends

TBC

High with significantIncrease in numbers of sick children, based on

seasonal trends

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C. drivinG fActorS Reference Indicators Acceptable Alert Serious Critical Very CriticalComplementary feeding15 in addition to breastfeeding

i. Introduction of complementary food at 6 mths of age: %introduced

ii. Meeting minimum recommended feeding frequency16

iii. Dietary diversity17 score

≥95%≥95%≥95%

80-94%80-94%80-94%

60-79%80-94%80-94%

0-59%0-59%0-59%

0-59%0-59%0-59%

Breastfeeding (BF) Practices18 I. Exclusive BF for 6mthsii).Continued BF at 1 yriii)Continued BF at 2yr reference

>90% >90% >90%

50-89%50-89%50-89%

12-49%12-49%12-49%

0-11%0-11%0-11%

Measles immunization/StatusVitamin A Supplementation Coverage19:1 dose in last 6 mths

>95%>95%

80-94.9%80-94.9%

<80%<80%

Population have access i). to a sufficient quantity of water for drinking, cooking, personal & domestic hygiene–min 15lts pp/ day ii).Sanitation facilities

100%

100%

TBC

TBC

TBC

TBC

TBC

TBC

TBC

TBC

Affected pop with access to formal/informal services: health services

Should not be necessary

Access to humanitarian interventions for most vulnerable

Reduced access to humanitarian support for most vulnerable

Limited access to humanitarian support for majority

Negligible or no access

Selective Feeding 20 Programs Available: Coverage of TFP /SFP & referral systems(Sphere04); -Admissions trends (R=3)

Should not be necessary

Access for most vulnerable

None available

Food Security Situation- current IPC statusGenerally Food Secure

Borderline Food Secure

Acute Food and Livelihood Crisis

Humanitarian Emergency

Famine/Humanitarian Catastrophe

Civil Insecurity Prevailing structural peace

Unstable disrupted tension

Limited spread, low intensity

Widespread, high intensity

Widespread, high intensity

3 MONTH NUTRITION SITUATIONOUTLOOK

Convergence of evidence on immediate Causes/Driving factors vis-à-vis Projected trend in 3 months timeNo change: Stable; Uncertain: Potential to deteriorate Potential to improve:

Analytical Process: key Points

1 Global Acute Malnutrition (weight for height <-2 Z score/oedema), IPC Vs 2, Nov 2011.2 Severe Acute Malnutrition (weight for height <-3 Z score/oedema): Thresholds derived from quintile distribution of SAM from 250

SMART survey datasets at FSNAU, January 20123 Bilateral oedema is riverine livelihood specific indicator rather than for the whole country4 Refs: i). Sphere 2004; ii). Emergency Field Handbook (A guide for UNICEF staff, pg 139) July 20055 WHO and Integrated Food Security Phase Classification Technical Manual Version 2.0, Final Draft, November 2011. Technical

consultations6 Mid Upper Arm Circumference, data source – rapid assessments, based on children 6-59 months: Thresholds derived from

quintile distribution of SAM from 200 SMART survey datasets at FSNAU, January 20127 Follow up with S. Collins study/ Mike Golden/ Mark Myatt and on-going studies8 Review of Nutrition and Mortality Indicators for the Integrated Food Security Phase Classification, Helen Young and Susanne

Jaspars, Sept 20099 Thresholds for adult MUAC (pregnant/lactating and non-pregnant women) derived from quintile distribution of MUAC data from

99 SMART survey datasets at FSNAU10 WHO Expert Committee, 199511 WHO Expert Committee, 199512 Health Information System, data source – health facilities13 Data source, over 120 sentinel sites in different livelihoods in South Central Somalia14 Data source, nutrition surveys, dietary studies and sentinel sites15 Data source, nutrition surveys, Health Information System, Sentinel sites, feeding centers, rapid assessments16 Data source, nutrition surveys and dietary studies17 WHO 2008. Indicators for assessing infant and young child feeding practices. 2-3 feeds recommended for 6-8 months old, &

3-4 feeds for 9months old and above18 WHO 2008. Indicators for assessing infant and young child feeding practices19 FANTA 2003. Generating indicators of appropriate feeding of children 6 through 23 months from the kPC 2000+ WHO, 2003. Infant and young child feeding. A tool for assessing national practices, policies and programmes20 WHO references21 Data source, 12 Therapeutic Feeding Centers (TFC) and 14 Supplementary Feeding Centers (SFC)

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Map 6: Gedo region livelihood Systems

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figure 6: trend in level of Acute Malnutrition (WhZ<-2 or oedema, Who 2006) in Gedo region, 2006-2012

4.1 GedO ReGiOn

Gedo region in southwest Somalia administratively comprises of six districts: Luuq, Dolo, Belet Hawa, Garbaharey, El Wak, and bardera, see Map 6. Gedo region has three main rural livelihood zones namely: pastoral, agro-pastoral and riverine (Juba riverine pump irrigation). The pastoral livelihood, is further sub-divided into the Southern Inland and Dawa pastoralists. The Dawa pastoral livelihood zone located in northern Gedo is the largest pastoral group in the region rearing mainly cattle, a few sheep, goats and camel. The Southern Inland pastoral population is located in southern Gedo and mainly keep camel besides a few sheep and goats. The agro-pastoral population is divided into Southern agro-pastoral and bay, bakool and Gedo agro-pastoral - the sorghum high potential. Figure 6 indicates the historical trends of acute malnutrition in Gedo since 2006.

historical overview - Post Deyr ‘11/12

Food SecurityThe FSNAU Post Deyr ‘11/12 integrated food security analysis classified both rural and urban livelihoods of Gedo region to be either in crisis or Emergency. In the rural livelihoods, the crisis phase was identified mainly among the southern agro-pastoral, southern inland pastoral, Juba Pump Irrigated and Dawa pastoralists. An estimated 32,000 people in the urban livelihoods were identified in crisis, while an estimated 11,000 people of the riverine livelihood (Juba riverine pump irrigation) were identified to be in Emergency. However, the overall food security situation in Gedo region showed an improvement, with the exception of the riverine livelihood which was affected by flash floods and remained in Emergency. The general improvement of the food security situation was due to a number of factors: good cereal and cash crop harvest, in addition to improved terms of trade (ToT) for local goat to cereal, increased access to humanitarian interventions and improved livestock body conditions. Good off-season maize harvests from the riverine areas, together with average camel milk production, increased livestock prices and household income also contributed to the improved food security situation in the region.

NutritionThe Post Deyr ’11/12 integrated nutrition situation analysis of Gedo region using data from health and feeding (SFP/OTP) facilities, indicated a sustained likely Very Critical nutrition situation across all the three (agro-pastoral, pastoral and riverine) livelihood populations of Gedo region. However, triangulation of data from health and feeding facilities in Gedo region indicated an improvement in levels

of acute malnutrition compared to the Gu ’11 season. These improvements were mainly linked to the enhanced food security situation and humanitarian response in the region. Nevertheless, the nutrition situation remained of concern and was generally linked to seasonal outbreaks of acute watery diarrhea AWD, cholera, malaria, measles and whooping cough.

current Situation-Post Gu‘12

Food SecurityThe FSNAU Post Gu ‘12 integrated food security analysis classifies both rural and urban livelihoods of Gedo region as either Stressed or in crisis. In the rural livelihoods, the crisis phase is mainly identified among the Gedo agro-pastoral high potential,and Juba Pump Irrigated livelihood zones. However, the overall food security situation in Gedo region shows an improvement from the respective crisis and Emegency in Deyr ‘11/12 due to a number of factors: good cereal and cash crop harvest, in addition to improved terms of trade (ToT) for cereal to local goat, increased

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figure 7: hiS Malnutrition trends in Gedo Agropastoral Mchs - 2011-12

access to humanitarian interventions, improved livestock body conditions and the anticipated good off-season maize harvests from riverine areas. Average camel milk production, increased in livestock prices and household income has also contributed to the improved food security situation.

Nutrition No surveys were conducted in Southern Gedo region due to inaccessibility as a result of civil insecurity, therefore the available data (from health and feeding facilities) is insufficient to make an overall nutrition situation estimation. The current Gu’12 integrated nutrition situation analysis of Northern Gedo region depicts a sustained Very Critical nutrition situation among the pastoral and riverine populations.

Nutrition assessments conducted in May ’12 in Northern Gedo region indicate elevated levels of acute malnutrition with GAM and SAM rates of 28.4% (23.0-34.5) and 6.2% (4.4-8.7) respectively in the Dawa pastoral, and GAM and SAM rates of 22.5% (19.2-26.1) and 6.1% (4.3-8.9) respectively, reported in the riverine livelihood zone. Data from health facilities from January to July 2012 in the pastoral, agro-pastoral (Figure 7) and riverine livelihood zones of Northern Gedo region, indicate a high (>20%) and decreasing trend of acutely malnourished children. Analysis of data from feeding facilities in Northern Gedo region indicates a decline in levels of acute malnutrition compared to the Deyr’11/12 season. The analysis indicates a sustained Very Critical nutrition situation in the two livelihoods in Nothern Gedo region. There was no statistically significant difference in the proportion of boys and girls acutely malnourished in both surveys (p> 0.05). The 90 days retrospective crude death rates is Serious among both the pastoral (0.59/10,000/day) and riverine (0.20/10,000/day) populations according to UNICEF classification. The respective U5 death rates 1.36 (0.77-2.36) and 1.60 (0.57-2.32) in pastoral and riverine livelihoods are also in Serious phase (Table 5).

The nutrition situation remains concerning, given the area is generally prone to seasonal outbreaks of AWD, cholera, malaria, measles and whooping cough. The situation is further aggravated by chronic underlying factors such as: household food insecurity, poor dietary quality, inadequate social and care environment (sub-optimal child care and feeding practices), and poor public health (limited access to basic human services such as safe water, health and sanitation facilities), which predispose the communities to high morbidity and subsequently high levels of acute malnutrition.

It is therefore crucial to initiate or continue interventions targeting the health and nutrition of the population and also address the underlying causes of food insecurity and disease, therefore close monitoring of the situation is crucial. The key reference nutrition indicators used for analysis are

provided in Table 5.dolow idPsAn exhaustive nutrition survey conducted among the Dolow IDPs in July 2012 reports a GAM rate of 25.9% and a SAM rate of 7.5%,which indicates a Very Critical nutrition situation. The 90 days retrospective crude and under five death rates reported are 0.60 and 0.81 per 10,000/day indicating an Alert situation according to UNICEF 2005 classification. Overall, the nutrition situation among the Dolow IDPs is Very Critical, and the population remains highly vulnerable due to the direct impact of household food insecurity and the high disease burden in the town, further aggravated by limited access to health services. Results further indicated that a high proportion of the children assessed in the survey had fallen ill two weeks prior to the survey.

The overall rate of morbidity reported is 36.7%. The proportion of children reported to have suffered from diarrhoea in the 2 weeks prior to the assessment is 18.4%, while those suffering from suspected pneumonia and measles is lower at 7.8% and 0.5% respectively. The measles immunization and vitamin A supplementation status for the assessed children in the 6 months prior to the assessment is high (89.4% and 90.9% respectively), however still below the recommended Sphere standards of 95%.

In addition chronic underlying factors that affect the nutritional status of the population persist such as; poor child care and feeding practices, inadequate sanitation facilities and lack of access to safe drinking water remain as long term challenges to the health and nutrition well- being of the population. It is therefore crucial to initiate or continue interventions targeting the health and nutrition of the population and also address the underlying causes of food insecurity and disease.

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Gedo Pastoral (N=694, Boys=339 ,Girls=335)

Gedo Riverine(N=757, Boys=397, Girls=360)

Dolow IDPs (N= 974 Boys=470, Girls=504)

Indicator Results Outcome Results Outcome Results OutcomeChild Nutrition StatusGlobal Acute Malnutrition (WHZ<-2 or oedema)BoysGirls

28.4 (23.0-34.5)31.0 (23.2-40.0)25.9 (21.0-31.5)

Very Critical22.5 (19.2-26.1)26.7 (22.6-31.3)17.8 (14.1-22.1)

Very Critical25.931.121.0

Very Critical

Severe Acute Malnutrition (WHZ<-3 or oedema)BoysGirls

6.2 (4.4-8.7)6.2 (3.6-10.4)6.2 (3.6-10.3)

Very Critical6.1 (1.3-8.9)7.8 (5.6-10.9)4.2 (2.1-8.0)


Very Critical

Mean of Weight for Height Z Scores -1.30±1.11 Very Critical -1.16±1.11 Very Critical -1.26±1.12 Very CriticalOedema 0.7 Very Critical 0 0.8 Very CriticalGlobal Acute Malnutrition (NCHS) 26.3 (20.5-33.1) Very Critical 22.9 (19.1-27.3) Very Critical 23.9 Very CriticalSevere Acute Malnutrition (NCHS) 2.1 (1.1-4.0) Acceptable 3.9 (2.5-6.2) Serious 5.1 CriticalProportion with MUAC (<12.5 cm or oedema)BoysGirls

7.0 (5.1-9.4)5.8 (3.9-8.6)8.1 (5.4-11.9)

Serious9.2 (6.4-12.9)7.0 (4.8-10.2)11.5 (7.0-18.2)

Critical13.814.013.5

Very Critical

Proportion with MUAC (<11.5 cm or oedema)BoysGirls

2.1 (1.3-3.5)2.3 (1.1-5.0)1.9 (1.0-3.9)

Critical0.9 (0.4-2.3)0.5 (0.1-2.1)1.4 (0.5-3.9)

Acceptable3.03.32.7

Critical

Stunting (HAZ<-2)BoysGirls

17.6 (13.9-22.0)15.4 (11.5-20.5)19.6 (14.1-26.6)

Critical19.0 (14.8-24.0)20.6 (15.3-27.2)17.1 (12.8-22.6)


Critical

Underweight (WAZ<-2)BoysGirls

23.1 (17.4-30.1)24.4 (17.0-33.8)21.9 (16.5-28.5)

Serious21.0 (17.2-25.5)23.6 (18.7-29.3)18.2 (13.7-23.7)

Serious31.634.628.7

Critical

HIS Nutrition Trends ( January –July 2012)

High (>30%) levels and increasing trends Very Critical High (>30%) levels and

increasing trends Very Critical

High (>30%) levels and increasing trends

Very Critical

Child Morbidity & Immunization

Disease trends (seasonally adjusted)Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey

Morbidity-29.2 (19.9-38.6)Boys 27.6 ;Girls-30.7

Diarrohea-10.2Boys-9.9; Girls -10.5 Pneumonia- 10.5 Boys 9.0 ;Girls 11.9

Measles-0.4 Boys- 0.5; Girls 0.2

Very Critical

Morbidity-25.9 (18.2-33.5)Boys-25.0;Girls-26.8

Diarrohea-10.3;Boys 9.2 Girls 11.5 Pneumonia-8.7 Boys-9.2 ;Girls 8.2

Measles0.3 Boys-0;Girls-0.8

Very Critical

Morbidity-36.7Boys-35.5;Girls-37.8

Diarroh-18.4Boys 18.7;Girls 18.1Pneumonia -7.8Boys 7.6;Girls 8.0

Measles-0.5Boys-0.2;Girls -0.7

Very Critical

Immunization

Vitamin A-93.8 Boys-95 :Girls-92.7

Measl-93.1Boys-95 .0;Girls-91.4 )

Alert

Vitamin A-93.1 Boys-93.2 :Girls-93.1

Measles-88.4:Boys-89.4; Girls-89.5

Alert

Vitamin A-90.8Boys-91.9;Girls-90.6

Measles-89.5Boys-89.9;Girls-89.2

Alert

Death RatesCrude deaths, per 10,000 per day (retrospective for 90 days)

0.59 (0.35-1.01) Serious 0.2 (0.11-2.32) Acceptable 0.60 Serious

Under five deaths, per 10,000 per day (retrospective for 90 days)

1.36 (0.77-2.36) Serious 1.6 (0.57-2.32) Serious 0.80 Alert

Pregnant and lactating women (MUAC <23.0 cm) 30(24.0-37.7) Critical 24.9(19.4-30.4) Critical 24.1(18.030.2) Critical

Pregnant and lactating women (MUAC <21.0 cm) 24.1(18.030.2) 4.3(2.6-6.1) 4.8(3.5-6.1)

Non pregnant and lactating women (MUAC <18.5 cm) 0 Acceptable 0.6(0.0-16) Acceptable 4.8(3.5-6.1) Serious

Food security phase Stressed Serious Stressed/Crisis Serious Stressed/Crisis Serious

Overall Risk to Deterioration Stable Stable Stable

Overall Situation Analysis Very Critical Very Critical Very Critical

table 5: Summary of key nutrition findings in Gedo livelihood Zones, May 2012

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Gender and nutrition analysis in Gedo region

Nutrition assessments conducted in two livelihoods zones of Northern Gedo region recorded a higher proportion of acutely malnourished boys than girls in the pastoral (31% vs 25.9%) and riverine (26.7% vs 17.8%) livelihoods. Similarly, a higher proportion of acutely malnourished boys than girls are observed in the Dolow IDPs (31.1% vs 21 %). However, these differences are not statistically significant (Pr<75%). Similar patterns are more or less observed in the other forms of malnutrition where in the pastoral livelihood, 15.4% of boys compared to 19.6% of girls were stunted; and 24.4% of boys as compared to 21.9% of girls were underweight. In the riverine livelihood 20.6% of boys compared to 17.1% of girls were stunted; and 23.6% of boys as compared to 18.2% of girls were underweight. In the Dolow IDPs, 29.3% of boys compared to 30.4% of girls were stunted; and 34.6% of boys as opposed to 28.7% of girls were underweight. A higher proportion of girls than boys were reportedly ill two weeks prior to the assessment in the pastoral, agro-pastoral and riverine populations. However, there is no statistically significant difference between the sexes showing that they were both equally affected (Pr<75%). The gender disaggregated results of the assessed children is summarized on Tables 6 and 7.

Dowlo IDPs(N=974, Boys=470, Girls=504)

Indicator Results OutcomeChild Nutrition StatusGlobal Acute Malnutrition (WHZ<-2 or oedema) 153Boys :Girls

25.931.121.0

Very Critical


7.59.60.8

Very Critical

Mean of Weight for Height Z Scores -1.26 ±1.12 Very CriticalOedema 0.80 Very Critical

Global Acute Malnutrition (NCHS) 23.9 Very CriticalSevere Acute Malnutrition (NCHS) 5.1 CriticalGlobal Acute malnutrition by MUAC (<12.5 cm or oedema)BoysGirls

13.81413.5

Serious

Severe Acute malnutrition by MUAC (<11.5 cm or oedema)BoysGirls

33.32.7

Critical


29.829.330.4

Critical


31.634.628.7

Critical

HIS Nutrition Trends (July- December 2011)Child Morbidity & Immunization

Disease trends (seasonally adjusted)

Morb-36.7Boys- 35.5Girls-37.8

Diarrohea-18.4Boys-18.7Girls-18.1

Pneum-7.8Boys 7.6Girls 8.0

Measle-0.5Boys-0.2Girls- 8.0

Very Critical

Death RatesCrude deaths, per 10,000 per day (retrospective for 90 days) 0.60 SeriousUnder five deaths, per 10,000 per day (retrospective for 90 days) 0.80 AlertFood security phase Crisis Very CriticalOverall Risk to Deterioration UnstableOverall Situation Analysis Very Critical

table 6: Summary of key nutrition findings in dowlo idPs May 2012

Gedo region

Pregnant and Lactating Women Non-pregnant and Lactating women

No.Assessed

Proportion with MUAC<23cm(%)

Proportionwith MUAC<21cm(%)

No.Assessed

Proportion with MUAC<18.5cm(%)

North Riverine 389 24.9(19.4-30.4) 4.3(2.6-6.1) 162 0.6 (0.0-16)

Dawo Pastoral 396 30 (24.0-37.7) 2.3(0.6-3.8) 189 0

Dollow IDPs 373 24.1(18.030.2) 4.8(3.5-6.1) 373 4.8(3.5-6.1)

Maternal nutrition status in Gedo regionIn the pastoral and riverine livelihoods of Northern Gedo and among the Dolow IDPs, a significantly higher proportion of pregnant and/or lactating women were acutely malnourished (MUAC< 23.0 cm, and 21.0 cm, and/or bilateral oedema) than non-pregnant and non-lactating women (MUAC<18.5). The proportion of acutely malnourished pregnant and/or lactating women ranged between 24.1% (Serious) among the Dolow IDPs population to 30% (Critical) in the Dawo pastoral livelihood. The maternal malnutrition in Dolow IDPs is Critical among the pregnant and lactating women, with 24% of the assessed women recording MUAC measurements of <23cm. The high levels of acute malnutrition among the pregnant and/or lactating women is linked to increased nutrient needs during these periods which may not be met.

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figure 8: trend in levels of Acute Malnutrition (WhZ <-2Z scores or oedema, Who 2006), Juba regions 2007 - 2012

NutritionThe nutrition situation of the Middle and Lower Juba pastoral, agro-pastoral, and riverine livelihood populations has been in a sustained Very Critical phase since Deyr ‘10/11. However, a significant reduction in the GAM and SAM rates of the three livelihoods was recorded compared to the Gu ’11. The poor nutrition situation in Juba regions was mainly linked to food insecurity exacerbated by high morbidity. The consecutive seasons of poor rainfall performance experienced in the regions led to poor crop and livestock production as well as high livestock deaths, especially cattle, sheep and goats, resulting in limited access to milk and diversified foods at household level. The reduced humanitarian interventions (health and nutrition services) and recurrent civil insecurity in the area was a major concern, especially since high morbidity remains a major risk factor to acute malnutrition. Figure 8 indicates the historical trends of acute malnutrition in Middle and Juba Regions since 2007.

4.2 MiddLe and LOWeR Juba ReGiOnS

Middle and Lower Juba regions have three main rural livelihood zones namely: the pastoral (the Southern Inland and Southeast Pastoralists), agro-pastoral (Lower Juba and Southern Agro-pastoral) and the Riverine communities who are purely agriculturalists. The Juba regions in southern Somalia have a total of seven districts namely: Sakow, buale and Jilib in Middle Juba, and Jamame, Afmadow, kismayo and badhadhe in Lower Juba see Map 7.

The food security and nutrition situation in the Juba regions has varied over time and has largely been linked to rainfall performance and its resultant impacts on the different livelihood systems. Heavy rainfall in the Juba regions or in the Ethiopian highlands often results in floods that devastate crop cultivation and sanitation facilities in the riverine areas, however, the riverine communities’ later benefit from recessional cropping from the Desheks and fishing opportunities from the flood waters. The agro-pastoral communities, who rely on rain-fed agriculture, are totally dependent on rainfall and so are the pastoralists, whose livelihood is greatly influenced by water and pasture conditions.


Food Security

The FSNAU Post Deyr ’11/12 analysis classified the food security situation of rural livelihoods of Juba regions in three phases: crisis, Emergency and Stressed and the urban populations in either Emergency or Stressed. A total of 169,000 people were in crisis and in need of humanitarian assistance and livelihood support. Out of these, 74,000 people in the two regions were in a state of crisis (35,000 in M/Juba and 39,000 in L/Juba). While another 95,000 were identified to be in Emergency (50,000 in M/Juba and 45,000 in L/Juba). The population facing food insecurity declined by 43% in the Deyr ‘11/12 (169,000) when compared with 295,000 in Gu ‘11. In addition, 20,000 people in both regions were identified to be Stressed (7,000 in M/Juba and 13,000 in L/Juba). In the urban livelihood in both regions, 69,000 people were identified to be in crisis with 26,000 in M/Juba and 43,000 in L/Juba in either Emergency or crisis. The situation of the riverine population in Middle and Lower Juba regions was critical due to the combined impacts of the previous droughts and severe flooding in Deyr ‘11/12 season, which resulted in total maize crop failure.

Map 7: Juba regions livelihood Zones

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current Situation - Post Gu ‘12

Food Security

The food security situation in Juba regions shows some improvements since Deyr ‘11/12. Currently, a portion of the Lower Juba agro-pastoral population (25% of Poor) is identified in Emergency, while the South-East Pastoral, Southern Agro-pastoral and Juba riverine livelihoods in both Lower and Middle Juba regions are identified to be in crisis. Significant improvements are visible in the Southern Inland Pastoral (camel herders) population, which are classified as Stressed. The positive changes discerned in the food security situations are largely attributable to the effects of previous Deyr ‘11/12 season which improved overall rangeland conditions, resulting in improved livestock body conditions and market value. Despite the above improvements in parts of Juba region, substantial food and income gaps still exist in most of the major livelihoods. Civil insecurity and closure of kismayo port activities have resulted in low trade activities and loss of employments from charcoal exports.

Nutrition Situation

Three comprehensive nutrition surveys conducted in July 2012 among the pastoral, agro-pastoral and riverine livelihoods of Juba region indicate a sustained Very Critical nutrition situation in the agro-pastoral and riverine populations but an improvement to a Critical phase among the pastoral. Survey findings recorded a GAM rate of 15.8% (11.8-20.7), 25.1% (22.2-28.3) and 21.1% (17.7-24.8) among the pastoral, agro-pastoral and riverine populations respectively. The SAM rates reported in the three livelihood zones were 2.1% (1.0-4.4), 5.8% (4.4-7.7) and 6.6% (5.0-8.7) in the pastoral, agro-pastoral and riverine livelihoods respectively.

Among the riverine population of Juba, these findings indicate a Very Critical nutrition situation, an improvement from the Extreme nutrition situation reported in the Deyr ‘11/12 season. This is a significant improvement (p<0.05) in the GAM and SAM rates observed in the October ’11 survey that reported GAM and SAM rates of 34.5% (29.9-39.5) and 11.8% (9.4-14.8) respectively. The 90 day retrospective crude and under five death rates are 0.20 (0.11-0.42 ) and 1.16 (0.57-2.32) respectively, indicating Acceptable and Alert situations (UNICEF 2005).

Among the pastoral population, a GAM rate of 15.8% (11.8-20.7) and a SAM rate of 2.1% (1.0- 4.4) is Critical, and when compared to the October ‘11 GAM and SAM rates of 27.3% (23.0-32.0) and 9.5% (7.1-12.8) respectively, illustrates an improvement from a Very Critical nutrition situation, with a significant decline in acute malnutrition rates (p<0.05). The crude and under five death rates are 0.44 (0.20-0.99) and 0.81 (0.29-2.27) respectively, indicating Acceptable and Alert situations. (UNICEF 2005).

The agro-pastoral population reported a GAM rate of 25.1% (22.2-28.3) and SAM rate of 5.8% (4.4-7.7), indicating a sustained Very Critical nutrition situation since Deyr ‘11/12. A comparison with the previous GAM rate of 26.1% (22.4-30.1) and SAM rate of 9.1% (7.1-11.5) reported in October ‘11 indicates no significant change (p>0.05). The 90 day retrospective crude and under five death rates reported in July 2012 are 0.25 (0.07-0.88 ) and 0.85 (0.41- 1.78) respectively, indicating acceptable and alert situations (UNICEF 2005)1. Nutrition data from health facilities in the Juba riverine, pastoral and agro-pastoral livelihoods all indicate high numbers (>30%) and an increasing trend of acutely malnourished children Figure 9 show the malnutrition trend in health facilities in agro-pastoral areas.

Close monitoring of the food security and nutrition situation will be crucial in the Juba population. The population still remain highly vulnerable to shocks and the current risk factors are: reduced access to humanitarian services, high morbidity burden- reported AWD and measles outbreaks , poor access to health care services and sanitation, sub-optimal child feeding and care practices which all have a direct impact on the health and nutritional status of children, therefore close monitoring of the situation is crucial. The key reference nutrition indicators used for analysis are provided in Table 7.

1 UNICEF, 2005: The Emergency Field Handbook. A guide for UNICEF staff. (pg 139), July 2005. Retrieved March 5, 2012 at http://www.unicef.org/lac/emergency_handbook.pdf.

figure 9: hiS Malnutrition trends in Juba agro-pastoral Mchs 2010-2011

Data Source: Muslim AID Uk, MSF and SCRCS

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Juba Pastoral (n=520, boys=261 ,Girls=259)

Juba Agro-pastoral (n=773, boys=369, Girls=404)

Juba riverine (n= 817 boys=381, Girls=436)

indicator results outcome results outcome results outcomeChild Nutrition StatusGlobal Acute Malnutrition (WHZ<-2 or oedema)boysGirls

15.8 (11.8-20.7)17.6 (13.0-23.4)13.9 (8.9-21.0)

Critical25.1 (22.2-28.3)30.9 (26.4-35.8)19.8 (16.2-24.0)

Very Critical21.1 (17.7-24.8)27.8 (22.6-33.7)15.1 (12.1-18.8)

Very Critical

Severe Acute Malnutrition (WHZ<-3 or oedema)boysGirls

2.1 (1.0-4.4)2.7 (1.2-5.9)1.5 (0.6-3.8)

Acceptable5.8 (4.4-7.7)6.8 (4.6-9.8)5.0 (3.2-7.5)

Critical6.6 (5.0-8.7)8.9 (6.2-12.7)4.6 (2.8-7.4)

Very Critical

Mean of Weight for Height Z Scores -0.78±1.09 Serious -1.22±1.11 Very Critical -1.20±1.06 Very CriticalOedema 1.5 Very Critical 0.8 Very Critical 0.7 Very CriticalGlobal Acute Malnutrition (NCHS) 14 (10.6-18.1) Serious 19.6 (17.0-22.6) Critical 18.8 (15.6-22.4) CriticalSevere Acute Malnutrition (NCHS) 2.1 (1.0-4.3) Acceptable 2.8 (1.9-4.3) Alert 2.4 (1.5-3.9) AcceptableProportion with MUAC (<12.5 cm or oedema)boysGirls

18.1 (12.2-26.1)17 (11.1-25.1)

19.2 (12.1-29.1)Very Critical

16.1 (13.7-18.8)15.3 (12.0-19.3)16.9 (13.6-20.8)

Very Critical14.6 (6.6-29.5)15.9 (6.8-32.8)13.5 (5.9-28.0)

Very Critical

Proportion with MUAC (<11.5 cm or oedemaboysGirls

4 (2.4-6.5)4.5 (2.4-8.5)3.5 (1.7-6.8)

Very Critical2 (1.3-3.3)

11.1 (0.4-2.7)2.9 (1.7-5.0)

Very Critical3.2 (0.8-12.1)3.3 (0.8-13.0)3.2 (0.8-11.5)

Very Critical

Stunting (HAZ<-2)boysGirls

24 (19.1-29.6)29.1 (21.6-38.0)18.9 (14.3-24.5)

Critical28.0 (24.9-31.3)33.1 (28.4-38.1)23.4 (19.5-27.8)

Critical27.8 (24.3-31.5)34.2 (30.2-38.4)22.2 (17.5-27.8)

Critical

Underweight (WAZ<-2)boysGirls

19.9 (15.3-25.4)23.8 (17.3-31.9)16 (11.3-22.1)

Alert33.4 (30.2-36.8)44.4 (39.4-49.5)23.4 (19.5-27.8)

Critical34.5 (30.3-38.9)44.1 (38.8-49.6)26 (21.6-31.0)

Critical

HIS Nutrition Trends ( January- July 2012)

High (>30%) levels and increasing

trendsVery Critical High (>30%) levels and

increasing trends Very CriticalHigh (>30%) levels

and increasing trends

Very Critical



Morb-31.1 (24.3-37.9)boys 32.6 ;Girl- 30.1

Diarr-11.9boys-14.3;Girls10.3

Pneumonia-7.6boys 5.4 ;Girls 9.0

Measles 2.1 boys 1.9 ;Girls 2.2

Very Critical

Morb-16.7 (13.1-20.3)boys 17.5;Girls-16

Diarr-9.6 boys 7.9;Girls11.1

Pneumonia -0.3 boys 0.2;Girls 0.4

Measles-0.7 boys 0.2 ;Girls 1.2

Very Critical

Morb-42.4 (6.8-28.6)boys 42.4; Girls 42.4

Diarr-8.7 boys 8.4;Girls 9.0

Pneumonia-8.0 boys 7.4 ;Girls 8.5

Measles 0.8 boys 0.9 ;Girls 0.6

Very Critical

Death RatesCrude deaths, per 10,000 per day (retrospective for 90 days) 0.44 (0.20-0.99) Acceptable 0.25 (0.07-0.88) Acceptable 0.20 (0.11-0.42) Acceptable

Under five deaths, per 10,000 per day (retrospective for 90 days) 0.81 (0.29-2.27) Alert 0.85 (0.41-1.78) Alert 1.16 (0.57-2.32) Critical

Pregnant and lactating women MuAc <23.0 cm 43.0(32-54) Very Critical 26.3(18.8 -34.2) Very Critical 26.3(18.8 -34.2) Very Critical

Pregnant and lactating women MuAc <21.0 cm 23.3(15.7-31.0) 3.0(0.7-5.2) 3.0(0.7-5.2)

non pregnant and lactating women MuAc <18.5 cm 16.3(13.0-19.7) Alert 4.7(2.2-7.2) Serious 0.7(0.0-2.2) Serious

food security phase Stressed Serious Crisis Serious Crisis SeriousOverall Risk to Deterioration Unstable Unstable Unstableoverall Situation Analysis Critical very critical very critical

table 7: Summary of key nutrition findings in Juba livelihood Zones, July 2012

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kismayo idPs (n=547, boys=277, Girls=270)

dobley idPsn=781, boys=392, Girls=389

indicator results outcome results outcomeChild Nutrition Status

Global Acute Malnutrition (WHZ<-2 or oedema) 153boys :Girls

28(24.6-31.4)32 (26.7-38.0)23.7(18.6-29.7)

Very Critical 222519

Very Critical

Severe Acute Malnutrition (WHZ<-3 or oedema)boysGirls

8.2 (5.7-11.78.7(5.7-12.9)7.8(4.6-12.9)

Very Critical7.6 9.2 5.9

Very Critical

Mean of Weight for Height Z ScoresOedema -1.45 ±0.92 -0.95±1.19Global Acute Malnutrition (NCHS) 23.8 (20.6-27.3) Very Critical 20.6 Very CriticalSevere Acute Malnutrition (NCHS) 4.2 (2.3-7.3) Serious 4.1 Serious

Global Acute malnutrition by MUAC (<12.5 cm or oedema)boysGirls

11.3 (8.5-14.9)11.7 (8.2-16.4)10.9( 7.3-16)


Very Critical

Severe Acute malnutrition by MUAC (<11.5 cm or oedemaboysGirls

4.5 ( 2.6-7.6)3.9 (1.8-8.1)5.1 ( 2.9-8.9)


Very Critical

Stunting (HAZ<-2)boysGirls

35.1 (31.8-38.5)38.5 (33.3-44.1)31.4(27.1-36.2)


Critical

Underweight (WAZ<-2)boysGirls

40.4 (36.2-44.8)45.6 (39.5-51.8)35.1 (30.3-40.2)


Critical

HIS Nutrition Trends (January - July 2012)Child Morbidity & Immunization

Disease trends (seasonally adjusted)

Morbidity 18.6 (13.7-24.4)boys 19.3 (13.9-24.7)Girls 17.8 (11.2-24.4)

Diarrohea 12 ( 9.1-15.0)boys 11.9 (7.3-16.2)Girls 12.1 8-16.2)

Pneum-2.6 ( 0-6.2)boys 2.8 ( 0-6.5)Girls 2.5 (0-6.2)

Meas-1.4 ( 0.3-2.4)boys1 ( 0-2.2)Girls 1.7 ( 0-3.5)

Critical

Morbidity 49.6 boys 49.7 Girls 49.5

Diarrohea- 27 boys 27 Girls 26.9

Pneum- 23.4 boys 22.7 Girls 24.1

Measle- 2.3 boys 1.8 Girls 2.8

Very Critical

Immunization Status

Vita A- N/AboysGirls

Measles – N/AboysGirls

N/A

Vita A-43.0boys 44.4Girls 41.6

Measles-40.1boys 41.2Girls 39.1

Very Critical

Death RatesCrude deaths, per 10,000 per day (retrospective for 90 days) 0.27 (0.13-0.55) Acceptable 0.32 AcceptableUnder five deaths, per 10,000 per day (retrospective for 90 days) 1.71 (1.08-2.71) Serious 0.96 Alert

food security phase Crisis Serious Crisis Seriousoverall risk to deterioration Unstable Unstableoverall Situation Analysis very critical very critical

kismayo and dhobley idPs

The nutrition situation of the internally displaced population in Kismayo Town is classified as Very Critical. A comprehensive nutrition survey conducted among the kismayo IDPs in July ‘12 reports a GAM rate of 28.0% (24.6-31.6) and a SAM rate of 8.2% (5.7-11.7) which indicates a sustained Very Critical nutrition situation. A survey conducted in October ‘11 survey reported a GAM rate of 26.7% (22.9-30.8) and a SAM rate of 9.5% (7.5-12.1), and thus there is no significant change

table 8: Summary of key nutrition findings in kismayo idPs July 2012

(p>0.05) in the nutrition situation. The 90 day retrospective crude and under five death rates are 0.27 (0.13-0.55) and 1.71 (1.08-2.71) respectively, both indicating Acceptable and Alert situations according to UNICEF (2005) classification. The worrying nutrition situation is mainly related to chronically poor food access, and high morbidity due to inadequate sanitation facilities and safe water and lack of health services.

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An exhaustive nutrition survey conducted among the Dhobley IDPs in July, 2012 reports a GAM rate of 22% and a SAM rate of 7.6% which indicates a Very Critical nutrition situation. The 90 days retrospective crude and under five death rates reported are 0.32 and 0.96 per 10,000/day indicating an Alert situation according to UNICEF (2005) classification. Overall, the nutrition situation among the Dhobley IDPs is Very Critical, and the population remains highly vulnerable due to the direct impact of household food insecurity and the high disease burden in the town, further aggravated by the limited access to health services. There is need for continued support to the displaced population in terms of targeted food supplementation, income-generating activities, health education, shelter improvement and continued immunization programmes and other development interventions to improve the health and nutrition situation of the vulnerable IDPs in Dobley town.

Gender and nutrition analysis in Juba region

The nutrition assessments conducted in the livelihood populations of Juba recorded a higher proportion of acutely malnourished boys than girls in the pastoral (17.6% vs 13.9%) and agro-pastoral (30.9% vs 19.8%) livelihoods. Similarly, a higher proportion of acutely malnourished boys than girls are observed in the riverine livelihoods (27.8% vs 15.1 %). These differences are statistically significant (p<0.05) among the boys and girls in the agro-pastoral and riverine livelihoods. In the pastoral livelihood, 29.1% of boys compared to 18.9% of girls were stunted; and 23.9 of boys as compared to 16% of girls were underweight. In the agro-pastoral livelihood ,33.1% of boys compared to 23.4% of girls were stunted; and 33.4% of boys as compared to 44.4% of girls were underweight, these differences are statistically significant (p<0,05). In the riverine livelihood, 34.2% of boys compared to 22.2% of girls were stunted; and 34.5% of boys as opposed to 44.1% of girls were underweight, therefore, these differences are statistically significant (p<0,05%). A higher proportion of boys than girls were reportedly ill two weeks prior to the assessment in the pastoral livelihoods while the proportions of girls and boys were similarly affected in the agro-pastoral and riverine populations. The gender disaggregated results of the assessed children is summarized on Tables 7 and 8.

Juba regionPregnant and Lactating Women Non-pregnant and Lactating women

No. Assessed Proportion with MUAC<23cm(%)

Proportion with MUAC<21cm(%) No. Assessed Proportion with

MUAC<18.5cm(%)Pastoral 135 43.0(32-54) 14.0(6.6-21.5) 526 16.3(13.0-19.7)

Agro-pastoral 304 46.7(38.8-54.6) 23.3(15.7-31.0) 148 4.7(2.2-7.2)

Riverine 369 26.3(18.8 -34.2) 3.0(0.7-5.2) 131 0.7(0.0-2.2)Dobley IDP 337 9.8(7.3-13.0) 8.3(5.7-11.9) 0 0Kiusmayo IDP 265 29.4(24-35.5) 9.1(5.9-13.2) 207 9.7(6.0-14.5)

Maternal nutrition status in Juba livelihoodIn the Juba livelihood, a significantly higher proportion of pregnant and/or lactating women were acutely malnourished (MUAC< 23.0 cm, and 21.0 cm, and/or bilateral oedema) than non-pregnant and non-lactating women (MUAC<18.5) across all the pastoral, agro-pastoral and riverine livelihoods in Juba region. The proportion of acutely malnourished pregnant and/or lactating women ranged between 9.8% (Acceptable) among the Dhobley IDPs to 46.7% (Very Critical) in agro-pastoral livelihood. The high levels of acute malnutrition among the pregnant and/or lactating women is linked to increased nutrients needs during these periods which may not be met.

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SuSTAiNEd hiGh LEvELS OF ACuTE mALNuTriTiON ACrOSS SOmALiA ANd KENyA BOrdEr

Seasonal rain failure is not unusual in the Horn of Africa negatively affecting the population’s livelihood systems in the region. Though all countries in the Horn of Africa are affected, the degree of severity varies depending on the governing structures and response mechanism in each country. Communities at the Somalia-Kenya-Ethiopia borders have experienced recurrent rainfall failure in the past ten years, which has hindered rain fed crop production among agro-pastoralists, and resulted in massive death of livestock among both agro-pastoralists and pastoralists. This has impacted negatively on the communities’ resilience over the years. The result includes food crises, alarming levels of acute malnutrition and mortality.

Nutrition and mortality assessments conducted between January and July 2012 along the Kenya-Somalia border show high levels of acute malnutrition and at the same time reveal a severe humanitarian crisis in Somalia1.

Nutrition situation in Wajir and mandera - KenyaBetween January to July 2012, five representative nutrition surveys were conducted by UNICEF Kenya and other partners in North East Kenya, in the two districts of Wajir and Mandera. The results of a nutrition assessment conducted are as follows: • Wajir South: GAM rate of 23.1% (19,5-27.3), and SAM rates of 4.6% (3.5%-6.3%). The retrospective crude

and the under five death rates are 0.30 (0.13-0.68) and 0.54 (0.19-1.52).• Wajir West and North: GAM rates of 14.6% (11.9-17.8) and SAM rates of 2.2% (1.4%-3.5%). The retrospective

crude and the under five death rates are 1.0(0.51-2.03) and 0.49(0.27-0.89). These findings on acute malnutrition depict a Very Critical situation in Wajir South, and Serious nutrition situation in Wajir West and North. Death rates are within acceptable levels in Wajir South, but slightly elevated to Alert levels in Wajir West and North based on UNICEF 2005 classification.

• Mandera West: GAM rate of 16.2% (13-19.9), and SAM rates of 3.5% (1.9% - 6.4%). The crude and under five death rates are 0.41 (0.22-0.77), 0.67 (0.29-1.53) respectively.

• Mandera Central: GAM rate of 17.9% (14.9-21.4) and the SAM rates of 3.4% (2.1%-5.3%). The crude and under five death rates are 0.18 (0.07-0.43) 0.22 (0.05-0.87) respectively.

• Mandera North and East: GAM rate of 15.9% (13.2-19.1) and the SAM rates of 2.2% (1.4%-3.5%). The crude and under five death rates are 0.23 (0.12-0.44) and 0.8 (0.34-1.84) respectively.These results depict indicate a Critical nutrition situation across Mandera. The crude and under five death rates are nevertheless within the Acceptable - Alert phases respectively, based on UNICEF 2005 classification.

Nutrition situation in Gedo and Juba regions - SomaliaIn July 2012, representative nutrition surveys conducted in Gedo and Juba regions in Somalia by FSNAU and partners are indicate a Critical and Very Critical nutrition situation among the populations in the two regions. No surveys were conducted in Southern Gedo region due to inaccessibility as a result of civil insecurity, therefore the available data (from health and feeding facilities) is insufficient to make an overall nutrition situation estimation. Nutrition assessments conducted in May ’12 in Northern Gedo region indicate elevated levels of acute malnutrition with GAM and SAM rates of 28.4% (23.0-34.5) and 6.2% (4.4-8.7) respectively in the Dawa pastoral, and GAM and SAM rates of 22.5% (19.2-26.1) and 6.1% (4.3-8.9) respectively, reported in the riverine livelihood zone. The analysis indicates a sustained Very Critical nutrition situation in the two livelihoods in Nothern Gedo region.

1 FSNAU Nutrition Update, May-June 2012

nutrition SurvEy MAP

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map showing nutrition situation in Somalia-Kenya border regionsThree other comprehensive nutrition surveys conducted in July 2012 among the pastoral, agro-pastoral and riverine livelihoods of Juba region indicate a sustained Very Critical nutrition situation in the agro-pastoral and riverine populations but an improvement to a Critical situation among the pastoral. Survey findings recorded a GAM rate of 15.8% (11.8-20.7), 25.1% (22.2-28.3) and 21.1% (17.7-24.8) among the pastoral, agro-pastoral and riverine populations respectively. The SAM rates reported in the three livelihood zones were 2.1% (1.0-4.4), 5.8% (4.4-7.7) and 6.6% (5.0-8.7) in the pastoral, agro-pastoral and riverine livelihoods respectively.

Conclusion: These results in the Somalia side as well as the neighboring country in Kenya indicate Serious, Critical and very Critical nutrition situation. These findings clearly reflect the severity of nutrition situation in the cross-border communities largely due to poor food availability and household access which is as a result of the consecutive seasons of rain failure that adversely affected the livestock dependent population and insecurity. Lack of pasture and water has led to massive deaths of livestock, the main source of food and income for food and non-food items while the remaining livestock have out-migrated. Access to health, safe water and sanitation facilities in these areas are very limited leaving the population highly vulnerable to diseases, thereby aggravating the nutrition situation.

In the two border countries, it would be crucial to increase interventions on health and nutrition as well as food security. Rehabilitation of severely and malnourished children remains a priority in the short term to prevent any further deterioration. For a lasting solutions to the persistent problems of food and nutrition insecurity, longer term interventions in health, food and livelihoods are required.

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4 .3 bakOOL and bay ReGiOnS

bakool and bay regions are located in southwest Somalia. both regions have two predominant livelihood systems: the agro-pastoral, found in bay region and in the southern parts of bakool, and the pastoral found mainly in Elberde district of bakool region (referred herein as bakool pastoralists). Bakool region comprises of five districts namely Huddur (Huddur town is the regional capital), Wajid, Tieglow, Rabdure and Elberde. bay region comprises of four districts, namely baidoa, (baidoa town is the regional capital), Qansahdere, Dinsor and burhakaba (Map 8). The two regions have a high agricultural potential, with bay region serving as the sorghum basket for Somalia.

bakool region

historical overview Post Deyr ‘11/12 Food SecurityThe Post Deyr ‘11/12 analysis classified the food security of the population in bakool region as crisis. The total population in crisis was 140,000 which indicated a significant decrease by 30% from the Gu ‘11 season. Overall, the food security situation in the rural areas had indicated a significant improvement following above normal rains that had led to an improvement of both livestock and crop production. Cereal production in Bakool region significantly improved compared to previous seasons due to the above normal Deyr ’11/12 rainfall performance. Humanitarian assistance and remittances from relatives within Somalia and in the Diaspora also contributed to the significant increase in food access across all livelihoods.

Nutrition The Post Deyr ‘11/12 integrated nutrition analysis based on health and nutrition facilities data classified the nutrition situation in both agro-pastoral and pastoral livelihood zones of bakool region as likely Very Critical. Nutrition surveys conducted in both livelihood zones in October 2011 did not meet the required quality standards for publication. The trend of acute malnutrition from 2002-2012 is shown on Figure 10.

current Situation, Post Gu ‘12

Food securityThe current FSNAU Post Gu ’12 integrated food security analysis identifies the Bakool Southern Inland Pastoral in Stressed phase, an improvement from crisis in Deyr ‘11/12. The improvement in the food security situation in the Southern Inland Pastoral livelihood zone is mainly attributed to the positive impact of the Deyr ‘11/12 rainfall performance which improved access to income and food from livestock and related products, and to the increased access to humanitarian interventions in the region. The agro-pastoral livelihoods however remains in crisis due to the effect of below normal rain performance affecting crop production; low terms of trade (labor to sorghum), low agricultural labor opportunities; reduced supply of cereal from neighbouring regions and limited humanitarian interventions due to the high civil insecurity in the region. These factors have affected both availability and access to food.

Nutrition SituationThe Post Gu‘12 integrated nutrition situation analysis using data from nutrition assessments, health and feeding facilities classifies the nutrition situation of the Bakool pastoral population as Very Critical. A nutrition assessment conducted in June 2012 in the bakool pastoral livelihood zone reported a GAM rate of 26.2% (20.6-32.8) and a SAM rate of 5.7% (3.6- 9.1) including four (0.5%) oedema cases. A significantly higher (p<0.05) proportion of boys (31.4%) than girls (21.7%) are acutely malnourished. The results show a Very Critical nutrition situation but an improvement compared to the July ‘11 findings when GAM and SAM rates of 55.9% (50.6-61.2) and 20.4 (15.2-26.7) with three (7.4 %) oedema cases were reported. OTP admission in bakool region is and increasing since April 2012 (See figure 11) The mortality rates are within the acceptable UNICEF levels with crude death rates (CDR) of 0.31 (0.15-0.61), and under five death rate of 0.86 (0.43-1.73), a significant improvement from the mortality rates reported in July 2011 (CDR - 1.89 and U5DR - 5.06).

Map 8: bay and bakool regions livelihood Zones

figure 10: trend in levels of acute malnutrition (WhZ< -2 or oedema, Who 2006) bakool region, 2002- 2012

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The main causes of death reported through respondent’s recall are measles and malaria for the under fives and TB and malaria for adults.

Pockets of high malnutrition rates are noted in the following clusters/villages: Maroodicade, Buur Caliyow, Habaasha Inashurbad, Elbaid, Morabus , Nuhley, Hiirey and Wargarweyne all in Elberde district. The concerned villages are hosting an influx of IDPs from areas with high civil insecurity particularly Huddur and Rabdhure.

No assessment was conducted in the agro-pastoral livelihood of bakool region, therefore there is insufficient data to estimate the overall nutrition situation. However, data from health facilities indicates a high (>45%), and a stable trend of acutely malnourished children. The information from partners conducting feeding programmes in the area indicates high and fluctuating admission trends in the area. (Figure 12. )

Disease outbreaks continue with measles incidences being reported in Elberde, Huddur and Tieglow (WHO bulletin, June 2012). Though limited, humanitarian interventions in the form of blanket, targeted and outreach supplementary feeding programs by organizations such as WFP, UNICEF, EPHCO and DADO1, in parts of the agro-pastoral and pastoral livelihood zone may have assisted to mitigate the poor nutrition situation in bakool region. The support needs to be continued and expanded to cover more rural villages in both livelihoods.

1 Dareeyl Awareness and Development organization

table 9: Summary of key nutrition findings in bakool Pastoral livelihood zone - July 2012

figure 11: Admissions trends into otP programmes bakool 2012

Blanket supplementary feeding program(BSFP) in Bakool,July 2012

Bakool Pastoral June‘2012(N=732;Boys=341;Girls= 391)

Indicator Results OutcomeChild Nutrition StatusGlobal Acute Malnutrition (WHZ<-2 or oedema)BoysGirls

26.2 (20.6-32.8)31.4 (24.6-39.0)21.7 (15.7-29.3)

Very Critical


5.7 (3.6- 9.1)8.8 (5.0-14.9)3.1 (1.4- 6.6)

Critical

Mean of Weight for Height Z Scores -1.35±1.03 Very CriticalGlobal Acute Malnutrition (NCHS) 24.8 (20.1-30.2) Very CriticalSevere Acute Malnutrition (NCHS) 3.1 ( 1.8- 5.4) AlertProportion with MUAC<12.5 cm or oedemaBoysGirls

15.1 (11.7-19.3)17.3 (13.3-22.1)13.3 ( 9.2-18.7)

Very Critical

Proportion with MUAC<11.5 cm or oedemaBoysGirls

1.9 ( 1.1- 3.3)2.3 ( 1.2- 4.4)1.5 ( 0.5- 4.7)

Serious


23.9 (19.4-29.1)30.1 (24.6-36.2)18.6 (13.1-25.7)

Serious


28.1 (22.2-34.9)34.8 (28.0-42.3)22.3 (15.8-30.5)

Critical

Child Morbidity & ImmunizationDisease trends (seasonally adjusted)Morbid i ty refers to the p ropor t ion o f ch i ld ren reported to be ill in the 2 weeks prior to the survey

Morbidity- 46.9 Boys-49.7; Girls-44.4Diarrhoea – 18.8 Boys- 19.0 :Girls-18.6Pneumonia- 18.7Boys-19.0;Girls- 18.4

Very Critical

Immunization Status

Vitamin A – 47.4Boys-45.6; Girls- 48.9Measles Vacc –34.6 Boys-32.7;Girls-36.2

Very Critical


0.31 Acceptable


0.86 Acceptable

Women Nutrition Status N= 595Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm)

0.6 (0.01-1.7) Critical

Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0)

2.4 (0.7-4.0)


22.0 (17.5-26.5) Serious

Food security phase Stressed Serious

Overall Risk to Deterioration StableOverall Situation Analysis Very Critical

figure 12: trend in levels of Acute malnutrition (WhZ< -2 or oedema , Who 2006) bay Agropastoral , 2002- 2012

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bakool region: Pastoral livelihood

The food security situation of the bakool pastoral population has improved, however, the milk availability remains low currently, but is however projected to improve in the coming months. Although the food security outlook in the region is positive, the nutrition situation in bakool region is projected to be Very Critical in the coming months due to the persistent disease outbreaks, high morbidity and poor child care and feeding practices. In addition, the population remains vulnerable to the chronic aggravating factors affecting malnutrition such as food insecurity, limited access to safe water and sanitation facilities as well as limited humanitarian services (health, nutrition, wash and food). The population will require appropriate humanitarian interventions to improve and prevent further deterioration. Table 9 highlights the key findings of the nutrition situation analysis.

Gender and nutrition analysis in bakool regionsAlthough nutrition surveys conducted in the bakool pastoral livelihood appeared to indicate a higher proportion of boys than girls as acutely malnourished, this difference is not of statistical significance (p>0.05). Other child data such as illness, and immunization status, also do not show any clear differential proportions by gender. Analysis of the distribution of malnutrition cases assessed by MUAC measurements reflects a slightly higher proportion of girls (17.3%) than boys (13.3% ) as acutely malnourished with MUAC<12.5 cm or oedema. The gender disaggregated data of the assessed children is summarized on Table 9.

CASE STudy 1: A FAmiLy’S ExPEriENCE duriNG A huNGEr PEriOd, iN huddur diSTriCT

Huddur town is the headquarter for Bakool region in southern Somalia and is located 180 km northwest of Baidoa and 90 km from the Ethiopian border. It has two main livelihood zones: the pastoral rearing mainly camel, sheep/goat and cattle and the agro-pastoralist who practice cropping farming alongside keeping different types of livestock. Bakool agro-pastoral livelihood was among areas where famine was declared on July 2011. The famine resulted from prolonged drought following very poor Deyr ’10/11 and Gu ’11 rainfall performances, which led to crop failure, loss of livestock. This situation contributed to poor household access to food, milk and income through sales, amidst very limited humanitarian activity to mitigate the situation. The results were a humanitarian catastrophe with malnutrition levels in excess of 30%, crude death rates above 2 per 10,000 per day, and at the least, 20% of households unable to access food needs. The case study below exemplifies how some households coped with the famine situation. Afifa, 34, is a mother of three children- two boys and one daughter and stays with her husband Adam in Dudmaale village, east of Huddur town.

The family has a small farm from which in normal circumstances, they produce enough food for their own consumption and for income. However, the last two seasons of the drought have been very harsh and the family farm did not produce anything from their farm. Prior to the drought, the family had seven goats and one pack camel. During the drought period, cereal prices escalated and so many families employed asset stripping distress coping strategies including sales of livestock at throw away prices, to meet the basic food needs. Afifa’s family sold their last goat with her kid in January 2012. For several times, the husband had to borrow cereals and cash from a nearby Abak beday village . As the drought intensified, the pack camel became weak and fell sick and could not stand on its own (see photo). For this reason, they were also forced to cheaply dispose off the camel at the local butchery. Unlike other families tha are relatively better off, Afifa’s family lacks has no means to fetch water, firewood, and lacked transport to move the family to a new place.

The health status of the family members worsened. About seven months prior to the interview, the youngest child was reportedly suffering from an unknown disease, with symptoms of high fever, cough, pallor, and swelling in the abdomen.. Afifa sought medical assistance for her son from a local drug vendor, in Huddur town, and ended up with wrong subscriptions. After several visits, spending borrowed cash buying medicine that did not help her son, she sought help from a new clinic supported by Muslim Aid. The child was diagnosed with Leishmaniasis, also known as kala-azar. He was treated and followed up for three weeks.

Travelling from Dudumaale to Huddur everyday was very expensive, and family was forced to split. Adam and Afifa agreed that Adam stays with their son in Huddur and Afifa takes care of the other children in the village. This was at a time, the many roadblocks erected by armed groups restricted trade movements limiting businesses in Huddur town. The lorries, cars, and even donkey carts were not allowed to deliver food to Huddur town. Due to this, many women smuggle in food from the villages in order to make a living. Circumstances forced Afifa to join this group. It’s a risky business but the little money she earns is what the family survives on. The case study explains how the population in this district is coping with the drought situation, highlighting resilience from the famine and the extent to which they have exhausted their coping strategies and are in dire need of assistance.

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Bay Region

historical overview - fSnAu Post Deyr ‘11/12

Food security

The FSNAU Post Deyr ‘11/12 integrated food security analysis classified the agro-pastoral (low and high potential) livelihood zones of bay region in crisis phase, indicating an improvement from the respective famine phase in Gu ‘11. The improvement in bay region was mainly attributed to good crop production, improved income from livestock and improved purchasing power resulting from the good Deyr ‘11 rainfall performance. Additionally, humanitarian assistance (cash and food distribution) and social support mitigated the situation. Cereal production from Deyr‘11/12 season was estimated at 6,1390 MT which was 195% of post war average (PWA) compared to 8% in Deyr ‘10/11. It was the third highest Deyr cereal production in the region since 1995. The purchasing power of households had improved as a result of better terms of trade (ToT) of daily labour wage and red sorghum. In addition, ToT between local goats and red sorghum had shown an increase due to the reduced cereal prices and improved livestock prices.

Nutrition

The Post Deyr ‘11/12 integrated analysis of data from nutrition assessments2 conducted in bay region in October ‘11, in addition to data collected from health and feeding facilities indicated a sustained Extremely Critical nutrition situation. However, although the GAM rates remained above 30%, a significant reduction in GAM rates was recorded (Figure 13) compared to July ‘11 (GAM>50%).

current situation, Post Gu‘12

Food security

The FSNAU Post Gu’12 integrated food security analysis classifies the agro-pastoral (low and high potential) livelihood zones of bay region in sustained crisis, though with increased numbers in crisis. This worsening trend in the Gu ‘12 season is mainly attributed to poor crop production as a result of below normal rainfall and long dry spell, crop loss

2 The surveys were conducted jointly by FSNAU/UNICEF, Somalia Red Crescent Society (SCRS)

to crickets, in addition to low cereal stock availability for the poor and deterioration of wage rates due to the low agricultural labour. Cereal production in this Gu’12 season is well below average. It’s the second lowest Gu‘ cereal production in the region since 2005. However, terms of trade between livestock/cereals has mitigated the situation.

Nutrition

The Post Gu‘12 integrated nutrition situation analysis, using data from nutrition assessments, health and feeding facilities classifies the nutrition situation of the Bay agro-pastoral livelihood population as Very Critical, indicating an improvement from the Extreme levels in the Deyr ‘11/12. The nutrition situation of the IDPs from baidoa town, assessed for the first time, indicates a Critical nutrition situation.

A nutrition survey conducted in July ‘12 in the agro-pastoral livelihood zone of bay region reported a GAM rate of 20.4% (16.7-24.5) and a SAM rate of 6.9% (5.0-9.4) with nine (1.0 %) oedema cases. These rates show a Very Critical nutrition situation, although an improvement from the Extreme nutrition situation reported in the October ‘11, when GAM and SAM rates reported were ~30.0% and ~7.0%. A higher proportion of assessed boys (22.2%) are acutely malnourished compared to girls (18.7%), although the difference is not statistically significant. The 90 days retrospective crude (CDR) and under five death rates (U5DR) of 1.40 (0.93-2.10) and 2.70 (1.86-3.89) indicate a Serious situation according to UNICEF classification, an improvement from Critical levels reported in October ’11 when CDR of <2 was recorded. The health facilities also indicate a high number (>50 %) and stable trend of acutely malnourished children and a stable trend (Figure 14). Morbidity levels reported in the two weeks prior to the assessment were high at 32.8% and immunization status for measles and vitamin A supplementation is extremely low (<20%) compared with the Sphere recommended coverage of 95%.

The sustained poor nutrition situation of the bay agro-pastoral populations is attributed to chronic food insecurity linked to overall poor crop production, high debt levels from the previous season, reduced wage rates, low agricultural labour coupled with high morbidity and limited humanitarian assistance. Further aggravating factors include chronic

figure 13: trend in levels of acute malnutrition (WhZ< -2 or oedema, Who 2006) bay region, 2002- 2012

Baneedi village hosting IDPs from Bakool

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problems of poor child feeding and health care practices, and low access to safe water, health and nutrition services, which predispose populations to high morbidity and consequently high levels of acute malnutrition.

Nevertheless, recently improved income and food access resulting from increased ToT (labour to sorghum), social support mainly from the diaspora, control of disease outbreaks as well as some limited humanitarian assistance may have mitigated further deterioration and contributed to the reduction of the GAM and SAM rates. Immediate and routine health, food and livelihood interventions are required to mitigate further deterioration and to address the extreme rates of acute malnutrition. In the medium term, interventions to support and rebuild livelihoods is critical. The key nutrition reference indicators of the analysis on the nutrition phase classification are provided in Table 10.

baidoa idPs

baidoa Town is host to internally displaced persons (IDPs) fleeing from Banadir, Bay and Bakool regions mainly because of insecurity and prolonged drought. Often, IDPs are faced with numerous problems including lack of food, malnutrition, poor sanitation and shelter due to loss of assets and a disruption of livelihood system.

In July 2012, FSNAU conducted a comprehensive nutrition survey among the baidoa IDPs. The GAM and SAM rates of 15.5% (11.6-20.4 ) and 5.1% (3.1-8.5) indicate a Critical nutrition situation (Table 10). More boys (17.1%) than girls (14.1%) are acutely malnourished but the difference is not statistically significant. The 90 days retrospective CDR and U5DR of 0.42 (0.27-0.66) and 1.52 (0.91-2.53) indicate Acceptable and Alert levels respectively, according to UNICEF levels. Morbidity, a key nutrition aggravating factor remains high (28.3%) in the IDPs. Malnutrition rates for pregnant and lactating women (MUAC <23.0 cm) is 24.1% (18.2-30.1). This rate is high and slightly above the baseline median rate of 22.0% recorded from nutrition surveys in Somalia conducted between 2007-2010. Lack of stable livelihood systems among the IDPs coupled with lack access to basic services continue to expose this population group to risks of malnutrition, ill health and food insecurity. Interventions to improve and stabilize food access and provision of health services are crucial in addressing food insecurity and in tackling the high morbidity levels, thereby mitigating the high levels of acute malnutrition.

Gender and nutrition analysis in bay regionsThe analysis of the nutrition data in the assessed rural livelihoods as well as the baidoa IDP populations shows no statistically significant difference in distribution of the malnutrition cases between boys and girls. A high proportion of boys than girls are acutely malnourished, stunted and underweight across bay agro-pastoral livelihood and baidoa IDP populations. For example, in bay agro-pastoral 22.2% (17.6-27.5 ) of boys compared to 18.7% (14.1-24.4) girls are acutely malnourished 39.9% (33.1-47.0 ) boys compared to 35.5% (27.4-44.5) of girls are stunted and 38.2% (31.8-45.4) of boys as opposed to 31.3% (24.5-39.1) of girls are underweight. Nevertheless, the distribution of malnutrition cases assessed by MUAC measurements in bay agro-pastoral shows slightly more girls (20.3%) than boys (15.7%) identified as acutely malnourished with MUAC<12.5 cm or oedema (see nutrition summary Tables).

Maternal nutrition Status in bay and bakool

Water source at Eldhere village in Bakool

figure 14: hiS Malnutrition trends in bay Agro-pastoral Mchs,2010-2011

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table 10: Summary of key nutrition findings in bay regions-July 2012

Bay Agro-Pastoral July 2012 (N=889;Boys=419 Girls= 470)

Baidoa IDP (July 2012) (N= 858 ;Boys= 391 Girls= 467)

Indicator Results Outcome Results OutcomeChild Nutrition Status

Global Acute Malnutrition (WHZ<-2 or oedema)BoysGirls

20.4 (16.7-24.5)22.2 (17.6-27.5)18.7 (14.1-24.4) Very Critical

15.5 (11.6-20.4) 17.1 (12.8-22.6)

14.1 ( 9.6-20.3) Critical


6.9 ( 5.0- 9.4 )6.7 ( 4.2-10.5)7.0 ( 4.6-10.6)

Critical5.1 ( 3.1- 8.5)6.1 ( 3.7- 9.9) 4.3 ( 2.1- 8.4)

Critical

Mean of Weight for Height Z Scores -1.08±1.09 Critical -0.76±1.16 SeriousGlobal Acute Malnutrition (NCHS) 21.0 (17.0-25.7) Very Critical 15.1 (11.0-20.4) Very CriticalSevere Acute Malnutrition (NCHS) 3.8 ( 2.5- 5.7) Alert 4.6 (2.6- 8.1) CriticalProportion with MUAC<12.5 cm or oedemaBoysGirls

18.1 (14.7-22.1)15.7 (12.4-19.8)20.3 (15.6-25.8)

Very Critical12.7 (8.8-17.9)14.4 (9.0-22.3)11.2 (7.8-15.7)

Very Critical


4.0 (2.6- 6.0) 2.8 (1.6- 4.9)5.0 (3.1- 7.9)

Very Critical2.6 (1.6- 4.4)3.5 ( 1.7- 7.0)1.9 ( 0.9- 4.1)

Critical


37.6 (31.5-44.0)39.9 (33.1-47.0)35.5 (27.4-44.5)

Critical36.0 (30.6-41.7)36.3 (29.7-43.6)35.6 (29.1-42.8)

Critical


34.6 (28.9-40.8)38.2 (31.6-45.4)31.3 (24.5-39.1)

Very Critical25.7 (20.5-31.7)25.6 (20.9-30.9)25.8 (19.6-33.2)

Critical

HIS Nutrition Trends(Jan – July 2012) High (>50% and a stable trend Very Critical N/A -

Admission trends at TFPs/SFPs Bay Region – (Jan-July 2012)

Low and fluctuating number of admissions Critical N/A



Morbidity- 32.8 Boys-31.9; Girls-33.6Diarrhoea – 16.4Boys- 13.4:Girls-19.2

Pneumonia- 8.4Boys-8.8;Girls- 8.1

Very Critical

Morbidity- 28.3 Boys-27.4;Girls-29.1Diarrhoea – 16.4Boys- 13.4:Girls-12.0

Pneumonia- 8.4Boys-7.2;Girls-7.5

Very Critical

Immunization Status

Vitamin A – 17.5Boys- 16.8;Girls- 18.2

Measles Vacc –19.4Boys-18.1;Girls-20.7

Critical

Critical

Vitamin A –28.7Boys-30.5;Girls-27.2Measles Vacc – 30.8Boys-32.6;Girls-29.3

Critical

CriticalDeath RatesCrude deaths, per 10,000 per day (retrospective for 90 days)

1.40 (0.93-2.10) Serious 0.42 (0.27-0.66) Acceptable

Under five deaths, per 10,000 per day (retrospective for 90 days) 2.70 (1.89-3.89) Serious 1.52 (0.91-2.53) Alert

Women Nutrition Status N=541 N=579

Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm)

N=4340.0 Critical N=177

0.6 (0.0-1.6) Serious


N=4342.3 (0.2-4.3)

N=4026.5 (3.4-9.5 )


N=14934.3(25.3-43.4) Serious N=402

24.1 (18.2-30.1) Serious

Food security phase Crisis Serious Crisis Critical

Overall Risk to Deterioration Stable UnstableOverall Situation Analysis Very Critical Critical

In Bay Region, a significantly higher proportion of pregnant and/or lactating women are acutely malnourished (MUAC< 23.0 cm) than non-pregnant and non-lactating women (MUAC<18.5 cm) across all livelihoods and among the baidoa IDPs settlements. Information on maternal nutrition indicates a worrying nutrition situation among women. Acute malnutrition (MUAC <23.0 cm) rates for pregnant and lactating women among the bay agro-pastoral, baidoa IDPs and bakool pastoral livelihoods are 34.3% (25.3-43.4), 24.1% (18.2-30.1) and 22.0% respectively. These rates are extremely high and are either similar to or significantly above the baseline median rate of 22.0% recorded from the FSNAU surveys conducted between 2007-2010 (see Table 10). The high level of acute malnutrition among the pregnant and/or lactating women is linked to increased nutrient demands during pregnancy needs which are not being met.

bay /bakoolSurveyed population Pregnant and/or lactating women non-pregnant/lactating women

no. Assessed Proportion with MuAc<23cm Proportion with MuAc <21cm no. Assessed Proportion with MuAc<18.5 cm

bayagro-pastoral 434 34.3 (25.3-43.4) 2.3 (0.2-4.3 ) 107 0baidoa IDP 402 24.1 (18.2-30.1 ) 6.5 (3.4-9.5 ) 177 0.6 (0.0-1.6 )bakool pastoral 595 22.0 (17.5-26.5) 2.4 (0.7-4.0 ) 173 0.6 (0.01-1.7)

mATErNAL NuTriTiON STATuS iN BAy rEGiONS

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CASE STudy 2: iNCrEASEd NuTriTiONAL vuLNErABiLiTy AmONG ThE FAmiLiES iN ThE BESiEGEd huddur TOWN, BAKOOL rEGiON.

BackgroundHuddur is the urban center for Bakool region in southern Somalia and is located 180 km north west of Baidoa and 90 km from the Ethiopian border. It has two livelihood zones: the pastoral and agro-pastoral low potential. Huddur district and Bakool region which has recently come under the administrative control of the transitional federal government (TFG) had been run by a militia group since February 2012, that restricted and controlled entry of people not only goods and services. This has affected the supply of both locally produced and imported food items in the town as well as delivery of the essential health and nutrition services. The case study below exemplifies how the households are coping with the situation and the impact of the siege on nutrition and health of the population.

Case studyKhazida, a 34 years old lactating mother and stays with her husband and their four children together with the paternal grandmother. The household of this family is located in Huddur town.

Hassan, Khazida’s husband was injured in a mortar shell bomb explosion in Mogadishu Bakara market two years ago, the mortar shell particles damaged the spinal code causing paralysis in his lower limps. Previously, Hassan was an unskilled labourer accessing income through construction work, unfortunately from the impact of his injury he is no longer physically fit to work in the same field. With the incapacitation of the household bread winner, Khazida had no alternative but to become the bread winner of her family which she does through sale of vegetables in Huddur market.

Unfortunately, the siege of the town has affected her business as she is unable to get vegetable supplies from other areas. This has led to the closure of the business, and also compelled her to switch to severe coping mechanism to meet the basic food needs. Some of the coping strategies she employs include reduction of the meals consumed from three to two and more lately, to only one meal in a day. When the situation persisted she was again forced to send two of her children aged 6 and 7 years to her relative in a pastoral village called Hogir. “This is one of the worst decisions I have ever made but the circumstances forced me as I had no alternative and I could not wait to see my children die.” she said, in tears.

Khazida lives in Huddur where, unfortunately there has not been a functional health facility for over a year, hence, most of her children are not immunized. As fate would have it, in August 2012, prior to this case study, she lost one of her sons to suspected measles.

As may be expected for such a poor family with reduced food and income; high morbidity and poor nutrition situation is prevalent. MUAC assessment of the family members indicates that the youngest child in the family has severe acute malnutrition with a MUAC<11.5 cm. Khazida who is lactating has a MUAC of 21cm indicating high risk of malnutrition. In addition, five weeks prior to the interview, the youngest child was reportedly suffering from suspected respiratory infection but with no health services available, no medical assistance was sought for Abdullahi, other than administering concoction made from traditional herbs.

ConclusionThe case study demonstrates how the population in this town is suffering from lack of supply of basic goods and services including food and health services and the extent to which they have exhausted their coping strategies and are in dire need of assistance. This piece therefore, calls for the immediate interventions to ease the human suffering in Huddur town, provision of essential nutrition and health services to rehabilitate the sick and malnourished children and adults as well as continued monitoring of the situation.

A severely malnourished child with MUAC<11.5 cm

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4.4 Middle and lower Shabelle regionS

Middle and lower Shabelle regions

Middle and Lower Shabelle rural livelihoods comprise of riverine (pure farmers) and agro-pastoralists (Map 9). The riverine population, located within 10 km of the Shabelle river cultivates maize, sesame and a variety of vegetables and fruits, and keep limited livestock holdings as a result of tsetse fly infestation. The agro-pastoral zone extends 20-40 km from the Shabelle River and incorporates both cultivation of crop (maize, cowpeas, sesame and fruit), and livestock rearing. The agricultural potential, as well as the labour and income opportunities in the area makes it a haven for seasonal casual work, and also for vulnerable populations in the event of shocks. The Shabelle regions continue to struggle with the negative impacts of civil insecurity. This has affected the population’s well being, through disruption of livelihoods, continued lack of access to humanitarian interventions, and a high number of IDPs in the region.


Food SecurityThe food security situation in Shabelle regions (Middle and Lower) showed improvement in the Deyr ‘11/12 season. The total population facing food insecurity in Middle Shabelle region significantly decreased by 55% from the Gu’11 season. Lower Shabelle region also showed significant improvement with only 2% of the population in crisis. The main factor contributing to the significant improvement in the food security situation in the two regions was related to the good rainfall performance in the Deyr ‘11/12 season across most livelihoods in the regions, in addition to the off season harvest in October 2011, this resulted in good cereal and cash crop production and a decrease in local cereal prices. The increased humanitarian assistance during the October to December 2011 period also mitigated the situation. In addition, the availability and access to pasture and water resources improved livestock production and sales, milk availability from goats also considerably improved. The urban population in crisis remained the same, estimated at 8,000 people.

Nutrition

In Lower Shabelle region, the Post Deyr‘11/12 integrated nutrition analysis indicated a likely Very Critical nutrition situation among the riverine and agro-pastoral population. Due to the lack of access in the region for security reasons, no surveys were conducted. However, data from health facilities in the areas and information from feeding programmes indicated a declining number of admissions and numbers of acutely malnourished children reported in health facilities and feeding centres. Among the agro-pastoral population, the data from health facilities indicated a high (>30%) and increasing trend, while in the riverine, data indicated a high (>10%), and a declining trend of the number of acutely malnourished children. Although the nutrition situation remained classified the same (Very Critical) as in the Gu 2011 season, it was probable the nutrition situation had improved with the positive food security outcome indicators reported in the region. Figure 15 show the trends of acute malnutrition 2007-2011

current Situation, Post Gu ‘12

Food Security

The food security and livelihood situations in Middle and Lower Shabelle regions continued to improve through the last Deyr 2011’/12 and Gu 2012 seasons.

A significant number of people in Adale and Aden Yabaal districts of Middle Shabelle remain in crisis, however the number affected has reduced since the Deyr 2011/12. This is attributed to the positive impacts of good rainfall that has led to above average crop production, improved livestock condition and purchasing power. This has resulted in improved availability of milk and milk products in Middle Shabelle region. The rest of the population is in Stressed Phase.

Map 9: Shabelle livelihood Zones

Figure 15: Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Middle and Lower Shabelle Regions (2007- 2012)

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Figure 17: HIS Malnutrition Trends in Shabelle Agropastoral MCHs 2010-2011

Mogadishu Town April 2012

(N=959 Boys=497 Girls=462)

Mogadishu Town July 2012

(N=676; Boys=304 Girls=372)

Indicator Results Outcome Results OutcomeChild Nutrition Status

Global Acute Malnutrition (WHO 2006)

BoysGirls

10.3 (7.9-13.4)

12.5 (9.3-16.6)

8.0 (5.6-11.3)

Serious

10.8 (8.3-13.9)

13.5 (9.9-18.2)

8.6 (5.1-14.1)

Serious

Severe Acute Malnutrition (WHO 2006)

BoysGirls

1.7 (0.9-3.1)1.8 (0.9-3.6)1.5 (0.7-3.4)

Acceptable 1.5 ( 0.7-3.0)3.0 (1.4-6.2)0.3 (0.0-2.0)

Acceptable

Mean WHZ (WHO, 2006) -0.57±1.13 Alert -0.44±1.16 Alert

Oedema 0 Acceptable 0.4 Very CriticalGlobal Acute Malnutrition (NCHS)

14.7 (11.8-18.0) Serious 9.3

(6.6-12.8) Alert

Severe Acute Malnutrition (NCHS)

2.3 (1.4-3.6) Acceptable 1.2 (0.4-3.1) Acceptable

Global Acute Malnutrition by MUAC (<12.5 cm or oedema) Boys

Girls

6.6 (5.1-8.6)6.9 (4.7-9.9)6.4 (4.4-9.2)

Serious5.4 (3.8-7.6)5.8 (3.5-9.4)5.0 (3.2-7.9)

Alert

Severe Acute malnutrition by MUAC (<11.5 cm or oedema) Boys Girls

1.2 (0.7-2.3)1.2

(0.4-3.2)1.3

(0.6-2.8)

Serious1.2 (0.5-2.6)1.3 (0.4-4.2)1.1 (0.3-3.5)

Serious

Morbidity 25.2 (19.7-30.7)

Very Critical

29.1 (22.6-35.6) Very Critical

Immunization Status:Measles vaccinationVitamin A Supplementation

55.5 (47.4-63.5)

60.5 (53.0-68.0)

Very Critical

56.3 (46.9-65.7)

56.9 (48.0-65.8)

Very Critical

HIS Nutrition Trends(January – July 2012)

Low (>10%) and decreasing

trend

SeriousLow (>10%) and stable

trendSerious

Admission trends at TFPs/SFPs (January – July 2012)

Reduced numbers of admissions to feeding

programmes

Serious


programmes

Serious


1.22 (0.56-2.00) Critical 1.23

(0.81-1.83) Critical


1.06 (0.88-1.69) Serious 1.54

(0.82-2.85) Serious

Women Nutrition N=570 N= 398Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm)

0.6 (0.0-1.7 Serious 0 Acceptable


6.4 (3.0-9.8) - 1.4 (0.02-2.84) -


17.3 (12.0-22.7) Alert 7.5

(4.2-10.9) Acceptable

Food Security -Food security phaseOverall Situation Analysis Serious Serious

table 11: Summary of key nutrition findings in Mogadishu town - April- July 2012

NutritionIn the Shabelle regions, there were no nutrition surveys conducted in the Gu 2012 due to lack of access. The last surveys to be conducted in the region were done in July 2011. Due to the lack of sufficient data, there is no overall nutrition situation estimate for the Shabelle regions. However data from health facilities in the region shows high (>30%) and stable trends of malnutrition among the Lower Shabelle agro-pastoral population and a high (>10%) and declining trend amongst the riverine population (Figure 16).

The nutrition situation in the coming months is expected to improve given the positive food security indicators in Shabelle. However the degree of gains will depend on the population’s exposure to risk factors which include seasonal outbreaks of acute watery diarrhoea (AWD) in October-November, reduced access to humanitarian interventions with the recent suspension of key actors and the increasing civil insecurity in the region. Persistent chronic factors - such as very limited access to specifically feeding and health programmes, inappropriate child feeding and care practices, poor access to safe water and sanitation facilities and civil insecurity are additional factors likely to negatively affect the nutrition situation.

Figure 16: HIS Malnutrition Trends in Shabelle Reverine MCHs 2010-2011

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Mogadishu IDPApril 2012

(N=929; Boys=456 Girls=473)

Mogadishu IDP July 2012

(N=675; Boys=313 Girls=362)Indicator Results % Outcome Results % OutcomeChild Nutrition StatusGlobal Acute Malnutrition (WHO 2006) Boys

Girls

16.1 (13.3-19.5)19.1 (15.4-23.4)13.3 (9.7-18.0)

Critical9.6 (7.1-13.0)11.8 (8.5-16.3)7.7 (4.7-12.4)

Alert

Severe Acute Malnutrition (WHO 2006)BoysGirls

3.7 (2.3-5.7)5.0 (3.1-8.2)2.3 (1.0-5.2)

Serious1.8 (1.0-3.2)2.2 (1.0-5.1)1.4 (0.6-3.3)

Acceptable

Mean WHZ (WHO, 2006) -0.85±1.09 Serious -0.57±1.08 AlertOedema 0 Acceptable 0.1 Very CriticalGlobal Acute Malnutrition (NCHS) 15.1 (12.2-18.7) Critical 8.8 (6.5-11.9) AlertSevere Acute Malnutrition (NCHS) 2.8 (1.8-4.3) Alert 0.9 (0.4-2.2) AcceptableGlobal Acute Malnutrition by MUAC (<12.5 cm or oedema) Boys

Girls

10.6 (7.9-14.0)8.4 (5.3-12.9)12.7 (9.1-17.5)

Critical8.4 (6.5-10.9)6.9 (4.4-10.7)9.7 (7.0-13.3)

Critical


1.9 (1.0-3.4)1.5 (0.7-3.3)2.3 (1.1-4.4)

Serious2.6 (1.5-4.5)1.6 (0.7-3.6)3.5 (1.9-6.3)

Critical

Morbidity 26.3 (18.2-34.5) Very Critical 45.9 (38.2-53.5) Very CriticalImmunization StatusMeasles vaccinationVitamin A Supplementation

61.3 (53.0-69.5)59.9 (50.4-69.4) Very Critical 67.2 (58.1-76.1)


HIS Nutrition Trends Low (>10%) and decreasing trend Serious Low (>10%) and stable

trend Serious

Admission trends at TFPs/SFPs (July- December 2011)


programmesSerious


programmesSerious

Death RatesCrude deaths, per 10,000 per day (retrospective for 90 days) 1.42 (1.05- 1.92) Critical 1.41 (0.99-2.02) Critical

Under five deaths, per 10,000 per day (retrospective for 90 days) 2.80 (1.87-4.17) Critical 2.81 (1.82-4.33) Critical

Women Nutrition N= 523Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm) 0.6 (0.0-1.9) Serious 0 Acceptable

Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0) 3.9 (1.8-6.0) - 5.2 (2.8-7.7) -

Proportion of acutely malnourished pregnant and lactating women (MUAC<23.0) 14.1 (9.4-18.7) Alert 19.1 (12.5-25.7) Alert

Food SecurityFood security phase

Overall Situation Analysis Critical Serious

table 12: Summary of key nutrition findings in Mogadishu idPs - April- July 2012

The nutrition situation of the Middle Shabelle agro-pastoral and riverine population is not classified due to lack of sufficient data. Data from the health facilities in the agro-pastoral livelihood areas indicates a high (>20%) and decreasing trend of acutely malnourished children (Figure 17), while among the riverine population, data indicates low proportions (<10%) and a declining trend of acutely malnourished children. The positive food security indicators noted in Lower Shabelle agro-pastoral and riverine areas are similar to the those of the riverine population of Middle Shabelle region. The population still remains highly vulnerable to shocks and risk factors namely: reduced access to humanitarian services, reduced rainfall, high morbidity burden- reported AWD and measles outbreaks, poor access to health care services and sanitation, sub-optimal child feeding and care practices. Therefore close monitoring of the situation is crucial.

bAnAdir rEGion (MoGAdiShu)

In April 2012, FSNAU and partners conducted nutrition surveys in banadir region among the IDP and urban population of Mogadishu town1. The nutrition survey results indicated a Serious and Critical nutrition situation among the urban and IDP populations respectively, with a GAM rate of 10.3% (7.9-13.4) among the urban population and 16.1% (13.3-19.5) among the IDP population. The 90 days retrospective crude and under five deaths reported were 1.22 (0.56-2.00) and 1.06 (0.88-1.69) while among the IDPs was 1.42 (1.05-1.92) and 2.80 (1.87-4.17).

In July 2012, FSNAU and partners conducted a repeat nutrition and food security assessments in Mogadishu Town among the urban and the IDP population, as a way of closely monitoring the nutrition and food security situation in the town.

1 All districts excluding Deynile and Huriwa

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The survey results of the urban population reported GAM and SAM rates of 10.8% (8.3-13.9) and 1.5% (0.7-3.0) respectively. The 90 days retrospective crude and under five death rates remain elevated at 1.23 (0.81-1.85) and 1.54 (0.82-2.85) respectively, indicating a Critical situation according to UNICEF classification, although a slight improvement was noted from results in April 2012 (Table 11). HIS data from health facilities in Medina, Waaberi, Hamarweyne and Hamarjajab indicated a low number (>10%) and stable trend of acutely malnourished children for the previous six months period. The results depict a sustained Serious nutrition situation among the Mogadishu urban population.

A survey conducted among Mogadishu IDPs in December ‘11 reported GAM rates of 20.5% (16.6-25.2) and SAM rates of 5.6% (3.8-8.1). In April 2012, the nutrition survey conducted among the IDP population showed improvements, with GAM and SAM rates of 16.1 (13.3-19.5) and 3.7 (2.3-5.7). The 90 days retrospective crude and under five deaths reported remain unchanged from the April 2012 reported rates of 1.42 (1.05-1.92) and 2.80 (1.87-4.17). A nutrition survey conducted among the IDP population in July 2012 reported a GAM and SAM rate of 9.6% (7.1-13.0) and 1.8% (1.0-3.2) respectively. The mortality rates remain elevated, with the 90 days retrospective crude and under five death rates of 1.41 (0.99-2.02) and 2.81 (1.82-4.33), indicating a Critical situation according to UNICEF classification (Table 12).

The nutrition situation of the Mogadishu IDPs is classified Serious, although the GAM and SAM rates are Alert, mainly because of the mortality and MUAC rates that remain elevated. However the results indicate an improvement from survey results of December 2011 and April 2012 that recorded Very Critical and Critical nutrition phases

respectively. The current integrated analysis indicates a Serious situation among the Mogadishu IDPs, although there has been a significant improvement (p=0.002) in acute malnutrition rates, the mortality rates still remain elevated.

The improvement is mainly attributed to the large scale multi-sectoral humanitarian interventions such as feeding, health, water sanitation and hygiene (WASH) and shelter programmes in the town. The reduced frequency of disease outbreaks and morbidity also helped to reduce acute malnutrition rates. The population still remains highly vulnerable and heavily reliant on the interventions currently in place. A disruption in the provision of humanitarian interventions may lead to a sudden deterioration in the nutrition situation of the population.

Gender: Analysis of findings from the nutrition assessments conducted in Mogadishu Town generally indicate a higher proportion of boys than girls as acutely malnourished (WHZ<-2 or oedema). However, these differences were generally not statistically significant (p>0.05). Other child data such as dietary diversity, illness, feeding practices, and immunization status, do not show any clear differences by gender (Table 11 and 12). See tables X-, indicating the gender disaggregated of the assessed children data by sex.

Information on maternal nutrition indicates a worrying nutrition situation among women. Acute malnutrition rates for pregnant and lactating women (MUAC <23.0 cm) is 19.1% (12.5-25.7). Although this rate is high it is still below the FSNAU median rate of 22.0% recorded from surveys between 2007-2010. Continued efforts in humanitarian assistance in activities like wet-feeding, supplementary and therapeutic programmes remain essential.

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NutritioN Survey reSultS iN MatabaN aNd beletweyNe, HiraN regioN iNdicate aN extreMely worryiNg HealtH SituatioN

The civil conflict in Hiran region has had a negative impact on the population’s means of livelihood and access to basic services, thus affecting their overall food security and nutrition well being. Lack of adequate health facilities and limited access to the few operational facilities is a major problem in the region. Humanitarian agencies face a great challenge in establishing and running health facilities in this highly insecure and volatile environment, where aid workers have in the past been directly targeted. From late 2011, many agencies closed their health programmes in the region as instructed by local authorities, leaving a major gap in the provision of health services to the population. As a result, the infrastructure, supplies and staff required for health facilities to function adequately is limited to only a few locations in Hiran region.

In July 2011 at the peak of famine in south Somalia, the nutrition situation of Hiran region was classified as Very Critical based on nutrition surveys conducted in all three livelihoods. In the Deyr ‘11/12 season, no nutrition surveys were conducted due to lack of access. The nutrition situation was classified as likely Very Critical based on contextual information and data from health and feeding facilities. The Gu ’12 nutrition surveys conducted in the accessible districts of Mataban and Beletweyne, indicate improvements in GAM rates from >20% in July 2011(Very Critical) ( GAM) to 16% (Critical) (GAM -). The 90 days retrospective crude death rates reported in July 2011 were 1.53, 1.37 and 1.50/ 10,000 per day among the pastoral, riverine and agro-pastoral population respectively. The July 2012 survey findings indicate improvements in crude death rates to 0.80 (0.53-1.22) and 0.99 (0.70-1.41) in Beletweyne and Mataban districts respectively.

Although the overall global acute malnutrition and crude mortality rates and food security indicators show an improving trend, the recent Beletweyne and Mataban survey results indicate no significant change in the under five death mortality rates, elevated morbidity levels and extremely low immunization coverage. In July 2011, the 90 days retrospective under five deaths reported were 3.67, 4.13 and 4.24 among the pastoral, riverine and agro-pastoral population respectively. The July 2012 survey results report a U5DR of 2.23 (1.30-4.11) and 4.50 (3.02-6.64) among the Beletweyne and Mataban district populations respectively. These results are currently the highest in the country. The main reported causes of death were diarrhoea and acute respiratory infections.

Also of concern are the elevated morbidity rates reported in the districts. The proportion of children reported to have fallen ill in the two weeks prior to the survey was 63.8% (55.2-72.5) and 28.2% (20.5-35.9) in Beletweyne and Mataban districts respectively.

Qualitative information collected indicated that not only were operational health facilities limited, but also access to them was extremely difficult especially in Mataban district. According to the figure, a high number of cholera cases have been reported in the region since April 2012 (WHO June 2012), further compromising the health and nutritional well being of the population.

Another indicator supporting evidence of poor health services in the area is the extremely low immunization coverage. In Mataban district the proportion of children immunized against measles and having received vitamin A supplementation is a only 11.0% (5.2-16.8) and 5.9% (1.2-10.5). In Beletweyne district, the proportion of children that have received vitamin A supplementation is slightly higher (20.4%), compared to Mataban district although this rate is still far below the Sphere recommended standards. The measles vaccination status in Beletweyne district was also extremely low 12.7% (19.4-31.3). High morbidity rates and low immunization coverage, combined with limited access to health facilities increases the children’s vulnerability to malnutrition and death, therefore the situation needs to be urgently addressed.

Even though the nutrition situation is likely to improve due to increased milk availability and better food access (production, cereal prices etc), unless appropriate health interventions are made accessible to reduce the high disease burden, the situation may not improve, as these high morbidity levels predispose the children to disease and death.

Proportion of children that have received Measles vaccination and vitamin A supplementation district Measles vaccination vitamin A Supplementation recommened Sphere Standards

beletweyn 12.7%(19.4-31.3)

20.4(7.6-33.1) Above 95%

Mataban 11.0%(5.2-16.8)

5.9%(1.2-10.5) Above 95%

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trends in reported cholera cases, Who, April – June 2012


4.5 HiRan ReGiOn

Pastoral, Agro-pastoral & riverine livelihoods

Hiran region comprises of three main livelihood groups: the Pastoral (Southern Inland and Hawd pastoral) covering Mataban and Mahas districts; and the Agro-pastoral and Riverine livelihood systems, both of which cut across Beletweyne, Buloburti and Jalalaqsi districts. (Map 10). Like many other regions in South Central Somalia, Hiran has not escaped the effects of high intensity civil conflict, which has affected people’s means of livelihood. Intermittent localised civil conflict, as well as the targeting of aid workers in the region, has continued to hinder humanitarian access.


Food Security

The overall food security situation in Hiran region showed an improvement following an average to good Deyr ‘11/12 rainfall performance in most of the livelihood zones. This resulted in increased own production (crop and milk), with the exception of the agro-pastoral livelihood zone where the ‘below normal’ rainfall led to poor crop production. The total number of people facing food insecurity was estimated at 71,000 people in both the rural and urban areas, of which 40,000 were in Emergency and 31,000 were in crisis. The agro-pastoral livelihood was the worst affected with 36,000 people in crisis. The situation also deteriorated in urban areas, where 28,000 people were identified in crisis. The food security situation was projected to deteriorate within 4-5 months if humanitarian assistance in the region remained limited. The good Deyr ’11/12 season also resulted in improved water availability and pasture, resulting in an increased number of saleable animals. Cereal availability in the market increased, consequently the price of staple foods continued to decline and was expected to drop further as more cereals arrive from other neighbouring regions. The ToT of labour and goat to cereal also increased, in addition, the levels of social support (zakat) also improved. Civil insecurity remained a major risk factor likely to affect the food security situation in the region.

figure 18: trend in levels of acute Malnutrition (WhZ<-2 or oedema, Who 2006) in hiran region, 2007-2012

NutritionNo surveys were conducted in the region during the Deyr ‘11/12 season due to inaccessibility as a result of insecurity. Therefore to estimate the Post Deyr ‘11/12 nutrition situation for the region, data from health facilities from July to October was used. Information from health facilities in the agro-pastoral livelihood zone of Hiran region, indicated a high (>20%) and increasing trend of acutely malnourished children. Although there was a marked improvement in the food security situation and control of disease outbreaks, in the Deyr season, the nutrition situation remained •likely Very Critical among both the agro-pastoralists and

pastoralists due to a high proportion (>20%) of acutely malnourished children reported in health facilities in each of these zones.

•likely Very Critical in the riverine livelihood zone with a high (>15%) number and stable trend of acutely malnourished children reporting at health facilities.

Figure 18 shows trend of acute malnutrition in Hiran for 2007-2012.

current Situation – Post Gu 2012

Food SecurityThe food security situation of Hiran region has shown a mixed trend in the Gu ’12 season. Hawd and Southern Inland Pastoral livelihood zones of the region were, previously classified in crisis and Stressed phases respectively. Hawd remains in Stressed, and Southern Inland Pastoral improved to Stressed phase. The agro-pastoral livelihood is the worst affected and is classified in crisis phase. In addition, the riverine livelihood population, in rural areas are in Stressed phase. The improvement in the pastoral livelihoods of the region is primarily attributable to average Gu’ 2012 seasonal rainfall performances that resulted in improved water availability pasture and browse conditions. Subsequently, livestock body condition continued to improve, resulting in increased number of saleable animals at high

Map 10: hiran livelihood Zones

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The Mataban district nutrition survey also conducted in July 2012 reported similar GAM and SAM rates of 16.7% (13.2-20.8) and 4.2% (2.3-7.3) respectively. The 90 days retrospective crude and under five deaths reported are 0.99 (0.70-1.41) and 4.50 (3.02-6.64) respectively. Of great concern are the under five death rates in the district which are the highest reported rate in the country. The main causes of death reported were diarrhoea and fever. The area has extremely limited health facilities and services, with the proportion of children immunized against measles and having received vitamin A supplementation a dismal 11.0% (5.2-16.8) and 5.9 (1.2-10.5) respectively. The overall morbidity is high with 28.2% of the assessed children falling ill in the two weeks prior to the survey. The proportion of children reported to have suffered from diarrhoea, pneumonia and fever is 9.1% (5.3-13.0), 8.8 (4.3-13.2) and 13.4 (8.2-18.5) respectively. The integrated nutrition situation analysis indicates a Critical nutrition situation, an improvement from the likely Very Critical, situation reported among the pastoral population in the preceding season, however the elevated under five mortality rates and extremely low immunization rates are alarming and should be immediately addressed.

The poor nutrition situation in Hiran region is mainly attributed to the lack of access to health facilities (high morbidity rates, low immunization coverage and high under five mortality rates), in addition to the impacts of persistent food insecurity (especially among the agro-pastoral population) and civil insecurity in the region. Although the projected outlook of the nutrition situation is likely to improve due to the anticipated increase in milk availability/production and the current positive food security indicators in the region, unless appropriate health interventions are accessible in the region to control the high morbidity levels reported, the situation may not improve (Table 13).

prices. In riverine livelihood zones where rainfall performance was similar to agropastoral zones, the poor wealth group was not able to cover high irrigation costs due to poor economical position and are thus faced with poor crop production. However, they have cereal stocks to last for a few months and they benefit from cash crop production employment. Levels of social support such as zakat continued to improve in pastoral zones due to average seasonal performances while it indicated declined trend in agro-pastoral and riverine zones of the region as a result of poor rainfall performances.

Nutrition

In the Gu ’12 season, lack of access to conduct livelihood based nutrition surveys in the region persisted, however in July 2012, FSNAU and partners were able to conduct administrative based nutrition surveys in beletweyne and Mataban districts of Hiran region which were accessible. Majority of the sampled clusters in beletweyne district were riverine, while in Mataban district the clusters were predominantly pastoral. No surveys were undertaken in Buloburti and Jalaqsi districts, therefore no overall nutrition situation is reported for these two districts because of lack of adequate sufficient data.

The nutrition survey conducted in beletweyne district, in July 2012 reported GAM and SAM rates of 16.6% (11.7-22.9) and 3.3% (1.7-6.3) respectively. Data from health facilities in Riverine show high (>20%) and increasing trend of acutely malnourished children (Figure 22). The 90 days retrospective crude and under five deaths reported are 0.80 (0.53-1.22) and 2.32 (1.30-4.11), with the under five death rate remaining elevated. The current integrated nutrition situation analysis indicates a Critical nutrition situation, an improvement from likely Very Critical in the deyr ‘11/12 with the under five mortality rates remaining of concern. The overall morbidity was very high with 63.8% of the assessed children falling ill in the two weeks prior to the survey, with 40% (27.9-52.1) suffering from diarrhoea. High morbidity levels predisposes the children to acute malnutrition. The high morbidity rates coupled with the extremely low immunization status - Measles 12.7% (19.4-31.3) and vitamin A supplementation of 20.4(7.6-33.1) increase the children’s vulnerability to malnutrition and should be addressed urgently.

figure 19: hiS Malnutrition trends in hiran riverine Mchs 2011-2012

Surveyed population Pregnant and/or Lactating women Non-pregnant/

lactating women

No. Assessed

Proportion with MUAC<23cm

Proportion with MUAC <21cm

No. Assessed

Proportion with MUAC<18.5 cm

Mogadishu Urban 398 7.5 (4.2-

10.9)1.4 (0.02-2.84) 123 0

Mogadishu IDPs 423 19.1

(12.5-25.7) 5.2 (2.8-7.7) 135 0

Beletweyne District 475 22.7

(15.4-29.9) 5.1 (1.6-8.5) 219 0.63 (0.0-2.2)

Mataban District 426 37.8

(28.7-46.9)16.5 (8.5-24.5) 196 0.7

(0.0-2.4)

Table 13: Proportion of the malnourished women in Banadir and Hiran Regions

The information on maternal nutrition indicates a worrying nutrition situation among the pregnant and lactating women in beletweyne and Mataban districts. Acute malnutrition rates for pregnant and lactating women in beletweyne and Mataban district (MUAC <23.0 cm) is 22.7 (15.4-43.29) and 37.8 (28.7-46.9) respectively. The rate is high in Mataban district and above the FSNAU median rate of 22.0% recorded from surveys between 2007-2010.

mATErNAL NuTriTiON STATuS iN BELETWyNE ANd mATABAN diSTriCTS

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table 14:Summary of key nutrition findings in hiran region - July 2012

Beletweyne District July 2012

(N=628; Boys=305 Girls=323)

Mataban DistrictJuly 2012

(N=480; Boys=247 Girls=233)

Indicator Results % Outcome Results % Outcome

Child Nutrition Status

Global Acute Malnutrition (WHO 2006) BoysGirls

16.6 (11.7-22.9)15.4 (10.7-21.7)17.6 (11.8-25.5)

Critical16.7 (13.2-20.8)21.1 (15.7-27.7)12.0 (8.7-16.4)

Critical


3.3 (1.7-6.3)3.0 (1.3-6.6)3.7 (1.9-7.0)

Serious4.2 (2.3-7.3)5.7 (3.2-9.8)2.6 (1.0-6.3)

Acceptable

Mean WHZ (WHO, 2006) -0.86 ± 1.14 Serious -0.91 ± 1.12 Serious

Oedema 0 Acceptable 0.4 Very Critical

Global Acute Malnutrition (NCHS) 16.5 (11.9-22.5) Critical 15.7 (12.3-19.7) Critical

Severe Acute Malnutrition (NCHS) 1.7 (0.8-3.6) Acceptable 2.2 (1.2-4.1) Acceptable

Global Acute Malnutrition by MUAC (<12.5 cm or oedema) Boys

Girls

20.1 (12.4-30.9)18.4 (10.9-29.4)21.7 (13.0-34.0)

Very Critical19.3 (14.7-24.9)18.6 (14.3-23.9)20.1 (14.1-27.8)

Very Critical


6.4 (3.4-11.5)5.5 (3.1-9.5)7.2 (3.6-13.8)

Extreme2.6 (1.6-4.2)1.9 (0.7-5.0)1.3 (1.8-6.1)

Critical

Morbidity 63.8 (55.2-72.5) Very Critical 28.2 (20.5-35.9) Very Critical

Diarrhoea 40.0 (27.9-52.1) Very Critical 9.1 (5.3-13.0) Serious

Pneumonia 9.0 (4.6-13.5) Serious 8.8 (4.3-13.2) Serious

Fever 26.6 (21.9-31.3) Very Critical 13.4 (8.2-18.5) Serious

Immunization StatusMeasles vaccinationVitamin A Supplementation

19.4 (7.6-31.3)20.4 (7.6-33.1) Very Critical 11.0 (5.2-16.8)


Infant and Young Child Feeding N = N = 89

Proportion Still BreastfeedingBoysGirls

66.2 (55.5-77.0)65.8 (51.8-79.6)50.0 (54.1-79.3)

Critical57.5 (39.8-75.2)64.1 (42.7-85.2)57.7 (29.7-85.7)

Critical

Proportion meeting recommended feedingBoys Girls

79.2 (71.0-87.5)79.7 (69.5-89.9)78.7 (66.9-90.4)

Critical 61.6 (45.3-78.0)76.9 (60.9-92.9)50.0 (29.1-70.9)

Critical

Death Rates (retrospective for 90 days)

Crude deaths, per 10,000 per day 0.80 (0.53-1.22) Serious 0.99 (0.70-1.41) Serious

Under five deaths, per 10,000 per day 2.32 (1.30-4.11) Critical 4.50 (3.02-6.64) Very Critical

Women Nutrition N= 475 N = 426

Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm)

0.63 (0.0-2.2) Serious 0.7 (0.0-2.4) Serious


5.1 (1.6-8.5) - 16.5 (8.5-24.5) -


22.7 (15.43-29.9) Serious 37.8 (28.7-46.9) Very Critical

Food security phase Stressed Serious Stressed Serious

Overall Situation Analysis Critical Critical

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4.6 CentRaL SOMaLia: GaLGadud and MuduG ReGiOnS

Central Somalia comprises of two regions, Galgadud and South Mudug. There are four main livelihood zones, namely the purely pastoral Addun and Hawd; the fishing and pastoral Coastal Deeh and the agro-pastoral Cowpea belt. The Hawd and Addun pastoral livelihoods extend across Galgadud, Mudug and southern Nugal regions, while the Coastal Deeh extends from the coast of Shabelle through Galgadud up to Allula district in bari region, cutting across the South, Central and Northeast zones (Map 13). This section will discuss the nutrition situation of the Hawd and Addun pastoral livelihood zones together with the other livelihood zones in the Central zone.


Food Security:The FSNAU Post Deyr ’11/12 analysis classified the Addun pastoral population of Central regions of Somalia in Crisis, indicating a sustained situation since Gu ’11. The Hawd pastoral livelihood had however showed improvement from the crisis in Gu ’11 to Stressed phase. The situation also improved in the Cowpea agro-pastoral livelihood from an Emergency in Gu ’11 to crisis phase due to the good Deyr’ 11/12 rainfall performance that led to improved local cowpea and sorghum production. The Coastal Deeh of central regions however, remained in persistent Emergency due to the significant loss of livestock in the past, caused by successive poor rainfall in previous seasons, in addition to widespread civil insecurity, limited humanitarian access and trade disruptions. The regions in Central and South Somalia continued to experience continuous civil unrest and the effects of droughts that led to internally displaced persons and pastoral destitution. Humanitarian access remained limited, aggravating the fragile food security and nutrition situation in the region further in Haradhere, Eldhere, and Elbur districts.

in the Hawd was however, projected to improve to Serious based on the favourable food security outlook. An AWD/cholera outbreak which was the main aggravating factor in the nutrition situation was under control by WHO and partners. The populations of the Addun pastoral livelihood showed improvement from Critical in Gu ‘11 to Serious in Deyr ‘11/12. The improvement in Addun was linked to improved access to milk, and dietary diversity, social support, and humanitarian programmes (health services, supplementary feeding, and WASH) in the region. From the outlook, Addun livelihood was projected to remain in a Serious phase based on seasonal trends (Fig. 19). No assessment was conducted in the cowpea agro-pastoral and Coastal Deeh pastoral livelihoods of Central Somalia. Therefore there was no data to indicate that the nutrition situation changed from the respective Critical and Very Critical levels reported among the cowpea agro-pastoral and Coastal Deeh pastoral livelihoods in Gu ‘11. The Dhusamareb IDPs were in a sustained Very Critical nutrition phase since post Gu ‘11.

Nutrition:The Post Deyr ‘11/12 integrated nutrition analysis depicted a mixed picture of worsening, sustained or improved nutrition situation in the livelihood zones of Central Somalia compared to the Gu’11 season. The nutrition situation deteriorated from Serious to Critical among the Hawd pastoral livelihood population. The Critical nutrition situation

current Situation- Post Gu ’11/12Food SecurityThe FSNAU Post Gu ’11/12 analysis classifies the Addun pastoral population of Central regions of Somalia as Stressed, indicating an improvement from the previous Crisis phase in the Post Deyr ‘11/12 analysis. The Hawd pastoral livelihood has sustained in Stressed phase since Deyr ’11/12. The situation has been sustained at the Crisis phase in the Cowpea agro-pastoral livelihood. The Gu ’12 rains though below normal, has contributed to some improvements in livestock performance, reduced cereal prices and positive goat/cereal ToT, since the Deyr ‘11/12 was good in the cowpea belt. The Coastal Deeh of central regions however, remains in persistent Emergency due to the significant loss of livestock in the past, caused by the previous successive poor rainfall seasons, in addition to wide spread civil insecurity, limited humanitarian access

Figure 21: HIS Malnutrition Trends in Hawd LHz of Central areas(2010-2012) Source: MoH; SRCS

figure 22: hiS Malnutrition trends in Addun l/Z of central areas (2011-2012)

Data Source: COSV/MSF-S

Figure 20: Trends in Levels of acute malnutrition (WHZ<-2 or oedema, WHO 2006) Central Regions, 2007-2012 Data Source: COSV/MSF-S

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and trade disruptions. Humanitarian access remains limited, aggravating the fragile food security and nutrition situation in the region further in Haradhere, Eldhere, and Elbur districts.

NutritionThe current Post Gu ‘12 integrated nutrition analysis depicts a mixed picture of either sustained or improved nutrition situation in the Central livelihood zones compared to the Post Deyr ’11/12. The nutrition situation improved from Critical to Serious among the Hawd pastoral livelihood population. The improvement in nutrition situation in the Hawd is attributed to favourable food security indicators including increased access to milk and improved dietary diversity. besides, there was no disease outbreak in the area unlike in Deyr ‘11/12 when AWD/cholera outbreak was the main aggravating factor in the nutrition situation. The populations of the Addun pastoral livelihood have shown a sustained Serious nutrition situation since Deyr ’11/12. The stable nutrition situation in Addun is linked to improved access to milk, and dietary diversity, social support, and humanitarian programmes (health services, supplementary feeding, and WASH) in the region. Assessments conducted in the cowpea agro-pastoral and Coastal Deeh pastoral livelihoods of Central Somalia show a likely Critical nutrition situation from the respective Critical and Very Critical situation reported in the Gu ‘11. No assessment were carried out in the Deyr ’11/12 nutrition analysis in these two livelihoods. The Dhusamareb IDPs are in a sustained Very Critical nutrition phase since post Gu ’11.

Gender: In the Hawd and Addun nutrition assessments conducted in the Galgadud and Mudug regions of Somalia, a higher proportion of boys than girls were acutely malnourished, however, there was no statistically significant difference (Pr<0.75). Other forms of malnutrition followed the same pattern, except Dusamareb IDPs where boys (26.5%) were significantly (p<0.05) more stunted than girls (8.7%) among the Dusamaerb IDPs. Other child data such as dietary diversity, illness, feeding practices, and immunization status, did not show any clear differences by gender. Analysis of household data by gender of household head did not find any significant difference nor clear trend in the proportion with access to sanitation facilities, access to safe drinking water nor consumption of a diversified diet. The gender disaggregated data by sex of the assessed children and sex of the household head per livelihood is summarized in Table 14.

hawd and Addun pastoral livelihoods of central and northeast regions

The detailed results of assessments in all the livelihoods transcending the Central and NE regions including the Hawd and Addun are discussed in the sections that follow. The results of the key findings are summarized in Table 12 below. The integrated analysis of data from nutrition assessments conducted in June 2012 among the populations of Hawd and Addun Livelihood zones of Northeast (Nugal) and Central (Mudug and Galgadud), and the health and feeding facilities’ information shows a sustained Serious phase in

the Addun and an improvement from Critical to Serious situation in Hawd pastoral livelihood. The Hawd pastoral livelihood assessment reported a GAM rate of 11.2% (8.9-14.0) and a SAM rate of 1.8% (0.9 – 3.4). No oedema was reported in the assessment. boys (11.4%) and (10.9%) girls were equally affected (Pr<0.75). The results show an improvement compared to the December ‘11 findings where GAM and SAM rates of 18.6% (14.5-23.4) and 5.5% (4.0-7.4) were reported respectively, including five (0.9%) oedema cases. The retrospective crude (CDR) and under-five death (U5DR) rates of 0.38 (0.19-0.76) and 0.50 (0.18-1.36) respectively indicate Acceptable levels according to UNICEF classification and indicates no change from the respective rates (CDR and U5DR) of 0.49 (0.28-0.84) and 0.86 (0.30-2.41) in Deyr ‘11/12. There were no outbreaks of any disease reported. The screening data from health facilities in the Hawd pastoral livelihood zone (Figure 21) show high (>30%) and stable trend of acutely malnourished children .

In the June ‘12 Addun assessment, the GAM rate was 14.5% (11.1-18.9) and the SAM rate was 2.4% (1.3 – 4.3) with two (0.3%) oedema cases reported, indicating a sustained Serious nutrition situation and no change from the respective GAM and SAM rates of 12.1% (9.0-16.0) and 2.8% (1.6-5.0) recorded in December ‘11. There are no significant differences in the level of acute malnutrition by gender, even though a higher proportion of assessed boys (16.2%) compared to girls (12.7%) are acutely malnourished (WHZ<-2/oedema). The retrospective CDR and U5DR rates are 0.48 (0.25-0.92) and 0.58 (0.19–1.76) both indicating Acceptable levels according to UNICEF classification, and similar to the retrospective CDR and U5DR rates of 0.32 (0.16-0.66) and 0.87 (0.31-2.42) reported in the December ’11 assessment.

figure 23: hiS Malnutrition trends in cowpebelt l/Z (2011-2012)

figure 24: hiS Malnutrition trends in central coastal deeh l/Z (2011-2012)

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Hawd (N=816: 432 boys; 384 girls)

Addun(N=701: (374 boys; 327 girls)

Dusamareb IDPs (N=202: 109 boys; 93 girls)

Indicator Results (%) Outcome Results (%) Outcome Results (%) OutcomeChild Nutrition StatusGlobal Acute Malnutrition (WHO 2006)

BoysGirls

11.2 (8.9-14.0)11.4 (8.7-14.9)10.9 (7.9-14.9)

Serious14.5 (11.1-18.9)16.2 (11.7-22.0)12.7 (9.1-17.5)

Serious22.0 (16.1-29.3)24.8 (17.1-34.4) 18.7 (11.2-29.6)

Very Critical


1.8 (0.9 – 3.4)1.9 (0.8-4.3)1.6 (0.7-3.5)

Acceptable2.4 (1.3 – 4.3)2.6 (1.1-6.0)2.2 (1.0-4.7)

Acceptable5.0 (2.5-9.8)6.4 (3.2-12.5) 3.3 (1.1-9.8)

Critical

Mean WHZ (WHO, 2006) -0.71±1.06 Serious -0.79±1.13 Serious -1.04±1.18 Critical

Global Acute Malnutrition (NCHS) 12.0 (9.6-15.1) Serious 14.8 (11.1-19.4) Serious 22.3 (16.2-29.8) Very Critical

Severe Acute Malnutrition (NCHS) 1.5 (0.8 – 2.8) Acceptable 1.7 (0.7 -4.4) Acceptable 3.0 (1.4-6.4) AlertProportion with MUAC (<12.5 cm or oedema)

BoysGirls

5.4 (3.3-8.6)5.3 (3.2-8.8)5.5 (2.9-10.0)

Alert8.4 (5.8 – 12.1)7.8 (5.1-11.5)9.2 (6.0-13.9)

Critical8.9 (5.1 – 15.1)8.3 (4.1-15.9)9.7 (5.0-18.0)

Critical

Proportion with MUAC (<11.5 cm or oedema) 0.4 (0.1– 1.1) Alert 1.7 (0.9-3.4) Serious 2.0 (0.6-6.5) SeriousStunting (HAZ<-2)

BoysGirls

11.1 (7.5-16.3)12.6 (8.5-18.3)9.5 (5.9-14.9)

Serious14.1 (10.1–19.4)17.9 (13.0-24.3)9.7 (6.1-15.0)

Serious18.0 (12.5-25.2)26.5 (17.2-38.4)8.7 (4.7-15.5)

Critical


10.7 (7.8–14.5)12.9 (9.2-17.9)8.2 (5.3-12.5)

Alert12.9 (9.7-17.1)14.7 (9.9-21.3)10.9 (7.6-15.2)

Alert23.1 (16.2-31.9)29.0 (21.0-38.5)16.3 (8.9-27.9)

Serious

HIS Nutrition Trends(Jan – Jun 2012)High (>30%) proportion and stable trends

Very CriticalHigh (>30%) proportion and stable trends

Very Critical N/A N/A

Proportion of acutely malnourished registered in SFsBoysGirls

6.17.04.8



Very Critical



Outbreak–NoneMorbidity– 30.6Boys– 30.1Girls -31.3

Diarrhea :10.2Pneumonia: 8.1Fever: 21.0

Critical

Outbreak–NoneMorbidity–36.8Boys – 37.2Girls -36.4

Diarrhoea - 11.7Pneumonia - 7.3Fever - 27.5

Critical

Outbreak -NoneMorbidity– 34.2Boys – 29.4Girls -39.8

Diarrhoea - 16.8Pneumonia – 16.8Fever - 17.8

Serious

Immunization Status

Vitamin A–70.2Boys – 69.2Girls – 71.4Measles – 71.4Boys – 70.1Girls – 72.9

Serious

Vitamin A –64.9Boys – 63.1Girls -67.0Measles – 60.8Boys – 60.2Girls -61.5

Critical

Vitamin A–72.8Boys – 77.1Girls – 67.7Measles – 88.1Boys – 92.7Girls – 82.8

Serious

Infant and Young child feeding N= 297 N=229 N=62Proportion still breastfeeding

Boys - Girls -

34.735.034.3



Serious

Proportion meeting recommended feeding frequenciesBoys - Girls -

41.445.037.2

Serious17.517.317.6


Very Critical

Proportion who reported to have consumed <4 food groupsBoys Girls

97.697.597.8



Very Critical

Death RatesCrude deaths per 10,000 per day (retrospective for 90 days) 0.38 (0.19-0.76) Acceptable 0.48 (0.25-0.92) Acceptable N/A N/AUnder five deaths per 10,000 per day (retrospective for 90 days) 0.50 (0.18-1.36) Acceptable 0.58 (0.19–1.76) Acceptable N/A N/AWomen Nutrition & Immunization Status N=416 N=375 N=99Proportion of acutely malnourished non pregnant/lactating women (MUAC≤18.5 cm) 0.8 (0.0-2.0) Serious 0.0 Acceptable 0.0 Acceptable

Proportion of acutely malnourished non pregnant/lactating women (MUAC≤21.0cm) 3.5 (0.7-6.3) Acceptable 5.8 (2.5-9.1) Alert 5.6 (0.0-6.2) Alert

Proportion of acutely malnourished pregnant/lactating women (MUAC<23.0). 13.5 (9.6-17.3) Acceptable 18.6 (10.5-26.7) Alert 33.3 (19.1-47.6) Critical

Proportion of Women who received Tetanus ImmunizationNo doseOne doseTwo dosesThree doses

24.213.721.340.8

Alert31.732.016.819.5

Serious

19.223.235.422.2

Alert

Public Health Indicators N=477 N=449 N=118Household with access to sanitation facilitiesMale headedFemale headed

76.577.970.2

Alert39.439.340.4


Serious

Household with access to safe waterMale headedFemale headed

44.443.847.6

Serious16.917.314.0


Alert

Food Security N=477 N=449 N=118Proportion who reported to have consumed <4 food groupsMale headedFemale headed

1.91.53.6

Acceptable9.68.914.0

Alert11.912.011.4

Serious

Household’s Main Food SourceOwn productionPurchase:Food aidBorrowing

0.694.14.40.6

Very Critical6.563.025.6-

Very Critical

5.133.348.7-

Very Critical

Food security phase Stressed Serious Stressed Serious Emergency Critical

Overall Situation Analysis Serious Serious Very Critical

Table 15: Summary of Key Nutrition Findings in Hawd, Addun and Dhusamareb IDPs Central regions

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Data from health facilities in the Addun pastoral livelihood zone reported a high proportion (>30%) and stable trend of acutely malnourished children (Figure 24).

Limited humanitarian interventions in the form of targeted interventions are ongoing in parts of the Hawd and Addun livelihood areas and may have assisted to mitigate the poor nutrition situation in Central regions. The support needs to be continued and expanded to cover more rural villages of Hawd, Addun and Coastal Deeh livelihood.

dhusamareb idPs

In May ‘12, FSNAU conducted a small sample cluster survey among IDPs in Dhusamareb, including those in Guriel area who have been displaced from South Somalia or are pastoral destitute from the Central pastoral livelihood zones. The GAM and SAM rates of 22.0% (16.1-29.3) and 5.0% (2.5-9.8) were reported respectively, indicating a Very Critical nutrition situation. Although the overall nutrition situation remains in the same phase (Very Critical), these findings are indicating an improvement from the Post Deyr ’11/12 results when the GAM and SAM rates were 32.3% (23.5-42.4) and 3.2% (1.0-6.2) respectively, likely due to limited humanitarian interventions and social support, and improving food security situation in the host and surrounding communities. This population group and many others cropping up in many other towns in the Central regions, however remain vulnerable to malnutrition, food insecurity and other health challenges, and require continued interventions.

The key nutrition evidence indicators of the analysis on the nutrition phase classification are provided in Table15.

central Agro-pastoral (cow pea belt) and coastal deeh pastoral livelihoods of central SomaliaThe integrated analysis of data from nutrition assessments conducted in June 2012 among the populations of Cow pea belt and Coastal Deeh of Central (South Mudug and Galgadud) regions, and the health facilities’ information shows a Critical phase in both livelihoods. These assessments did not meet certain data quality criteria (recording high standard deviations and plausibility scores) for SMART surveys and therefore only point estimates calculated from standard deviation of 1 are provided.

The Cow pea (central agro-pastoral) livelihood assessment reported a GAM rate of 16% and a mean weight-for-height Z score of -1.01 (±1.60). The HIS data from health facilities in the cowpea belt livelihood zone remains high (>20%) and show a stable trend (Figure 23). There was no survey conducted on these populations in Deyr ‘11/12 and thus no data to compare seasonal change. Integrated nutrition analysis from health facility data and rapid assessment conducted a year earlier in July 2011, had reported acute malnutrition (MUAC<12.5/oedema) and severe acute malnutrition (MUAC<11.5/oedema) rates of 12.5% and 4.9% respectively, classified the nutrition situation as likely Critical.

The Coastal Deeh pastoral livelihood assessment reported a GAM rate of 16.2% and a mean weight-for-height Z score of -1.04 (±1.49). The HIS data from health facilities in the Coastal Deeh of central areas remains high (>20%) and show a stable trend (Figure 24).

There were no outbreaks of any disease reported. Even though not directly comparable, rapid assessment conducted a year earlier in July 2011, had reported acute malnutrition (MUAC<12.5/oedema) and severe acute malnutrition (MUAC<11.5/oedema) rates of 16.9% and 5.4% respectively, and Post Gu ’11 integrated analysis classified the nutrition situation as likely Very Critical. The key nutrition evidence indicators of the analysis on the nutrition phase classification for cow pea belt and Coastal Deeh are provided in Table16.

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Cowpea Belt (N=1174: 592 boys; 582 girls)

Coastal Deeh(N=491: (244 boys; 247 girls)

Indicator Results (%) Outcome Results (%) Outcome

Child Nutrition Status

Global Acute Malnutrition (WHO 2006)[Calculated from SD of 1] 16.0 Critical 16.9 Critical

Severe Acute Malnutrition (WHO 2006) - - - -

Mean WHZ (WHO, 2006) -1.01 ±1.60 Critical -1.04 ±1.49 Critical

Stunting (HAZ<-2)[Calculated from SD of 1] 17.3 Critical 19.5 Critical

Underweight (WAZ<-2)[Calculated from SD of 1] 18.2 Alert 23.2 Serious

HIS Nutrition Trends(Jan – Jun 2012) High (>20%) proportion and stable trends Very Critical

High (>20%) proportion and stable trends

Very Critical



Outbreak–NoneMorbidity– 37.1

Diarrhoea :21.5Pneumonia: 14.6Fever: 17.2

Critical

Outbreak–NoneMorbidity–49.7


Critical

Immunization Status Vitamin A–2.3Measles – 3.3 Very Critical Vitamin A –0.4

Measles – 0.2 Very Critical

Death Rates

Crude deaths per 10,000 per day (retrospective for 90 days) 0.76 (0.48-1.22) Alert 0.56 (0.27-1.14) Alert

Under five deaths per 10,000 per day (retrospective for 90 days) 1.46 (0.86-2.48) Alert 1.34 (0.73–2.44) Alert

Food Security N=702 N=297

Food security phase Crisis Serious Emergency Critical

Overall Situation Analysis Likely Critical Likely Critical

table 16: Summary of key nutrition findings in cowpea belt Agro-pastoral and coastal deeh Pastoral of central regions - July 2012

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FOOd SAFETy ANd mALNuTriTiON iN SOmALiA

Food safety is not only an aspect of food security (access to sufficient amounts of safe and nutritious food), but also affects nutrition status by impacting on consumption and utilization of food in the body. Tens of thousands of people fall ill every year and many die due to consumption of unsafe food including water and basic drinks1. Given the absence of a stable government, that can legislate and reinforce food safety standards and regulations, food safety is one of the major public health problems in Somalia. According to WHO’s Somalia Emergency Health Update bulletins, serious food born diseases, mainly acute watery diarrhea (AWD), Salmonellosis, Hepatitis A and recurrent cholera epidemics are often observed in all regions of Somalia on a monthly, or seasonal basis.

According to the Meta analysis draft report (FSNAU, 2009)2, Somalia bears a heavy burden of reported child illness with 44.8% of the 105,314 children assessed between 2001-2008 having been reported ill in the two weeks prior to the (one month for suspected measles) individual surveys. A regression model (from the meta-analysis report) for the causes of malnutrition in Somalia reported a basal GAM prevalence of 9.6% and identified morbidity and dietary diversity as significant predictive factors, explaining 25.2% of the GAM prevalence, the remaining three quarters of the wasting prevalence thus explained by other causal factors including child feeding, food safety & hygiene, sanitation and food security factors as well as other diseases not covered in the surveys.

Food borne diseases, due to consumption of unsafe foods and drinks, whether infectious or toxic, are possibly major contributors to high malnutrition levels and related adverse effects including disability3 and organ dysfunctions in Somalia. While all population groups are susceptible to food-borne disease, there are groups more susceptible due to their low-levels of immunity, early stages of development or greater exposure, the most vulnerable groups being pregnant women and infants, developing foetus as well as young children4.

Due to poor storage and food handling practices, lack of a food safety policy and strategy, and monitoring system to evaluate the food safety and hygiene, there is unreliable data to measure the magnitude and severity of the problem. There is no active inspection for both imported and exported foods, nor a drug safety system. There is therefore some doubt whether all imported foods consumed in Somalia meet the internationally required standards and food safety criteria5. However, it is generally expected that most food storage systems at the household and commercial level are inappropriate and may contribute to both communicable and non communicable diseases country wide. For instance, there is great concern in sorghum and maize producing regions, because if this cereal is stored before it is fully dried it may facilitate aflatoxin contamination which leads to serious liver damage. Bay region is especially known for persistent elevated malnutrition levels even during bumper harvests, usually a time of sufficient food access6. The high malnutrition rates are attributed to a poor quality staple sorghum-based diet, and consumption of possibly contaminated sorghum stored underground. Further investigations are needed to determine the state of health of the population in regards to liver disease and oedematized wasting (very common in Juba regions) and the relationship with consumption of aflatoxin-contaminated cereals.

In Somalia it is also very common for food, diesel, kerosene, insect killers, fatal poisons, human or vet drugs to be all poorly stored together in one small living room, exposing people to mycotoxin, heavy metal and bacterial contamination. In addition, consumption of under-cooked meat and un-boiled milk contributes to the major zoonotic diseases such as brucellosis and bovine. Food spoilage is not restricted to cereal foods and affects animal source foods as well. The photo above illustrates a delicious Somali high-energy, high-protein ready-to-eat meat product that is common among Somali pastoralists called Muqmad or odkc that has been contaminated due to poor handling. The meat is preserved with ghee and sometimes, especially in urban areas, dates and sugar. The meat can be stored for a long time, but when it is not handled properly, and contaminated by dirty hands or spoons, the meat is easily spoiled.

To address this problem, the community (women, commercial groups, youth groups, and local governments) need to be educated on proper food storage and handling practices. Awareness on food safety standards in the community can be done through the local media and periodic workshops. In areas with more stable authorities, there is need to develop, implement, monitor and evaluate policies, strategies and programs that meet high levels of food safety for optimal nutrition.

1 Leon, W., & DeWaal, C.S. (2002). Is our food safe?: a consumer’s guide to protecting your health and the environment. Three Rivers Pr2 FSANU (October 2009). Malnutrition Trends (2001-2008) in Somalia – A meta analysis study report. 3 WHO global strategy for food safety: safer food for better health4 WHO/FAO, International Food safety Authority Network,2008.5 FAO/WHO-The Codex Alimentarius.6 FSNAU (August 2009). Nutrition Analysis Post Gu 2009. Technical Series Report .

Contaminated odka (Fried meat)

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4.7 nORtHeaSt ReGiOnS The Northeast regions are predominately pastoral with seven livelihood zones namely: the Hawd, Addun, Coastal Deeh, East Golis, Karkaar/Dharoor Valley, Nugal Valley and Sool Plateau. The Hawd and Addun cut across the Northeast and Central regions and the East Golis, Sool and Nugal Valley livelihoods cut across the NE and NW regions. (Map 11).

historical overview – Post Deyr ‘11/12

Food SecurityThe FSNAU Post Deyr ‘11/12 integrated food security analysis classified the East Golis/ Karkaar/Dharoor valley in Stressed phase, indicating an improvement from Crisis in the previous Gu ’11 season, and the Sool plateau and Nugal Valley livelihood zones of bari and Nugal regions remained in crisis. The Coastal Deeh livelihood zone was classified in a sustained Emergency since Deyr ‘10/11. The Hawd and Addun pastoral livelihoods in Nugal and northern Mudug regions that were classified in Aflc (or crisis) in Gu ‘11 were classified as Stressed, indicating an improvement. Food security improvements in the Golis, Hawd and Addun livelihood zones were attributed to a combination of factors such as improved income from frankincense sales/export in the East Golis and a boom in livestock trade in the regions during Hajj, strengthened purchasing power resulting from increased goat to rice ToT, and less restricted humanitarian access in the northeast regions. Declined fishing activities (in the coastal areas) due to hot weather and insecurity in main export market (yemen), limited access to milk and number of saleable animals amongst the poor, high water prices, and high debt levels contributed to the sustained livelihood crisis, especially in the Coastal Deeh and parts of Nugal Valley of Iskushuban and Qandala districts that had received below normal Deyr ‘11 rains.

NutritionThe Post Deyr ‘11/12 integrated nutrition situation analysis indicated a general improvement in the nutrition situation in most of the livelihood zones compared to the Gu ‘11 season. The nutrition situation improved in the populations of Sool plateau, Addun, and Coastal Deeh livelihood zones from Critical in Gu ‘11 to Serious. The nutrition situation was classified as Critical in the Nugal Valley livelihood zone, an improvement from Very Critical in the Gu ‘11 season. However, the nutrition situation slightly deteriorated in the East Golis/Karkaar and Hawd pastoral livelihoods from Serious to Critical. These deteriorations were due to the limited access to milk and poor dietary diversity following the effects of previous consecutive poor seasonal performance and disease in these livelihood zones. The WHO/MOH reported AWD and cholera outbreaks in the Hawd areas of Galkayo and Adaado districts that aggravated the situation. However, considering the positive food security indicators, the situation in Hawd was projected to improve. The nutrition situation also improved Garowe IDPs from the Very Critical phase in Gu ’11 to Critical, however a sustained Very Critical situation was observed among the bossaso, Qardho and Galkayo IDPs. The results were consistent with historical data on nutrition surveys conducted among the IDPs in the northeast region, which highlights the chronic nutritional vulnerabilities.

current Situation

Food SecurityThe current FSNAU Post Gu ‘12 integrated food security analysis has classified the East Golis/ Karkaar/Dharoor valley, the Hawd and Addun livelihood zones of Nugal and northern Mudug regions in sustained Stressed phase. The Sool plateau and Nugal Valley livelihood zones of Bari and Nugal regions are also classified in Stressed phase, indicating an improvement from the Crisis phase in Deyr ‘11/12. The upper partd (Alluula and Iskushuban) Coastal Deeh livelihood zone of Bari region is classified in a sustained Emergency since Deyr ‘10/11. However, the lower part of Coastal Deeh (Bandar beyla, Eyl and Jarriban) has improved to crisis from Emergency in Deyr ‘11/12. Food security improvements in the Sool plateau and Nugal Valley livelihood zones are attributed to a combination of factors such as improved access to milk and strengthened purchasing power resulting from increased goat to rice ToT, and less restricted humanitarian access in the northeast regions. The lower part of Coastal Deeh (Bandar beyla, Eyl and Jarriban) has also shown improvement in goat/rice ToT, and increased milk production. However, limited (below baseline) livestock holding, low fishing activities, poor milk production in most parts of the Coastal Deeh livelihood and presence of pastoral destitutes aggravate the food security situation. The situation is projected to improve in the upper part of the livelihood in the next six months due to anticipated improvements in livestock body condition and sales, following the good rainfall prospects for the area and a reduction in the international antipiracy activities opening up fishing opportunities. However, low kidding/calving and associated milk production is expected for all species due to low conception rates in the current season.

NutritionThe Post Gu ‘12 nutrition situation depicts a mixed picture in the nutrition situation in the livelihood zones compared to the Deyr ‘11/12 season (Figure 25). The nutrition situation has improved in the populations of East Golis and Hawd livelihoods, from Critical in Deyr ‘11/12 to Serious. The nutrition situation in Sool, Addun and Coastal Deeh is classified in a sustained Serious phase. However, the nutrition situation deteriorated among the populations of Nugal Valley to Very Critical from Critical in Deyr ‘11/12. The situation in Nugal valley follows a seasonal pattern of improvements in Deyr and deteriorations in Gu, having improved from Critical in Deyr ‘11/12 and deteriorated back to the Very Critical phase reported in Gu ’11. A measles outbreak reported in parts of the western districts of Nugal Valley largely contributed to the worsened situation, despite

Map 11: northeast livelihood Zones

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the positive food security indicators. The improvements in East Golis and Hawd are linked to improved milk access, dietary diversity and humanitarian intervention. The WHO/MoH had reported AWD and cholera outbreaks in the Hawd areas of Galkayo and Adaado districts that aggravated the situation in Deyr ‘11/12, however, this was controlled and there was no disease outbreak reported in the livelihood zone this season. Among the IDPs, the nutrition situation has improved in bossaso and Galkayo from Very Critical to critical level, and sustained Critical and Very Critical levels in Garowe and Qardho respectively. The results are consistent with historical data on nutrition surveys conducted among the IDPs in the northeast region, which highlights the chronic nutritional vulnerabilities.

(U5DR) of 0.11 (0.03-0.34) and 0.15 (0.02-1.18) indicate an Acceptable situation according to UNICEF classification, similar to the respective CDR and U5DR of 0.26 (0.10-0.65) and 0.36 (0.04-2.82) reported in December ‘12.

besides the chronic poor infrastructure, the area received a second season of near normal rains , though with exception of pocket areas after a long period of four consecutive below normal rainfall in the previous seasons, and so is yet to recover fully from livestock losses and debts. Improved sheep/goat calving has increased access to milk, but is limited due to the previous herd size reduction/losses. Access to camel milk is poor to average due to low conception and calving in the previous season.

figure 26: hiS Malnutrition trends in Golis/ karkaar lZ (2010-2012)

Data Source: MoH; SRCS

Figure 25: trends in levels of acute malnutrition (WhZ<-2 or oedema, Who 2006) northeast regions (2007-2011)

Gender: Analysis of findings from the nutrition assessments conducted in the northeast regions of Somalia generally indicates a higher proportion of boys than girls as acutely malnourished (WHZ<-2 or oedema). Conversely, a higher proportion of girls than boy were acutely malnourished based on MUAC (< 125 mm or oedema). However, these differences were generally not statistically significant (Pr<0.75). Other child data such as dietary diversity, illness, feeding practices, and immunization status, do not show any clear differences by gender. Analysis of household data by gender of household head did not find any significant difference nor a clear trend in the proportion with access to sanitation facilities, access to safe drinking water nor consumption of diversified diet. The gender disaggregated data by sex of the assessed children and sex of the household head per livelihood is summarized on Tables 17 and 18.

The detailed results of the assessments in the Hawd and Addun, cutting across both NE and Central regions are discussed in the section for Central zone.

East Golis/ karkaar/dharoor livelihood ZonesThe current Post Gu ’12 integrated nutrition situation analysis classifies the nutrition situation of the population in East Golis/Karkaar/Dharoor livelihood zone of Bari region as Serious. In July‘12, FSNAU and partners conducted a comprehensive nutrition survey in the East Golis/Karkaar/Dharoor livelihood zone of bari region. The results indicated a GAM rate of 13.9% (10.8-17.6) and SAM rate of 4.1% (2.6-6.5) including two (0.3%) oedema cases. These rates show an improvement from the Critical situation reported in the December ‘12 assessment conducted in the same livelihood and region, when the GAM rate was 15.2% (12.1-18.8) and SAM rate was 3.8% (2.3-6.4). Higher proportions of assessed boys (14.1%) were acutely malnourished as compared to girls (13.6%), although the difference was not statistically significant. The 90 days retrospective crude (CDR) and under five death rates

Data from the health facilities namely Ufeyn, Waaciye and Iskushuban indicate high proportions (>10%) of acutely malnourished children, with an increasing trend in three (Apr-Jun ’12) months (Figure 26). Considering these HIS trends, low mortality rates, and the continued gradual recovery of food security indicators, it is projected that the nutrition situation among the East Golis livelihood population is likely to remain Serious in the coming six months with expected above normal rainfall forecasts. The population remains vulnerable to natural shocks and requires close monitoring, in addition, there is need to address the chronic issues affecting the nutrition status of the population such as inadequate health and sanitation facilities, poor child feeding and care practices and lack of adequate safe drinking water. In the short term, the rehabilitation of the acutely malnourished children, is required.

Sool Plateau livelihood Zone of northeastThe nutrition situation of the Sool plateau of bari and Nugal regions has sustained the Serious phase since Deyr ‘11/12. Results from the nutrition survey conducted in July ‘12 covering four regions of bari, Nugal, Sool and Sanaag report a GAM rate of 11.3% (9.3-13.8) and a SAM rate of 1.7% (0.9-3.0). No oedema was reported. The rates indicate no significant change from the December ‘12 GAM and SAM rates of 11.6% (8.7-15.3) and 3.4% (2.0-5.7). A higher percentage of boys (13.7%) than girls (9.0%) were acutely malnourished, though not statistically significant. The 90 days retrospective CDR and U5DR of 0.12 (0.05-0.31) and 0.40 (0.13-1.24) were reported respectively, both indicating Acceptable levels according to UNICEF classification. HIS data in the area recorded low (<10%) and stable proportions of acutely malnourished children screened at health facilities (Figure 27).

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The nutrition situation in the livelihood is mitigated by increased milk access in the area, following successive good Deyr ‘11/12 and Gu ’12 rains and localized humanitarian interventions such as cash relief, food aid, health and nutrition. Although a sustained improvement is projected with a good Deyr ‘12/13 forecast, the vulnerability of the region to natural shocks, e.g. drought, rise in prices, and disease outbreaks necessitates continued close monitoring of the situation.

nugal valley livelihood ZoneThe current Post Gu ‘12 integrated nutrition analysis classifies the nutrition situation of the Nugal Valley as Very Critical, a deterioration from the Critical levels in the Deyr ‘11/12 (Table 14). The nutrition survey conducted in July ‘12 by FSNAU and partners covering the Nugal Valley livelihood zone that cuts across NW and NE regions, reported a GAM rate of 20.1% (16.5-24.3) and a SAM rate of 5.4% (3.9-7.5). No oedema was reported in the assessment. These results show a deterioration (Pr>75%) from the GAM rate of 16.3% (13.5-19.6) and a SAM rate of 5.2% (3.9-6.8) reported in the December ‘11 assessment. The 90 days retrospective crude (CDR) and under five death rates (U5DR) of 0.04 (0.01-0.32) and 0.19 (0.02-1.46) respectively, are Acceptable and did not show any significant change from the respective CDR and U5DR of 0.19 (0.09-0.40) and 0.48 (0.15-1.45) recorded in December ‘11.

Though not statistically significant, a higher proportion of assessed boys (22.2%) than girls (17.9%) were acutely malnourished. Data from the health facilities namely Sinujiif, Gambool and Waaberi, indicates low numbers (<10%) but an increasing trend of acutely malnourished children (Figure 28). The deterioration in the nutrition situation is likely linked to disease outbreaks. A measles outbreak was reported in the western parts of the livelihood. However, improved dietary diversity and increased intake of milk and meat products following the good Gu rainy season, and access to humanitarian support given the relative stability in the area are mitigating factors and the situation is likely to improve in the next season if disease outbreak is controlled.

High morbidity rates (23.9%) reported from the survey and from the local health facilities, low vitamin A supplementation status (74.8%) and measles vaccination status (77.2%), poor water and sanitation and limited health facilities in the community are some of the aggravating factors for the Very Critical nutrition situation. More than 40% of the households do not have sanitation facilities and a large majority (>80%) of the assessed population do not have safe drinking water. Therefore, the population groups in this livelihood zone need continued nutrition and livelihood interventions with close monitoring especially in light of the chronic vulnerability in the area. The key findings for East Golis, Sool and Nugal livelihood zones are summarized in Table 17.

coastal Deeh livelihood Zone of northeastThe nutrition situation of the Coastal Deeh population of Nugal, bari and North Mudug regions has sustained Serious levels since Deyr ‘11/12. Except for a few spots that received below normal Deyr rains, the area has experienced improved access to milk and income associated with favorable terms of trade (local goat to rice).

A nutrition survey conducted in July ‘12, reported a GAM rate of 12.8 % (8.7-18.4) and SAM rate of 3.5% (1.7-6.8), indicating a Serious nutrition situation and no change from the situation in Deyr ‘11/12 when a GAM rate of 12.2

% (8.9-16.3) and SAM rate of 3.1% (1.9-5.0) were recorded. A higher proportion of assessed boys (15.0%) were acutely malnourished (WHZ<-2 or oedema) compared to girls (10.0%) but this difference was not statistically significant. The 90-days retrospective crude (CDR) and under five death rates (U5DR) of 0.56 (0.27-1.14) and 1.34 (0.73-2.44) respectively were recorded, both indicating Alert levels and a slight deterioration from the Acceptable levels with respective CDR and U5DR of 0.19 (0.08-0.43) and 0.77 (0.28-2.08) recorded in December ‘11. The reported deaths were suspected to have mainly been caused by diarrhoea. Data from health facilities in the NE coastal areas also indicated a high (>15%) but decreasing proportion of acutely malnourished children.

Morbidity, poor access to sanitation and drinking water in the area remain critical, with 20.3% of the assessed children reported to have fallen ill in the two weeks preceding the assessment and only 63.1% and 55.2% of the households having access to sanitation facilities and safe drinking water respectively. Previous consecutive rain failures in the Deyr ‘10/11 and Gu ‘11 led to a significant deterioration of livestock body conditions and deaths resulting in reduced household income, and meat and milk consumption. Therefore a second successful season with pockets of poor rains is not sufficient for the households to fully recover their assets and livestock heads. The situation needs close monitoring amidst seasonal changes in labour opportunities from fishing activities due to the presence of sea pirates, strong sea tides, and chronically poor infrastructure and frequent disease outbreaks. The findings for Coastal Deeh pastoral livelihoods are summarized in Table 17.


figure 27: hiS Malnutrition trends in Sool Plateau lZ (2011-2012)


figure 28: hiS Malnutrition trends in nugal valley lZ (2011-2012)

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table 17: Summary of key nutrition findings in northeast regions - July 2012East Golis(N= 695: Boys= 360; Girls=335)

Nugal Valley (N=619: Boys=311; Girls=308)

Sool Plateau (N=748: Boys= 365; Girls=383)

Indicator Results Outcome Results Outcome Results OutcomeChild Nutrition StatusGlobal Acute Malnutrition (WHO 2006)

BoysGirls

13.9 (10.8 – 17.6)14.1 (10.5 – 18.7)13.6 (9.8 – 18.6)

Serious20.1 (16.5-24.3)22.2 (17.2-28.5)17.9 (14.4-22.0)

Very Critical11.3 (9.3-13.8)13.7 (9.9-18.6)9.0 (6.8-11.9)

Serious


BoysGirls

4.1 (2.6 – 6.5)4.2 (2.5 – 7.2)4.0 (2.2 – 7.3)

Serious5.4 (3.9-7.5)6.2 (4.1-9.5)4.6(2.9-7.4)

Critical1.7 (0.9-3.0)1.4 (0.6-3.4)1.9 (1.0-3.7)

Acceptable

Mean WHZ (WHO, 2006) -0.89 ±1.08 Serious -0.96 ±1.19 Critical -0.67 ±1.08 Alert

Oedema 0.3 Very Critical 0.6 Very Critical 0.0 Acceptable

Global Acute Malnutrition (NCHS) 13.0 (10.4 – 16.1) Serious 20.0 (16.4-24.2) Very Critical 11.9 (9.4-15.1) Serious

Severe Acute Malnutrition (NCHS) 1.9 (1.2 – 3.1) Acceptable 2.4 (1.5-3.9) Acceptable 2.0 (1.2-3.5) AcceptableProportion with MUAC <12.5 cm or edema

BoysGirls

5.2 (3.7 – 7.1)4.7 (2.8 – 7.9)5.7 (4.0 – 8.0)

Alert2.8 (1.5-4.9)3.2 (1.5-4.9)2.3 (1.0-5.0)

Alert2.7 (1.7-4.1)1.9 (1.0-3.6)3.4 (2.0-1.3)

Alert

Proportion with MUAC <11.5 cm or edema

1.0 (0.5 – 2.0)1.4 (0.6 – 3.2)0.6 (0.1 – 2.5)

Serious1.5 (0.9-2.7)1.5 (0.7-3.4)1.6 (0.7-3.5)

Serious0.5 (0.2-1.3)0.5 (0.1-2.2)0.5 (0.1-2.1)

Acceptable


11.2 (8.5 – 14.7)11.5 (7.4 – 17.5)10.8 (8.1 – 14.4)

Alert5.2 (3.5-7.7)6.1(3.8-9.7)4.2 (1.9 -9.3)

Acceptable12.0 (9.0-15.9)16.2 (11.5-22.5)8.0 (5.3-11.7)

Acceptable


14.5 (11.4 – 18.3)

15.0 (11.1 – 20.0)13.9 (10.3 –

18.6)

Alert14.6 (12.2-17.4)16.5 (12.1-22.0)12.7 (9.2-17.4)

Alert11.6 (8.5-15.6)12.6 (8.5-18.2)10.7 (7.4-15.2)

Alert

HIS Nutrition Trends(Jan-Jun 2012) High (>10%) and increasing Serious Low (<10% but

increasing Serious Low (<10) and stable Alert

Proportion of acutely malnourished registered in SFs

BoysGirls

3.03.92.0

Very Critical

19.822.916.1


Very Critical



Outbreak –NoneMorbidity- 27.9

Boys- 27.5Girls-28.4

Diarrhoea – 9.1Boys -9.2Girls- 9.0

Pneumonia- 9.5Boys- 8.9Girls- 10.1

Fever= 21.3Boys- 20.6Girls- 22.1

Serious

Measles outbreak in the western partsMorbidity- 23.9

Boys-24.8Girls-23.1

Diarrhoea – 8.1Boys-9.6Girls-6.5

Pneumonia- 8.1Boys-8.7Girls-7.5

Very Critical

Outbreak – NoneMorbidity-22.3

Boys-21.7Girls-23.0



Very Critical

Immunization Status

Vitamin A – 71.7Boys- 73.9Girls- 69.3

Measles –69.8Boys-71.1Girls-68.4

Serious

Vitamin A –74.8Boys-76.5Girls-73.1Measles – 77.2Boys-77.8Girls-76.6

Serious

Serious

Vitamin A- 78.3Boys-79.4Girls-77.3

Measles – 74.5Boys- 75.1Girls-73.9

Serious

Serious

Infant and Young child feeding N= 221 N=217 N=249Proportion still breastfeeding (6-24 months)BoysGirls

46.646.446.8

Serious43.339.547.2

Serious42.539.245.8

Serious

Proportion meeting recommended feeding frequenciesBoysGirls

60.656.365.1

Serious45.650.140.1


Very Critical

Proportion who reported to have consumed <4 food groupsBoysGirls

76.575.078.0



Very Critical

Death RatesCrude death per 10,000 per day (retrospective for 90 days)

0.11 (0.03 – 0.34) Acceptable 0.04 (0.01-0.32) Acceptable 0.12 (0.05-0.31) Acceptable

Under five deaths/10,000 /day (retrospective for 90 days) 0.15 (0.02-1.18) Acceptable 0.19 (0.02-1.46) Acceptable 0.40 (0.13-1.24) Acceptable

Women Nutrition & Immunization Status N=410 N=435 N=496

Proportion of acutely malnourished non pregnant/lactating women (MUAC≤18.5 cm)

N=2780.0 Acceptable N=299

0.0 Acceptable N=2680.0 Alert

Proportion of acutely malnourished non pregnant/lactating women (MUAC≤21.0cm)

N=1328.3 (3.4-13.3) Alert N=136

2.9 (0.0-7.2) Acceptable N=2280.0 Acceptable

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Proportion of acutely malnourished pregnant/lactating women (MUAC<23.0).

N=13228.8 (18.6-39.0) Critical N=136

10.6 (1.7-19.4) Acceptable N=2280.0 Critical

Proportion of Women who received Tetanus Immunization

No doseOne doseTwo dosesThree doses

36.18.821.733.4

Alert

24.723.816.235.4

Serious

16.817.834.031.3

Serious

Public Health Indicators N= 442 N= 351 N=425Household with access to sanitation facilities

Male headedFemale headed

60.257.365.0



Critical


31.031.929.4

Critical12.37.128.9


Very Critical

Food SecurityProportion who reported to have consumed <4 food groupsMale headed-Female headed-

1.60.73.1

Acceptable11.712.39.6 Alert

1.61.80

Acceptable

Household’s Main Food SourceOwn productionPurchase:Borrowing

-97.52.5



Acceptable

Food security phase Stressed Serious Stressed Serious Stressed Serious

Overall Risk to Deterioration Likely to sustain Uncertain Likely to sustain

Overall Situation Analysis Serious Very Critical Serious

idPs of the northeast: bossaso, Qardho, Garowe and Galkayo The nutrition situation of IDPs in the northeast regions has either improved or remains at sustained Critical-Very Critical phases as classified in the Post Deyr ’11/12. Based on surveys conducted in May ‘12, the nutrition situation is currently classified as Critical among bossaso, Garowe and Galkayo IDPs, and Very Critical among Qardho IDPs, as the population remains vulnerable to effects of pastoral destitution conflict and unfavourable market forces.

Findings from the bossaso IDPs assessment recorded a GAM rate of 18.7% (15.7-22.1) and SAM rate of 3.9% (2.8 - 5.4), with two (0.2%) oedema cases. Significantly more boys (22.4%) than girls (15.4%) were acutely malnourished (Pr>87.5%), a disparity possibly explained by the use of the new WHO 2006 sex-differentiated reference standards, which has been observed to discriminatively identify more boys as acutely malnourished. The results indicate a Critical nutrition situation, a significant improvement (Pr>87.5%) from the Very Critical situation reported in the November 2011 assessment when a GAM rate of 24.1% (21.3-27.2) and SAM rate of 7.2% (6.0 - 8.7) were recorded. The retrospective crude and under five death rates of 0.33 (0.15-0.73) and 0.61 (0.28-1.32), both indicate Acceptable levels among the bossaso IDPs according to UNICEF classification. The CDR and U5DR show a slight

improvement from the Alert levels with respective rates of 0.68 (0.44-1.07) and 1.51 (0.84-2.72) reported in the November 2011 assessment. The results also show an improvement from seasonal levels of GAM rates >20% usually observed in the Gu since 2009. Data from health facilities in bossaso indicated a high (>15%) but decreasing trend of acutely malnourished children. The improvement is attributed to interventions by humanitarian organizations and the Puntland authorities in the form of targeted food distributions for the acutely malnourished and other nutrition and health services. Other factors such as unstable access to casual labour at the bossaso port, out-migration of the better off escaping the high temperatures, and reduced fishing activities because of the high tides and winds at sea, still contribute to the persistent poor nutrition situation. The findings of IDPs assessments among Bossaso, Garowe and Galkayo IDPs are presented in Table 17.

Among the Qardho IDPs, a small sample cluster survey conducted in May 2012, reported a GAM rate of 21.7% (16.8-27.6) and SAM rate of 5.6% (3.3-9.2), indicating a Very Critical nutrition situation. These findings are consistent with the November 2011 assessment that reported a GAM rate of 20.4% (14.8-27.4) and SAM of 6.1% (3.6-10.2), indicating a sustained Very Critical nutrition levels. Similar proportions of boys (20.2%) and girls (23.2%) were acutely malnourished based on weight-for-height Z scores (<-2) and/or oedema. The displaced populations in Qardho have

Summary of key nutrition findings in northeast regions - July 2012-continued

figure 29: trend in levels of Acute Malnutrition (WhZ<-2 or oedema, Who 2006) in northeast idPs (2006-2012)

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Hawd (N=816: 432 boys; 384 girls)

Addun(N=701: (374 boys; 327 girls)

Coastal Deeh(N=385: 209 boys; 176 girls)

Indicator Results (%) Outcome Results (%) Outcome Results OutcomeChild Nutrition StatusGlobal Acute Malnutrition (WHO 2006)

BoysGirls

11.2 (8.9-14.0)11.4 (8.7-14.9)10.9 (7.9-14.9)

Serious14.5 (11.1-18.9)16.2 (11.7-22.0)12.7 (9.1-17.5)

Serious12.8 (8.7–18.4)15.0 (9.4–23.3)10.0 (6.1–15.9)

Serious


1.8 (0.9 – 3.4)1.9 (0.8-4.3)1.6 (0.7-3.5)

Acceptable2.4 (1.3 – 4.3)2.6 (1.1-6.0)2.2 (1.0-4.7)

Acceptable3.5 (1.7–6.8)3.9 (1.9–7.1)2.9 (1.0–8.0)

Serious

Mean WHZ (WHO, 2006) -0.71±1.06 Serious -0.79±1.13 Serious -0.77 ±1.09 Serious

Global Acute Malnutrition (NCHS) 12.0 (9.6-15.1) Serious 14.8 (11.1-19.4) Serious 13.5 (9.3–19.2) Serious

Severe Acute Malnutrition (NCHS) 1.5 (0.8 – 2.8) Acceptable 1.7 (0.7 -4.4) Acceptable 1.3 (0.5 – 3.5) AcceptableProportion with MUAC (<12.5 cm or oedema)

BoysGirls

5.4 (3.3-8.6)5.3 (3.2-8.8)5.5 (2.9-10.0)

Alert8.4 (5.8 – 12.1)7.8 (5.1-11.5)9.2 (6.0-13.9)

Critical2.6 (1.2 – 5.6)1.9 (0.7 – 4.9)3.4 (1.1 – 10.3)

Alert

Proportion with MUAC (<11.5 cm or oedema) 0.4 (0.1– 1.1) Alert 1.7 (0.9-3.4) Serious 0.8 (0.2 –2.5) Alert


11.1 (7.5-16.3)12.6 (8.5-18.3)9.5 (5.9-14.9)

Alert14.1 (10.1–19.4)17.9 (13.0-24.3)9.7 (6.1-15.0)

Alert12.0 (8.8–16.2)12.9 (8.5–19.1)11.0 (6.4– 18.4)

Alert


10.7 (7.8–14.5)12.9 (9.2-17.9)8.2 (5.3-12.5)

Alert12.9 (9.7-17.1)14.7 (9.9-21.3)10.9 (7.6-15.2)

Alert14.2(10.4–19.3)16.5(11.4–23.3)11.6 (6.7–19.3)

Alert

HIS Nutrition Trends(Jan – June 2011) High proportion (>10%) and stable Serious High (>15%) but

decreasing Critical High (>15%) but decreasing Critical


BoysGirls

6.17.04.8



Critical



Outbreak–NoneMorbidity– 30.6

Boys– 30.1Girls -31.3

Diarrhea :10.2Pneumonia: 8.1Fever: 21.0

Critical


Boys – 37.2Girls -36.4


Critical


Boys – 20.1Girls -20.5


Serious

Immunization Status

Vitamin A–70.2Boys – 69.2Girls – 71.4

Measles – 71.4Boys – 70.1Girls – 72.9

Serious

Vitamin A –64.9Boys – 63.1Girls -67.0

Measles – 60.8Boys – 60.2Girls -61.5

Critical

Vit A –76.1Boys – 78.5Girls -73.3

Measles – 68.3Boys – 70.3Girls - 65.9

Serious

Infant and Young child feeding N= 297 N=229 N=129Proportion still breastfeeding (6-24 months)Boys - Girls -

34.735.034.3



Critical

table 18: Summary of key nutrition findings in hawd, Addun and coastal deeh northeast regions

also benefitted from the supplementary and therapeutic nutrition interventions by Puntland authorities, together with local and international organizations, which have mitigated the situation from further deterioration.

The results of the Garowe nutrition assessment conducted in May 2012 show a GAM rate of 19.2% (15.9- 23.1) and a SAM rate of 4.7% (0.9- 3.7), including two (0.2%) oedema cases, indicating a sustained Critical nutrition situation. Similar levels were reported in the November 2011 survey with GAM and SAM rates of 17.8 % (14.7-21.2) and 4.5 % (3.2-6.3) respectively. boys (19.3%) and girls (19.2%) were equally acutely malnourished (WHZ<-3/oedema). The CDR and U5DR of 0.43 (0.25-0.75) and 0.59 (0.25-1.39), both indicate Acceptable levels among the Garowe IDPs according to UNICEF 2005 classification. The CDR and U5DR show similar levels to the retrospective rates of 0.30 (0.15-0.59) and 0.77 (0.31-1.88) reported in the November 2011 survey. The internally displaced populations in Garowe have historically reported stable Serious-Critical levels since June 2010 (Fig. 31). Continued government, non-governmental organization interventions including active case finding and referral of acutely malnourished

children and Diaspora support, have contributed to the stability, and in mitigating possible deterioration in this vulnerable population. However, continued conflict-related displacements from the south-central regions have exerted pressure on the host communities, coupled with limited labour opportunities and high food prices have constrained access to food and economic resources among the IDPs.

Results for the Galkayo IDP assessment conducted in May 2012 recorded a GAM rate of 19.2% (16.1-22.8) and SAM rate of 4.1% (3.0-5.6) including two (0.5%) cases of oedema, indicating a Critical nutrition situation. The proportion of boys (21.3%) who were acutely malnourished was higher than that of girls (17.3%), but the difference was not statistically significant. Although these findings show improvement from Very Critical levels of 21.8% (18.6-25.4) and 5.9% (4.2-8.2) for GAM and SAM rates respectively reported in November 2011, the change is not statistically significant (Pr<75%). The retrospective crude and under five death rates of 0.22 (0.11-0.43) and 0.62 (0. 27-1.44) among Galkayo IDPs are both within the Acceptable levels according to WHO classification and an improvement from the respective Alert rates of 0.80 (0.45-1.42) and 1.39 (0.62-2.08 reported in the November 2011 survey.

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Proportion meeting recommended feeding frequenciesBoys - Girls -

41.445.037.2

Serious17.517.317.6


Serious

Proportion who reported to have consumed <4 food groupsBoys - Girls -

97.697.597.8



Very Critical

Death RatesCrude deaths/ 10,000/ day (retrospective for 90 days) 0.38 (0.19-0.76) Acceptable 0.48 (0.25-0.92) Acceptable 0.56 (0.27-1.14) Alert

Under five deaths/ 10,000 /day (retrospective for 90 days) 0.50 (0.18-1.36) Acceptable 0.58 (0.19–1.76) Acceptable 1.34 (0.73–2.44) Alert

Women Nutrition & Immunization Status N=416 N=375 N=238


0.8 (0.0-2.0) Serious 0.0 Acceptable 0.0 Acceptable


3.5 (0.7-6.3) Acceptable 5.8 (2.5-9.1) Alert 1.0 (0.0-3.2) Acceptable

Proportion of acutely malnourished pregnant/lactating women (MUAC<23.0). 13.5 (9.6-17.3) Acceptable 18.6 (10.5-26.7) Alert 14.4 (7.5-21.4) Alert



24.213.721.340.8

Alert31.732.016.819.5

Serious20.28.830.340.8

Alert

Public Health Indicators N=477 N=449 N=252Household with access to sanitation facilitiesMale headedFemale headed

76.577.970.2

Alert39.439.340.4


Serious


44.443.847.6

Serious16.917.314.0


Serious

Food Security N=477 N=449 N=252Proportion who reported to have consumed <4 food groupsMale headedFemale headed

1.91.53.6


Alert2.41.24.8

Acceptable

Household’s Main Food SourceOwn productionPurchase:Food aidBorrowing

0.694.14.40.6

Very Critical6.563.025.60.0

Very Critical0.075.823.40.0

Very Critical

Food security phase Stressed Serious Stressed Serious Crisis Serious

Overall Situation Analysis Serious Serious Serious

These findings indicate considerably high morbidity rates (>37%) which have a direct effect on the nutrition status of the children. Suspected measles outbreak reported in Galkayo district during the Gu season was controlled. For all the four IDP populations, vaccination status by recall and Vitamin A supplementation are still sub-optimal (60-80%) and far below the Sphere (2004) threshold (Table 19).

Although the IDPs population in the urban settlements often have better dietary diversity and access to safe water and sanitation facilities compared to the rural households, the household’s access to food, water and other basic services among this group is dependent on the level of income or purchasing power and social support, which remain a major challenge for most displaced populations when food prices rise. Among the assessed IDP populations, only 5% or fewer households in bossaso, Qardho, Garowe and Galkayo IDP settlements consumed poorly diversified diets, comprising of three or fewer food groups, mainly obtained through purchase (87-99.6%). Furthermore, a high proportion of the assessed households among the IDP settlements have access to sanitation facilities, with the proportion of the assessed households reporting access to some type of sanitation facility ranging from 84% in bossaso, to 100% in Qardho IDP settlements. Similarly, the proportion of the assessed households reporting access to safe drinking water ranged from 71.1% in Garowe to 99% in Qardho.

Overall, the nutrition situation is Critical to Very Critical among IDPs of Northeast. bossaso, Garowe and Galkayo IDPs are in Critical levels while Qardho IDPs is in Very Critical nutrition. The reasons for the persistent situation and for the improvements are multiple and are associated with climate, food security, level of social support, population and conflict dynamics in the south as well as health related factors. The reliance of IDPs on insufficient humanitarian assistance and on irregular casual labour for income to buy food and other none food items makes them susceptible to food insecurity and malnutrition. The situation is exacerbated by the high food prices and poor food access resulting from the effects of conflict and past drought in the region and inability of the host communities to provide social support. Interventions to improve and stabilize food access and provision of health services are crucial in addressing limited food and in tackling the high morbidity levels, thereby mitigating the high levels of acute malnutrition. Where substantial support was reported and the food security indicators of the surrounding host communities improved, the nutrition situation also showed some improvement. Continued and concerted efforts are thus needed to rehabilitate acutely malnourished children and prevent further deterioration.

Summary of key nutrition findings in hawd, Addun and coastal deeh northeast regions-continued

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table 19: Summary of key nutrition findings among northeast idPs (bossaso, Qardho, Garowe and Galkayo) – May 2012

Bossaso (N=1009; 481boys, 528 girls)

Qardho IDPs(N=202; 101 boys, 101 girls)

Garowe (N=821; 422 boys, 399 girls)

Galkayo (N= 997; 473 boys, 524 girls)

Indicator Results Outcome Results Outcome Results Outcome Results OutcomeChild Nutrition Status

Global Acute Malnutrition (WHO 2006)

BoysGirls

18.7 (15.7 – 22.1)22.4 (17.5 – 28.1)15.4 (12.6 – 18.7)

Critical21.7 (16.8-27.6)20.2 (14.0-28.3)23.2 (17.2-30.6)

Very Critical19.2 (15.9 – 23.1)19.3 (15.4 – 23.9)19.2 (14.8 – 24.5)

Critical

19.2 (16.1 – 22.8)21.3 (17.2 – 26.1)17.3 (13.2 – 22.4)

Critical


BoysGirls

3.9 (2.8 – 5.4)4.9 (2.9 – 8.0)3.1 (1.9 – 4.9)

Serious5.6 (3.3-9.2)6.1 (2.7-13.0)5.1 (2.2-11.4)

Critical4.7 (3.2 – 6.8)4.6 (2.6 – 8.0)4.9 (3.2 – 7.3)

Critical4.1 (3.0 – 5.6)5.2 (3.6 – 7.5)3.1 (1.9 – 4.9)

Serious

Mean WHZ (WHO, 2006) -1.06 ±1.05 Critical -0.83 ±1.37 Serious -0.97 ±1.15 Serious -1.04 ±1.11 Critical

Global Acute Malnutrition (NCHS) 16.6 (14.1 – 19.5) Critical 22.5 (17.2-28.9) Very Critical 17.8 (14.5 – 21.7) Critical 19.3 (16.4 –

22.6) Critical

Severe Acute Malnutrition (NCHS) 1.3 ( 0.6 – 2.8) Acceptable 2.5 (1.0-5.9) Alert 2.3 (1.5 – 3.7) Acceptable 2.1 (1.4 – 3.3) Acceptable

Proportion with MUAC <12.5 cm or oedema

BoysGirls

11.5 (9.0 – 14.4)9.4 (6.8 – 12.7)13.4 (9.9 – 17.5)

Critical12.4 (8.7-17.3)16.0 (10.0-24.2)8.9 (4.7-16.4)

Very Critical9.9 (7.7 – 12.6)7.1 (4.7 – 10.7)12.8 (9.5 – 17.0)

Critical6.6 (4.8 – 8.8)4.5 (2.8 – 7.0)8.4 (5.8 – 11.9)

Serious

Proportion with MUAC <11.5 cm or oedema 3.8 (2.6 – 5.5) Very Critical 3.0 (1.4-6.4) Critical 2.1 (1.3 – 3.3) Critical 1.3 (0.7 – 2.6) Serious


34.9 (31.1 – 39.0)40.2 (35.6 – 44.9)30.2 (25.3 – 35.6)

Serious33.3 (25.9-41.7)36.8 (25.4-49.9)29.8 (20.3-41.5)

Serious25.9 (22.0 – 30.3)25.3 (20.4 – 30.9)26.6 (21.9 – 31.9)

Serious

17.3 (13.1 – 22.5)19.0 (14.7 – 24.1)15.8 (11.1 – 22.0)

Alert


32.0 (27.6 – 36.8)37.0 (31.5 – 42.8)27.5 (22.2 – 33.4)

Serious25.4 (18.8-32.4)27.6 (19.7-37.1)22.4(15.6-31.1)

Serious36.2 (32.4 – 40.2)37.2 (32.2 – 42.5)35.1 (28.9 – 41.9)

Serious

22.6 (18.6 – 27.1)26.1 (20.9 – 32.1)19.4 (15.1 – 24.5)

Serious

HIS Nutrition Trends(Jan-Jun’12)

High (>15%) but decreasing Critical N/A - N/A - N/A -

Admission trends at TFPs/SFPs (Jan-July’12)

High but steadily decreasing in number of OTP admissions

Critical N/A -Low and stable number of SC admissions

Critical N/A -


BoysGirls

12.410.910.1




Very Critical




Boys- 43.0Girls- 44.9

Diarrhoea -19.0Pneumonia- 22.1Fever-23.6

Critical


Boys- 42.6.9Girls- 42.6

Diarrhoea -20.3Pneumonia- 7.4Fever-36.6

Critical

Outbreak -NoneMorbidity–41.0

Boys-40.8Girls-41.4

Diarrhoea- 21.4Pneumonia-6.6Fever-29.0

Critical

Suspected measles outbreak-controlled. Morbidity–37.5

Boys-38.1Girls-37.0

Diarrhoea -15.7Pneumonia-9.9Fever-29.6

Very Critical

Immunization Status

Vitamin A–80.2Boys-81.5Girls- 79.0

Measles – 82.8Boys-84.4Girls-81.3

Alert

Vitamin A–66.3Boys-63.4Girls- 69.3


Serious

Vitamin A– 73.6Boys-75.6Girls-71.4

Measles- 73.0Boys-76.3Girls-69.4

Serious

Vitamin A– 85.9

Boys-87.3Girls-84.5

Measles- 82.9Boys-83.7Girls-82.3

Alert

Infant and Young child feeding N=407 N=76 N=313 N=413

Proportion still breastfeeding (6-24 months)BoysGirls

54.156.152.3

Alert46.1 45.247.1

Serious52.150.953.2

Alert37.338.536.3

Critical

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56.657.156.0

Alert28.931.026.5


Serious32.434.231.0

Critical


80.175.783.9




Very Critical

Death Rates

Crude deaths, per 10,000 per day (retrospective for 90 days) 0.33 (0.15 – 0.73) Acceptable N/A - 0.43 (0.25-0.75) Acceptable 0.22 (0.11 –

0.43) Acceptable


0.61 (0.28 – 1.32) Acceptable N/A - 0.59 (0.25-1.39) Acceptable 0.62 (0.27 – 1.44) Acceptable

Women Nutrition & Immunization Status N=597 N=52 N=326 N=544


N=3540.6 (0.0-1.4) Serious N=19

5.3 - N=2170.5 (0.0-1.4) Alert N=314

0.3 (0.0-0.9) Alert


N=2253.1 (0.2-6.0) Alert N=33

10.3 Very Critical N=1096.4 (2.1-10.7) Serious N=230

1.7 (0.0-3.9) Alert

Proportion of acutely malnourished pregnant/lactating women (MUAC<23.0).

N=22513.3 (7.8-18.9) Acceptable N=33

46.7 Very Critical N=10924.8 (15.9-33.7) Alert

N=23033.9 (27.9-39.8)

Very Critical



17.1 9.5 18.3 55.1

Alert

15.43.823.157.7

Alert

15.05.222.457.4

Alert

19.311.228.940.6

Serious

Public Health Indicators N=611 N=100 N=498 N=597Household with access to sanitation facilitiesMale headedFemale headed

84.083.785.4

Serious100.0100.0100.0 Acceptable

95.896.194.4 Acceptable



93.3 93.592.1 Alert


71.171.370.0

Serious95.1 96.890.5 Acceptable

Food Security N=611 N=100 N=498 N=597Proportion who reported to have consumed <4 food groupsMale headedFemale headed

2.1 1.74.5 Acceptable




Household’s Main Food SourcePurchase:BorrowingFood Aid

99.30.00.0

Alert87.01.00.0

Serious99.60.00.0

Alert94.11.80.0

Alert

Food security phase Emergency Very Critical Emergency Very Critical Emergency Very Critical Emergency Very Critical

Overall Situation Analysis Critical Very Critical Critical Critical

Gender and nutrition analysis in Northeast Regions

In most of the nutrition assessments conducted in the NE regions of Somalia, a higher proportion of boys than girls were acutely malnourished, even though this was generally not statistically significant (Pr<0.75), except for Bossaso IDPs (22.4% vs. 15.4%) where there was a statistical significance (Pr>75%). However, other child data such as dietary diversity, illness, care and feeding practices, and immunization status, do not show any clear differences by gender and so the disparity is likely due to the use of the new WHO 2006 sex-differentiated reference standards, which has been observed to discriminatively identify more boys as acutely malnourished. With the new WHO reference standards, a girl of a certain height has to be much lighter than a boy of the same height to meet the WHZ<-2 threshold for acute malnutrition. In the other IDP assessments

conducted during Gu ’12, more boys than girls were acutely malnourished in Galkayo IDPs (21.3% vs. 17.3%), but the differences was not statistically significant. Similar trends are reported in the livelihood based assessments where higher percentage of the boys tend to be more malnourished than the girls including Nugal Valley (22.2% vs. 17.9%) and Sool plateau (13.7% vs. 9.0%) livelihoods of bari and Nugal regions, as well as in Addun (16.2% vs. 12.7%) and Coastal Deeh (15.0% vs. 10.0%) pastoral livelihoods of NE regions.

Analysis of household data by gender of household head did not find any significant difference nor clear trend in the proportion with access to sanitation facilities, access to safe drinking water nor consumption of diversified diet. The gender disaggregated data by sex of the assessed children and sex of the household head per livelihood is summarized on Tables 18-19.

Summary of key nutrition findings among northeast idPs (bossaso, Qardho, Garowe and Galkayo) – May 2012-continued

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MAtErnAl nutrition StAtuS in northEASt And cEntrAl SoMAliA

The proportion of the global and severely malnourished pregnant and/ or lactating women based on the Sphere MUAC cut-offs of 23.0, and 21.0cm, and/or bilateral oedema in the Northeast and Central regions, vary widely from Acceptable-Alert in most rural livelihood population groups to Very Critical situation in some IDP population groups. For the non-pregnant or non-lactating, the situation is within Acceptable levels in most surveys based on MUAC cut -off of 18.5cm or presence of bilateral oedema.

Pregnant and/or Lactating Women Non Pregnant/Lactating Women

No Assessed Proportion with MUAC <23cm(%)

Proportion with MUAC <21cm(%) No Assessed Proportion with MUAC

<18.5cm(%)bossaso IDPs 225 13.3 (7.8-18.9) 3.1 (0.2-6.0) 354 0.6 (0.0-1.4)

Qardho IDPs 33 46.7 10.3 19 5.3 Garowe IDPs 109 24.8 (15.9-33.7) 6.4 (2.1-10.7) 217 0.5 (0.0-1.4)Galkayo IDPs 230 33.9 (27.9-39.8) 1.7 (0.0-3.9) 314 0.3 (0.0-0.9)Hawd 171 13.5 (9.6-17.3) 3.5 (0.7-6.3) 245 0.8 (0.0-2.0)Addun 172 18.6 (10.5-26.7) 5.8 (2.5–9.1) 203 0.0Coastal Deeh 97 14.4 (7.5-21.4) 1.0 (0.0-3.2) 141 0.0Nugal Valley 152 9.8 (4.5-15.3) 1.3 (0.0-3.2) 207 0.5 (0.0-1.5Sool Plateau 133 21.1(13.2-28.9) 5.3 (0.1-11.5) 236 0.4 (0.1-1.3)East Golis 132 28.8 (18.6-39.0) 8.3 (3.4-13.3) 278 0.0

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4.8 nORtHWeSt ReGiOnS

The Northwest regions comprise mainly of pastoral livelihood zones namely: West Golis, Guban, East Golis/ Gebbi Valley of Sanaag region, the Hawd of Hargeisa and Togdheer, Sool Plateau and the Nugal Valley. In addition, there is an agro-pastoral livelihood zone that is sub-divided into two, namely, the Agro-pastoral of Awdal and Woqooyi Galbeed regions and Agro-pastoral of Togdheer region. The livelihood zones cut across the five administrative regions of Awdal, Woqooyi Galbeed, Togdheer, Sool and Sanaag. (Map 12). The East Golis, Nugal Valley and Sool plateau also extend to the Northeast regions of bari and Nugal respectively.

Historical Overview Post Deyr ‘11/12

Food Security

The FSNAU Post Deyr ‘11/12 integrated food security analysis classified the food security situation of the agro-pastoral, West Golis/Guban, East Golis and Hawd pastoral livelihoods in the Northwest as Stressed indicating a stable food security situation since the Gu ‘10 season, but an improvement for East Golis and Hawd of Togdheer livelihoods which were in crisis in the Gu ‘11. The population in Nugal Valley and Sool plateau were in crisis, a sustained phase for Nugal Valley livelihood but an improvement from Emergecy for Sool Plateau since the Deyr ‘09/10. The general improvement in the food security situation in these livelihoods was mainly attributed to the improved milk availability owing to improved pasture condition and water availability. Other factors that contributed to the improvement included kidding among the small rumminats, increased income from sale of livestock and related products, better purchasing power due to improved livestock prices and reduced household expenses and unrestricted humanitarian access due to relative civil tranquility.

NutritionThe Post Deyr ‘11/12 integrated nutrition situation analysis showed a general improving trend in the nutrition situation in Northwest livelihoods with most livelihoods showing either a significant improvement or stable situation compared to the Gu ‘11 situation. The nutrition situation for the West Golis and Nugal Valley livelihoods significantly improved from Very Critical in Gu ‘11 to Serious and Critical respectively. The situation among the population in the Sool Plateau improved from Critical in Gu ’11 to Serious while that of the agro-pastoral and East Golis/Gebbi Valley livelihood zones remained stable at Serious level. The improvement recorded in the respective livelihoods was mainly attributed to improved milk access at the household level and declined morbidity levels.

However, the nutrition situation among the population in the Hawd livelihood significantly deteriorated from Alert levels in Gu ‘11 to Serious. This was mainly attributed to reduced milk access following opportunistic livestock out-migration to Ethiopia where water and pasture condition was better compared to the situation in Hawd of Togdheer and Sool regions. The nutrition situation of the IDPs in Hargeisa town was sustained at Serious level since Deyr ‘10/11, while the nutrition situation among the burao IDPs deteriorated from Critical in Gu ’11 to Very Critical in Deyr ‘11/12. The nutrition situation among the berbera IDPs also deteriorated to Critical levels from Serious in Gu ‘11. The lack of stable livelihood systems among the IDP populations, coupled with irregular access to basic services continue to expose this population group to risks of malnutrition, morbidity and food insecurity. The chronic risk factors for malnutrition among the populations in the Northwest region include high morbidity rates, a precarious food security situation, poor dietary diversity, poor child feeding and care practices, in addition to inadequate safe drinking water, limited access to health and sanitation facilities, remain a challenge to the population especially among the displaced persons and the rural populations. The historical trend of malnutrition in the respective livelihoods since 2003 is shown in (Figure 30).

current Situation Post Gu ‘12

Food Security

The FSNAU Post Gu ‘12 integrated food security analysis in the most of Northwest indicates a Stress phase of acute food insecurity situation in the agro-pastoral, , Hawd, Sool Plateau and Nugal Valley pastoral livelihoods which is an improvement from crisis for Nugal Valley and Sool plateau in Deyr ‘11/12 but a stable situation for the other livelihoods. The general improvement in the food security situation in these livelihoods is mainly attributed to the positive impact normal of Gu ’12 rainfall in most parts of these livelihoods which improved livestock body conditions and production and thus increased milk availability and access owing to

Map 12: northwest livelihood Zones

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figure 30 : trends in levels of Acute Malnutrition (WhZ <-2Z scores or oedema), Who 2006 in north West regions 2006-2011

improved pasture and water availability and kidding among the small rumminats, increased income from sale of livestock and livestock products (milk and ghee). The food security situation among the population in Golis Guban and East Golis livelihood has deteriorated from Stressed in Deyr ‘11/12 to crisis. The deterioration in these livelihoods is linked to the effect of failure of the hays rains over last two seasons in most of Golis Guban affecting water availability and rangeland condition thereby resulting in poor livestock body condition, low milk production and limited saleable livestock. These together with the increased level of indebtness has affected food availability and access in these livelihoods.

NutritionThe Post Gu ‘12 integrated nutrition situation analysis shows either stable or deteriorating trend in the nutrition situation in Northwest livelihoods compared to the Deyr ‘11/12. The nutrition situation for the West Golis and Nugal Valley livelihoods has deteriorated from Serious and Critical respectively in Deyr ‘11/12 to Very Critical. The nutrition situation among the population in the Hawd livelihood has significantly deteriorated from the Serious levels in Deyr ‘11/12 to the current Critical. This deterioration is mainly attributed to reduced food access especially household milk access in Guban1 where following below normal Gu rainfall performance, livestock have been forced to out-migrate in search of water and pasture while those remaining in the area are weak with low milk production. Out-migration of livestock often leads to family splitting where women and young children are left behind with inadequate or no milk access and without saleable animals to cater for food and non-food items and services. In Nugal Valley and Hawd livelihoods where food security is either stable or improved, high morbidity and especially measles outbreak in burao and Ainabo districts has significantly contributed to the

1 For nutrition assessment, West Golis and Guban livelihoods are sampled together as one population and therefore there is one GAM rate, however food security assessment and classification treat the two livelihoods separately

deterioration. On the other hand, the nutrition situation among the populations in the Sool Plateau, East Golis/Gebbi Valley and Agro-pastoral livelihoods has remained stable at Serious levels since Deyr ‘11/12.

The nutrition situation of the displaced people in Hargeisa and berbera towns is sustained at Serious and Critical levels respectively since Deyr ‘11/12, while the situation among the burao IDPs has improved from Very Critical to Critical. Household access to food, health and other basic services among the IDP is highly dependent on humanitarian services and availability of casual labour and petty trades in the host urban areas. This irregular access to basic services continue to expose this population group to risks of malnutrition, morbidity and food insecurity. Gender: The analysis of nutrition data among the assessed rural livelihood population as well as the IDPs populations of the northwest regions, shows no statistical differences in the distribution of acute malnutrition, morbidity levels, access to vitamin A supplementation and immunization services between boys and girls. However, across all livelihoods and IDPs, slightly higher proportion of boys than girls are acutely malnourished, stunted and underweight. Additionally, there is no statistically significant difference between the female and male headed households in terms of distribution of acute malnutrition, consumption of diversified diets, and access to safe water and sanitation facilities.

Pastoral Livelihood Zones

West Golis, Nugal Valley and Sool Plateau Livelihood Zones The current nutrition situation of the populations in both West Golis/Guban and Nugal Valley livelihoods is Very Critical, indicating a deterioration from the Serious and Critical levels respectively in the Deyr ‘11/12. The results of the nutrition surveys conducted in July 2012 among West Golis population indicate a GAM rate of 21.7% (17.9-26.1)

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and a SAM rate of 5.5% (3.7-7.9) indicating a significant deterioration (p<0.05) when compared with a GAM rate of 13.8% (11.4-16.6) and a SAM rate of 2.2% (1.4-3.5) recorded in the December ‘11 assessment. Similarly, results from an assessment done among the Nugal Valley livelihood population reported a GAM rate of 20.1% (16.5-24.3) and a SAM rate of 5.4% (3.9-7.5), showing a deterioration compared with a GAM rate of 16.3% (13.5-19.6) and a SAM rate of 5.2% (3.9-6.8), reported in the December 2011. The change was however not statistically significant (p>0.05). In Sool plateau, results indicate a sustained Serious nutrition situation since Deyr ‘11/12 with a GAM rate of 11.3% (9.3-13.8) and a SAM rate of 1.7% (0.9-3.0) reported in July 2012 assessments. This is similar to the GAM rate of 11.6% (8.7-15.3) and a SAM rate of 3.4% (2.0-5.7) recorded in December 2011 assessment. The nutrition data from health facilities in the West Golis and Nugal Valley livelihood zone indicate a high (>10%) and stable proportion of acutely malnourished children (Figure 31), while in Sool plateau, a low (<10%) and fluctuating trend is recorded. Morbidity, a key nutrition aggravating factor remain high (>22%) in the three livelihoods while child feeding practices in terms of continued breastfeeding, feeding frequency and dietary diversity is persistently below the recommended standards. The measles immunization and vitamin A supplementation status was relatively high but below the recommended Sphere standard of 95%. The CDR and U5DR is 0.24 (0.11-0.53) and 0.45 (0.10-1.89) respectively among West Golis; 0.04 (0.02-0.32) and 0.19 (0.02-1.46) among Nugal Valley, and 0.12 (0.05-0.31) and 1.22 (0.13-1.24) in Sool plateau. These death rates are all within the Acceptable

levels, according to UNICEF classification which is similar to levels recored in Deyr ‘11/12 assessments. In Deyr ‘11/12 assessment, the respective crude death rate and under five death rate were 0.54 (0.33-0.89) and 0.27 (0.06-1.13) among West Golis; 0.19 (0.09-0.40) and 0.48 (0.15-1.45) among Nugal Valley, and 0.48 (0.22-1.06) and 1.22 (0.19-7.31) in Sool Plateau livelihood. The key nutrition findings in these livelihoods which form the basis of the analysis and classification outcome are provided in table 20.

The deterioration recorded in the two pastoral livelihoods is linked to multiple causes. Severe reduction in household milk access has played a key role in West Golis/Gubban where livestock out migration has left some family member especially women and young children with reduced milk access and without saleable livestock or livestock’s products to generate income to buy food and other essential goods and services. In Nugal Valley, outbreak of measles in burao and Ainabo districs has aggrevated the nutrition situation with almost half of all acute malnutrition cases identified in the livelihood concentrated in the two districts. It is important to point out that for the second successive Gu season, Nugal Valley and West Golis/Guban livelihoods have recorded a Very Critical nutrition situation indicating seasonal vulnerability that need targeted response to address underlying causes. Appropriate interventions to address both the short term acute needs such as rehabilitation of acutely malnourished children and long term programmes that address chronic food insecurity, nutrition and health are vital to address a conspicuous seasonal hunger gaps in Gu season especially in West Golis/Guban and underlying factors that influencing the health and nutrition situations in the area. Concerted efforts to manage and control recurrent outbreaks of measles in Togdheer region and Sool regions need to be imple bmented as a matter of priority.

An enumerator conducting an interview in a hargeisa idP camp

figure 31: hiS Malnutrition trends in health facilities in nW West Golis Mchs - January

2011-June 2012

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Table 20: Summary of Key Nutrition Findings in West Golis/Guban, Nugal Valley and Sool Plateau Livelihood Zones, July 2012

West Golis/Guban (N=588: Boys=312; Girls=276)

Nugal Valley (N=619: Boys=311; Girls=308)

Sool plateau (N=748: Boys= 365; Girls=383)


21.7 (17.9-26.1)27.0 (23.4-31.0)15.8 (9.8-24.4)

Very Critical

20.1 (16.5-24.3)22.2 (17.2-28.5)17.9 (14.4-22.0) Very Critical

11.3 (9.3-13.8)13.7 (9.9-18.6)9.0 (6.8-11.9)

Serious


5.5 (3.7-7.9)8.4 (6.0-11.5)2.2(1.1-4.5)

Critical5.4 (3.9-7.5)6.2 (4.1-9.5)4.6 (2.9-7.4)

Critical1.7 (0.9-3.0)1.4 (0.6-3.4)1.9 (1.0-3.7)

Acceptable

Mean of Weight for Height Z Scores -1.06±1.15 Critical -0.96±1.19 Serious -0.67±1.08 Alert

Oedema 0 Very Critical 0.6 Very Critical 0 AcceptableGlobal Acute Malnutrition (NCHS) 22.1 (18.1-26.0) Very Critical 20.0 (16.4-24.2) Very Critical 11.9 (9.4-15.1) SeriousSevere Acute Malnutrition (NCHS) 2.6(1.5-4.5) Alert 2.4 (1.5-3.9) Acceptable 2.0 (1.2-3.5) AcceptableProportion with MUAC<12.5 cm or oedema)BoysGirls

6.5 (4.5-9.2)5.4 (3.5-8.5)7.6 (4.6-12.3)

Serious 2.8 (1.5-4.9)3.2 (1.5-4.9)2.3 (1.0-5.0)

Alert 2.7 (1.7-4.1)1.9 (1.0-3.6)3.4 (2.0-1.3)

Alert


1.2 (0.5-2.7)1.6 (0.7-3.8)0.7 (0.2-3.0)

Serious1.5 (0.9-2.7)1.5 (0.7-3.4)1.6 (0.7-3.5)

Serious0.5 (0.2-1.3)0.5 (0.1-2.2)0.5 (0.1-2.1)

Acceptable


9.0 (6.7-12.1)12.9 (9.0-18.0)

4.7 (2.9-7.7)Alert

5.2 (3.5-7.7)6.1 (3.8-9.7)4.2 (1.9 -9.3)

Alert12.0 (9.0-15.9)

16.2 (11.5-22.5)8.0 (5.3-11.7)

Serious


16.8 (13.1-21.2)23.2(18.4-28.6)9.5 (5.9-14.9)

Alert14.6 (12.2-17.4)16.5 (12.1-22.0)12.7 (9.2-17.4)

Alert11.6 (8.5-15.6)12.6 (8.5-18.2)10.7 (7.4-15.2)

Alert

Malnutrition Trends at Health facilities (January – July 2012)

High (>20% and stable

trend of acutely malnourished

children in MCHs

Very Critical

High (>10%) and stable

trend of acutely malnourished

children in MCHs

Serious Low (<10% and trend Alert

Proportion of acutely malnourished children in SFsBoysGirls

9.49.59.3



Very Critical



Morbidity- 29.3Boys- 31.1Girls-27.2

Diarrhoea– 12.9Boys- 13.8Girls- 12.0

Pneumonia- 3.9Boys-4.5Girls- 3.3

Very Critical

Measles outbreak in Burao and Ainabo

distritcsMorbidity- 23.9

Boys-24.8Girls-23.1



Very Critical

Morbidity-22.3Boys-21.7Girls-23.0



Very Critical

Immunization Status

Vitamin A –72.8Boys- 74.0Girls- 71.4

Measles –75.3Boys-75.3Girls-75.4

Serious

Serious

Vitamin A –74.8Boys-76.5Girls-73.1


Serious

Serious

Vitamin A- 78.3Boys-79.4Girls-77.3

Measles – 74.5Boys- 75.1Girls-73.9

Serious

Serious

Infant and Young Child Feeding (6-24 Months) N=183 N=217 N=249

Proportion still breastfeedingBoysGirls

52.047.257.1

Alert43.339.547.2

Serious42.539.245.8

Serious


38.837.540.0



Very Critical


100100100



Very Critical

Death RatesCrude deaths, per 10,000 per day (retrospective for 90 days) 0.24 (0.11-0.53) Acceptable 0.04 (0.01-0.32) Acceptable 0.12 (0.05-0.31) Acceptable

Under five deaths, per 10,000 per day (retrospective for 90 days) 0.45 (0.10-1.89) Acceptable 0.19 (0.02-1.46) Acceptable 0.40 (0.13-1.24) Acceptable

Women Nutrition and Immunization StatusProportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm)

N=3180.5 (0.0-1.6) Serious N=299

0 Acceptable N=2680 Acceptable


N=2604.6(0.0-13.9)

N=1362.9 (0.0-7.2)

N=2280

Acceptable

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N=26028.1(8.6-47.6) Critical N=136

10.6 (1.7-19.4) Acceptable N=2280 Acceptable

Proportion of Women who received Tetanus immunizationNo doseOne doseTwo dosesThree doses

29.719.518.132.7

Serious

24.723.816.235.4

Serious

16.817.834.031.3

Serious

Public Health Indicators N= 349 N= 425 N=351Household with access to sanitation facilitiesMale HeadedFemale Headed

40.440.539.4



Critical

Household with access to safe waterMale HeadedFemale Headed

39.837.760.6

Very Critical12.37.1

28.9Very Critical

10.210.39.3

Very Critical

Food SecurityProportion who reported to have consumed <4 food groupsMale HeadedFemale Headed

12.911.427.3


Acceptable1.61.80

Acceptable

Household’s Main Food Source- PurchaseMale HeadedFemale Headed

68.567.181.8



Acceptable

Food security phase Crisis Serious Stressed Serious Stressed Serious

Overall Risk to Deterioration Unstable Unstable Stable

Overall Situation Analysis Very Critical Very Critical Serious

East Golis/Gebbi Valley and Hawd Livelihood Zones of NWThe integrated nutrition analysis of East Golis/Gebbi Valley livelihood indicates a sustained Serious nutrition situation since the Post Deyr ‘10/11. A nutrition survey among the population in this livelihood in July 2012 reported a GAM rate of 13.6% (10.5-17.5) and a SAM rate of 2.6% (1.5-4.5), showing similar results with those of December ‘11 assessment when a GAM rate of 10.5% (7.4-14.7) and a SAM rate of 0.8% (0.3-2.8), were reported. On the other hand, integrated nutrition analysis among the Hawd pastoral population indicates a Critical nutrition situation, a significant deterioration from the Serious level recorded in Deyr ’11/12 season. A nutrition survey conducted in July ‘12 among the Hawd pastoral population reported a GAM rate of 16.7% (11.5-23.5) and a SAM rate of 4.2% (2.3-7.6) which indicates a significant deterioration from rates recorded in a similar assessment in December 2011, when a GAM rate of 10.7% (8.4-13.6) and a SAM rate of 1.8% (0.9-3.6) (Pr= 93.4%) was recorded. The deterioration among the Hawd livelihood group is largely linked to high (>20%) morbidity, especially the outbreak of measles in burao district reported since March 2012. Morbidity in Hawd livelihood showed a statistically significant association with acute malnutrition where children who were reportedly sick in two weeks prior to the assessment were almost two times more likely to be malnourished as compared to those who were not sick. (RR=1.62: 1.03-2.54)

The analysis of nutrition data from health facilities in Hawd areas of Northwest indicates Critical levels of malnutrition with high (>15%) and stable proportions of acutely malnourished

children recorded in these facilities (Figure 32). In East Golis livelihoods, data from health facilities shows a high (>10%) and fluctuating trend of acutely malnourished children which is similar to trends observed in 2011 indicating a stable nutrition situation. Good access to milk at household level in East Golis/Gebbi Valley livelihoods, better access to humanitarian support and income from the sale of frankincense are key mitigating factors to acute malnutrition. The retrospective crude and under five death rates of 0.26 (0.09-0.75) and 0.47 (0.11- 1.95) respectively in Hawd and of 0.18 (0.06-0.49) and 0.36 (0.09-1.52) in East Golis/Gebbi Valley livelihood, are all within the Acceptable level according to UNICEF classification. These show similar levels as the retrospective crude and under five death rates of 0.78 (0.50-1.21) and 0.19 (0.02- 1.50) in Hawd and 0.59 (0.27-1.27) and 0.75 (0.28-2.00) in East Golis/bebbi Valley livelihood respectively reported in Deyr ‘11/12 assessments. The key nutrition findings in these areas which form the basis of the analysis in the classification outcome, are provided in Table 21.

figure 32: hiS Malnutrition trends in health facilities in nW hawd Mchs - January 2010-June ’12

Summary of Key Nutrition Findings in West Golis/Guban, Nugal Valley and Sool Plateau Livelihood Zones, July 2012-Continued

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Agro-pastoral livelihood Zones: Awdal/Galbeed and togdheer AgropastoralThe Northwest agro-pastoral zone comprises the agro-pastoralists of Togdheer who are more pastoral than agro-pastoralist and mainly grow grass/hay for livestock and the agro-pastoralist of Awdal and Galbeed Regions who mainly practice crop farming alongside keeping different types of livestock. The integrated nutrition situation analysis of the Northwest agro-pastoral population indicates a sustained Serious nutrition situation since Post Deyr ‘10/11.The nutrition assessment conducted among these agro-pastoral population in July 2012 reported a GAM rate of 13.5% (10.3-17.3) and a SAM rate of 1.1% (0.5-2.6) indicating a sustained Serious nutrition situation, similar to levels recorded in the December ‘11 assessment when a GAM rate of 10.1% (7.1-14.1) and a SAM rate of 2.6% (1.4-4.9) were reported. Morbidity is relatively low (12.2%) as compared to the other livelihoods in Northwest and is within the seasonal trend for the area. The nutrition data from health facilities indicates a high (>10%) and fluctuating proportion of acutely malnourished children reflecting a Serious nutrition situation.

The death rates from the current assessments indicate sustained Acceptable mortality levels with CDR of 0.21 (0.05-0.75) and U5DR of 0.36 (0.09-1.52). These rates are similar to those reported in Deyr ‘11/12 assessment when CDR of 0.05 (0.0-0.10) and U5DR of 0.28 (0.15-0.53) was recorded.

Across all livelihoods in Northwest region, both pastoral and agro-pastoral population in the rural areas are characterized with persistent sub-optinmal child feeding practices where children are breastfed for short period, are fed infrequently and on poorly diversified diets. In addition, limited access to safe water, sanitation and health facilities is evidenced across rural livelihoods, predisposing children to diarrhoeal disease. Morbidity trends are persistently high in these livelihoods. Provision of safe drinking water, adequate health and sanitation facilities and improvement of child care and feeding practices remain crucial issues that require immediate interventions and sustained efforts. The key nutrition findings in these areas which form the basis of the analysis in the classification outcome are provided in Table 21.

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The Hawd Livelihood Zone (N=410: Boys=215; Girls=195)

East Golis/Gebbi Valley (N=504: Boys=232; Girls=272)

Agro-pastoral Zone (N=451:Boys=233; Girls=218)

Indicator Results Outcome Results Outcome Results OutcomeChild Nutrition StatusGlobal Acute Malnutrition(WHZ<-2 or oedema)BoysGirls

16.7 (11.5-23.5)18.8 (12.0-28.1)14.4 (9.7-20.9)

Critical13.6 (10.5-17.5)

18.0 (13.9-23.0)9.8 (5.9-15.8)

Serious13.5 (10.3-17.3)17.0 (12.3-32.9)9.7 (6.8-13.6)

Serious


4.2 (2.3-7.6)5.8 (3.2-10.2)2.6 (0.9-6.9)

Serious2.6 (1.5-4.5)2.2 (0.9-5.0)3.0(1.4-6.2)

Alert1.1 (0.5-2.6)0.9 (0.2-3.6)1.4 (0.5-4.2)

Acceptable

Mean of Weight for Height Z Scores -0.90±1.14 Serious -0.69±1.14 Alert -0.68±1.16 AlertOedema 0 Acceptable 0.2 Very Critical 0 AcceptableGlobal Acute Malnutrition (NCHS) 17.6 (12.7-24.0) Critical 14.2 (10.7-18.6) Serious 12.4 (8.9-17.0) SeriousSevere Acute Malnutrition (NCHS) 2.7 (1.6-4.5) Alert 2.0 (1.0-3.9) Acceptable 0.4 (0.1-1.8) AcceptableProportion with MUAC <12.5 cm or oedemaBoysGirls

5.6 (3.6-8.7)5.1 (2.8-9.2)6.2 (3.1-12.0)

Serious4.8 (3.2-7.1)5.6 (3.5-8.9)4.0 (2.3-7.0)

Alert2.2(1.2-4.2)2.6 (1.2-5.3)1.8 (0.7-4.7)

Alert

Proportion with MUAC <11.5 cm or oedemaBoysGirls

1.2 (0.4-3.3)1.4 (0.3-5.9)1.0 (0.2-4.2)

Serious0.8 (0.3-2.0)0.9 (0.2-3.6)0.7 (0.2-3.0)

Acceptable0.2 (0.0-1.7)00.5 (0.1-3.5)

Acceptable


1.5 (0.5-4.4)0.9 (0.2-3.7)2.1 (0.6-6.5)

Acceptable3.4 (1.9-6.1)4.4 (2.1-8.8)2.6 (1.6-6.4)

Acceptable5.1 (3.2-8.1)7.3 (4.5-11.7)2.8 (1.2-6.3)

Alert


15.4 (11.1-20.8)17.2 (11.7-24.6)13.3 (8.9-19.5)

Alert7.4 (5.0-10.8)11.7 (7.6-17.6)3.7 (1.4-9.4)

Acceptable8.2 (5.4-12.3)11.6 (6.9-18.7)4.6 (2.8-7.4)

Acceptable

Malnutrition Trends at the health facilities (Janauray- July 2012)

High (>15%) and stable trends Critical Low (<10%) and

increasing trend Alert High (>10%) and fluctuating trend. Serious

Proportion of acutely malnourished children in SFs

17.114.620.7



Very Critical



Measles outbreak in Burao districtMorbidity-22.8Boys-21.6Girls-24.1Diarrhoea– 8.5Boys- 7.9Girls-9.2Pneumonia- 4.4Boys-5.1Girls-3.6

Very Critical

Morbidity- 12.3Boys-12.5Girls-12.1Diarrhoea – 5.8Boys-6.5Girls-5.1Pneumonia-3.4Boys-3.4Girls-3.3

Critical

Morbidity- 12.2Boys-11.6Girls-12.8Diarrhoea– 5.6Boys-6.3Girls-4.8Pneumonia-1.6Boys-1.7Girls-1.4

Critical

Immunization Status

Vitamin A– 75.4Boys- 75.3Girls-75.4Measles – 67.6Boys-69.3Girls-65.6

Serious

Critical

Vitamin A– 66.4Boys-65.9Girls-66.9Measles – 64.1Boys-65.1Girls-63.2

Critical

Critical

Vitamin A-64.5Boys-70.0Girls-58.7Measles –66.7Boys-72.1Girls-61.0

Critical

Critical

Infant and Young Child Feeding (6-24 Months) N=177 N=183 N=155

Proportion still breastfeedingBoysGirls

30.829.931.9

Serious 54.846.460.0

Alert 43.147.939.0

Serious


30.832.229.2

Critical 51.445.356.7

Critical 45.851.441.5

Critical


36.231.241.7

Critical 100100100


Very Critical

Death Rates

Crude deaths, per 10,000 per day retrospective for 90 days) 0.26 (0.09-0.75) Acceptable 0.18 (0.06-0.49) Acceptable 0.21 (0.05-0.79) Acceptable

Under five deaths, per 10,000 per day retrospective for 90 days) 0.47 (0.11-1.95) Acceptable 0.36 (0.09-1.52) Acceptable 0.36 (0.09-1.52) Acceptable

Table 21: Summary of Key Nutrition Findings in Hawd, East Golis and Agro-pastoral Livelihood Zones, July 2012

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However, it is important to note that although the current GAM rate indicates a change in the nutrition situation classfication as it is below 20%, the change is not statistically significant (Pr<75%). It is anticipated that the nutrition situation among these IDPs will continue improving as has been seasonally observed in Deyr seasons when livestock-related export casual labour opportunities increases in burao town during Haji festivities. Availability of casual labour provide income which is key among the IDPs who rely on food purchase as a major source of food. Figure 33 shows historical trend of acute malnutrition 2007-2012.

idPs of the north West: hargeisa, burao and berbera

The integrated nutrition situation analysis of the Northwest IDPs populations indicates a sustained Serious and Critical nutrition sitaution among the Hargeisa and berbera IDPs respectively, and an improvement in burao IDPs from Very Critical to Critical. The results of a nutrition assessment conducted among the IDPs in Hargeisa town in June 2012 reported a GAM rate of 12.0% (9.2-15.5) and a SAM rate of 2.9% (1.7-4.8), rates which are similar to the a GAM rate of 12.0% (8.9-16.1) and a SAM rate of 1.3% (0.7-2.3) reported in November ’11 assessment. Among the berbera IDPs, a GAM rate of 16.3% (13.6-19.3) and a SAM rate of 3.5% (2.1-5.6) was recorded in June 2012 assessments indicating a stable Critical nutrition situation. These results are within similar nutrition levels as the findings of an exhaustive nutrition survey in November ‘11 when a GAM rate of 18% and SAM rate of 3.1% were recorded.

In burao IDPs assessment, a GAM rate of 18.4% (14.7-22.7) and a SAM rate of 4.3% (2.6-6.9) are reported indicating a Critical nutrition situation and a slight improvement from the Very Critical situation reported in November ’11 assessment when a GAM rate of 20.3% (15.3-26.3) and a SAM rate of 4.5% (2.6-7.9) was recorded.

Women Nutrition and Immunization StatusProportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm)

N=2390 Acceptable N=334

0 Serious N=2310 Acceptable

Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0 cm)

4.7 (0.2-9.1) 2.4 (0.0-7.5) 0.8 (0.0-2.5)

Proportion of acutely malnourished pregnant and lactating women (MUAC<23.0 cm)

N=12716.3 (5.4-27.2) Alert N=172

14.6 (0.0-35.1) Alert N=2086.5 (0.9-12.0) Acceptable


31.227.923.317.6

Serious

22.413.433.830.6

Serious

19.014.840.026.3

Alert

Public Health Indicators N= 237 N= 271 N=269

Household with access to sanitation facilitiesMale HeadedFemale Headed

38 40.1 30.9



Very Critical


11.010.4 12.7



Very Critical

Food Security

Proportion who reported to have consumed <4 food groupsMale HeadedFemale Headed

28.7 29.4 27.9 Critical

2.22.60 Acceptable

10.49.915.4 Alert

Household’s Main Food Source-PurchaseMale HeadedFemale Headed

96.296.794.5

Acceptable98.598.3100


Acceptable

Food security phase Stressed Serious Stressed Serious Stressed Serious


Overall Situation Analysis Critical Serious Serious

figure 33: trend in levels of acute Malnutrition (WhZ<-2 or oedema, Who 2007) in northwest regions region, 2007-2012

Summary of Key Nutrition Findings in Hawd, East Golis and Agro-pastoral Livelihood Zones, July 2012-Continued

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Hargeisa IDPs (N=497 Boys=238; Girls=259)

Burao IDPs Returnees (N=517: Boys=257; Girls=260)

Berbera IDPs Returnees (N=555 Boys=257; Girls=260)


12.0 (9.2-15.5)14.9 (10.9-20.0)9.2 (6.2-13.6))

Serious18.4 (14.7-22.7)23.36 (18.2-29.4)13.5 (9.8-18.2)

Critical 16.3 (13.6-19.3)19.0 (14.8-24.0)13.6 (10.0-18.1)

Critical


2.9 (1.7-4.8)3.8 (2.2-6.7)2.0 (0.9-4.6)

Alert4.3 (2.6-6.9) 5.4 (3.1-9.5)3.1 (1.5-6.4)

Serious3.5 (2.1-5.6)4.4 (2.3-8.2)2.61 (1.2-5.5)

Serious

Mean of Weight for Height Z Scores -0.61 ±1.17 Alert -0.93 ±1.13 Serious -0.94 ±1.06 Serious

Oedema 0.4 Very Critical 0.6 Very critical 0 Acceptable Global Acute Malnutrition (NCHS) 12.3 (8.8-17.0) Serious 19.1 (15.3-23.6) Critical 15.1 (12.9-17.6) Critical

Severe Acute Malnutrition (NCHS) 1.2 (0.5-3.0) Acceptable 3.8 (2.3-6.1) Serious 0.7 (0.3-1.9) AcceptableProportion with MUAC <12.5 cm or oedemaBoysGirls

4.1 (2.4-6.9)3.8 (1.7-8.3)4.4 (2.5-7.5)

Alert10.3 (7.2-14.5)8.3 (4.6-14.5)12.2 (8.8-16.8)

Critical 4.4 (2.9-6.8)2.8 (1.3-5.9)6.1 (3.5-10.3)

Alert

Proportion with MUAC <11.5 cm or oedemaBoysGirls

1.4 (0.6-3.5)1.3 (0.4-3.9)1.6 (0.5-5.3)

Serious3.0 (1.7-5.4)2.7 (1.0-6.5)3.3 (1.7-6.3)

Critical 1.4 (0.6-3.5)1.3 (0.4-3.9)1.6 (0.5-5.3)

Serious


10.7 (7.0-15.9)15.7 (10.3-23.1)6.0 (3.3-10.8)

Serious8.4 (5.9-11.9)12.1 (8.5-16.8)4.9 (2.7-8.7)

Alert

1.4 (0.6-3.3)1.8 (0.7-4.2)1.1 (0.3-3.4) Acceptable


13.3 (9.7-18.1)16.1 (11.5-22.0)10.8 (6.8-16.6)

Alert16.8 (13.2-21.1)22.0 (16.7-28.5)11.7 (8.3-16.2)

Alert9.6 (7.3-12.6)12.3 (8.9-16.8)6.8 (4.2-11.0)

Acceptable

HIS Nutrition Trends(January – July 2012) Low (<10%) but increasing Alert Low (<5%) and

stable trend Alert High (>10%) and fluctuating Serious

Proportion of acutely malnourished children in SFs - -Child Morbidity & Immunization


Morbidity-31.8Boys-31.5Girls-32.0Diarrhoea– 20.3Boys- 21.4Girls-19.3Measles- 4.2Boys-2.5Girls-5.8

Very Critical


Very Critical


Very Critical

Immunization Status

Vitamin A– 84.5Boys- 83.6Girls-85.3Measles – 83.7Boys- 82.8Girls- 84.6

Alert

Alert


Serious

Serious


Serious

Serious

Infant and Young Child Feeding (6-24 Months)Proportion still breastfeedingBoysGirls

47.1 45.948.1

Serious38.3 41.036.0

Serious 54.9 54.055.8

Alert


41.0 38.843.0

Critical 21.8 20.522.8

Critical 45.146.044.2

Critical


95.696.595.0

Very Critical100100100


Very Critical

Death RatesCrude deaths, per 10,000 per day retrospective for 90 days) 0.14 (0.03-0.61) Acceptable 0.50 ( 0.28-0.88) Serious 0.49 (0.39-0.79) AcceptableUnder five deaths, per 10,000 per day retrospective for 90 days) 0.21 (0.03-0.61) Acceptable 1.01 (0.36-2.80) Serious 0.74 (0.28-19.7) Acceptable Women Nutrition and Immunization StatusProportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm)

N=1400 Acceptable N=165

2.2 (0-4.6) Very Critical N=2290 Acceptable


0 0 1.5 (0.0- 4.4)


N=1272.3 (0.0-4.9) Acceptable N=100

12.4 (4.9-19.8) Acceptable N=1385.1 (1.4-8.7) Acceptable

Table 22: Summary of Key Nutrition Findings for Hargeisa, Burao and Berbera IDPs, June 2012

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12.1 (7.8-16.4)20.7 (14.8-26.6)29.3 (23.4-35.2)37.9 (31.0-44.7)

Critical 22.1 (16.8-27.5)14.5 (9.4-19.6)30.2 (23.5-37.0)33.2 (26.8-39.6)

Critical

5.3 (2.6-8.08)5.6 (2.5-8.8)33.5 (24.1-42.9)


Public Health IndicatorsHousehold with access to sanitation facilitiesMale HeadedFemale Headed

87.8 89.183.8

Alert82.882.583.1

Alert96.196.195.9

Acceptable


100100100 Acceptable

95.495.595.2


Acceptable

Food SecurityProportion who reported to have consumed <4 food groupsMale HeadedFemale Headed

4.5 4.64.1


Critical 13.0 13.012.2

Serious

Household’s Main Food Source-PurchaseMale HeadedFemale Headed

100100100 Acceptable



Food security phase Stressed Stressed Stressed


Overall Situation Analysis Serious Critical Critical

The mortality rates are within acceptable UNICEF levels in Hargeisa with crude death rates (CDR) of 0.14 (0.03-0.61) and under five death rate of 0.21 (0.03-0.61) and among the berbera IDPs with recorded CDR of 0.49 (0.39-0.79) and U5DR of 0.74 (0.28-19.7). In burao IDPs assessment an Alert CDR of 0.50 (0.28-0.88) and a Serious U5DR of 1.01 (0.36-2.80) was reported. These rates are similar to the respective crude and under five death rates of 0.31 (0.18-0.54) and 0.14 (0.02-1.11) recorded among burao IDP, 0.38 (0.20-0.71) and 0.44 (0.14-1.40) among Hargeisa IDPs, and 0.37 (0.18-0.76) and 1.27 (0.55-2.95) reported among the berbera IDPs in November 2011 assessments.

Morbidity levels remain high among IDP populations in the three host towns, with the reported morbidity in the two weeks prior to the assessment of 31.8% in Hargeisa , 40.3% in burao and 20.7% in berbera. Household dietary diversity remains a concern among the displaced population and especially among the burao IDPs where nearly a half (43.7%) of the households were consuming poorly diversified diets comprised of three or fewer food groups. Access to basic human services such as access to safe water and sanitation facilities among the IDPs is relatively better than among the rural populations but it is highly dependent on humanitarian support. The key nutrition findings in these areas which form the basis of the analysis are provided in Table 22.

Immediate interventions to rehabilitate acutely malnourished children and address food and health needs are required. Income generation activities to boost the economic status of the displaced population are needed, these interventions should also be backed by long term interventions such as improved child care and feeding practices, improved dietary diversity and enhanced access to safe water and sanitation

and health facilities. High morbidity rates that persist among the assessed IDPs also need to be addressed through both curative and preventive measures. In the absence of a stable livelihood system among the displaced populations, they are constantly faced with chronic food insecurity and poor nutrition situation. Access to basic services such as safe water, good shelter and sanitation facilities remain limited and whatever is available is dependent on humanitarian assistance. Continued monitoring to assess the constantly changing food security and nutrition situation among the IDPs should be maintained, so as to provide up-to-date information that will guide on appropriate interventions to meet the needs of this vulnerable group. A long term solution such permanent settlement of the protracted IDPs will be required in the long run for the people to have stable livelihood and bring to an end the humanitarian dependence status of the displaced people in Somaliland.

Gender and nutrition analysis in North West RegionsAnalysis of the nutrition data in the assessed rural livelihoods as well as among the internally displaced populations shows no statistically significant differences in the distribution of the acute malnutrition cases between boys and girls. In addition, there was no statistically significant difference in the distribution of stunting and underweight between boys and girls in the assessed rural and IDPs populations. This is with exception of the population in Sool plateau, Hargeisa and burao IDPs where a significantly higher proportion of boys than girls was stunted and in West Golis where significantly higher boys (12.9% (9.0-18.0) than girls 4.7% (2.9-7.7) was underweight (P<0.05). In all other rural livelihoods and IDPs populations, more boys than girls are acutely malnourished, stunted and underweight with exception of Hawd livelihoods where slightly more girls than boys are

Summary of Key Nutrition Findings for Hargeisa, Burao and Berbera IDPs, June 2012-Continued

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stunted but the differences were statistically insignificant (p>0.05). For example, in Nugal valley, 22.2% (17.2-28.5) of boys compared with 17.9% (14.4-22.0) of girls were acutely malnourished; 6.1% (3.8-9.7) of boys as opposed to 4.2% (1.9-9.3) of girls were stunted; and 16.5% (12.1-22.0) of boys compared to 12.7% (9.2-17.4) of girls were underweight. This disparity is likely given the use of the new WHO 2006 sex-differentiated reference standards, which has been observed to discriminatively identify more boys as malnourished than girls. With the new WHO reference standards, a girl of a certain height has to be much lighter than a boy of the same height to meet the WHZ<-2 threshold for acute malnutrition. A review of TFC data from 13 African countries found that when children 6-59 months were admitted using UNISEX tables; there was no significant difference in the number of boys and girls admitted and there was no significant difference in the mortality rate2[1]. The distribution by sex of morbidity cases, childfeeding practices and access to health services such as measles vaccination and vitamin A supplements showed a mixed pattern where in some surveys a higher proportion of boys

2 [1] Golden, M., Grellety, y., Schwartz, H., & Tchibindat, F. (2010). Report of a Meeting to harmonize the criteria for monitoring and evaluation of the treatment of acute malnutrition in West and Central Africa. 30th November – 1st December 2010; Dakar, Senegal. Retrieved February 27, 2012 http://www.ennonline.net/pool/files/ife/consensus-meeting-on-m&e-imam-dakar-2010-eng.pdf

than girls was ill, better fed or had higher access to health and nutrition services while the opposite was true in other surveys. The differences were however not statistically significant (p>0.05).

At the household level, results showed a large majority (~80%) of the households assessed were male headed. Analysis of the differences of household characteristics such as consumption of diversified diets, access to basic services such as safe water and sanitation facilities did not show a clear pattern, whereby in some livelihoods slightly more male headed households had better access to these services and the opposite was true for other livelihoods. These differences were however not statistically significant (p>0.05). It is important to point out that due to the small proportion of the female headed households and unclear definition of a household head in Somalia context, existence/or lack of any difference in access to public health services between male and female headed households may have been obscured. A meta-analysis of a large set of similar studies or a study designed to capture such households characteristics would address this limitation. The gender disaggregated data by sex of the assessed children and sex of the household head per livelihood is summarized on Tables 20,21&22.

NW/IDPsSurveyed population Pregnant and/or Lactating women Non-pregnant/lactating women

No. Assessed Proportion with MUAC<23cm

Proportion with MUAC <21cm

No. Assessed

Proportion with MUAC<18.5 cm

Hargeisa IDP 127 2.3 (0.0-4.9) 0 140 0Berbera IDP 138 5.1 (1.4-8.7) 1.5 (1.4-8.7) 229 0Burao IDP 100 12.4(4.9-19.8) 0 165 2.2(0.0-4.6)West Golis 260 28.1 (8.6-47.6) 4.6 (0.0-13.9) 318 0.5 (0.0-1.6)NW Hawd 127 16.3 (5.4-27.2) 4.7 (0.2-9.1) 239 0NW Agro-pastoral 208 6.5 (0.9-12.0) 0.8 (0.0-2.5) 231 0Nugal Valley 136 10.6 (1.7-19.4) 2.9 (0.0-7.2) 299 0Sool Plateau 228 0 0 268 0East Golis 172 14.6 (0.0-35.1) 2.4 (0.0-7.5) 334 0

Proportion of the malnourished women in Northwest Regions

MAtErnAl nutrition StAtuS in northWEStIn the northwest, a significantly higher proportion of pregnant and/or lactating women were acutely malnourished (MUAC< 23.0 cm) than non-pregnant and non-lactating women (MUAC<18.5 cm) across all livelihoods and among the three IDPs settlements. The proportion of malnourished pregnant and/or lactating women ranged between 2.3% (Acceptable) among the Hargeisa IDPs to 28.1% (Critical) among women in West Golis livelihood while most of the assessed non-pregnant and non-lactating women were not identfied as malnourished with exception of 2.2% in Burao IDPs and 0.5% of the West Golis. The high level of malnutrition among the pregnant and/or lactating women is linked to increased nutrients needs which are not being met.

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STrENGThENiNG OF iNFANT ANd yOuNG ChiLd FEEdiNG PrOGrAmmiNG ANd PLANNiNG

FOr EmErGENCy PrEPArEdNESS ANd rESPONSE.

The Infant and Young Child Feeding (IYCF) London Workshop (25-29 June 2012)

Infant and young child feeding (IYCF) is core to child health, growth, development and survival. Unfortunately, poor IYCF practices persist in many countries including Somalia where nutrition assessments across the country continue to report sub-optimal child feeding practices. Improved non-emergency IYCF programming is therefore one of the best ways of ensuring good infant and child feeding in emergency (IYCF-E). In light of this, a workshop on Strengthening of infant and young Child Feeding Programming and Planning for Emergency Preparedness and response was jointly organized and funded by the Inter Agency Standing Committee (IASC), Global Nutrition Cluster, IYCN Unit in UNICEF and Save the Children UK and held in London, UK from 25th to 29th June 2012. A total of 68 nutritionist/IYCF experts, representing 22 countries, participated, including the UNFAO-FSNAU Somalia IYCF focal point (See Photo of the participants below).

The main goal of the workshop was to determine how to improve non-emergency infant and young child feeding in (IYCF) programming and learn how to streamline appropriate infant and young child feeding in emergency (IYCF-E) in programming. The specific objectives of the workshop were to ;

i. Increase awareness of the importance of IYCF and IYCF-E;

ii. Share experiences, challenges, and lessons-learned in IYCF and IYCF-E programming in different contexts;

iii. Orient and disseminate IYCF and IYCF-E policies and capacity development tools;

iv. Assist in the development of agency/wider consortium action plans.

The workshop used various methods of training including power point presentations, lesson sharing on best practices, discussions, questions and answers session and group work. Among the topics covered included: the current global situation of IYCF and IYCF-E; policies and programming of IYCF and IYCF-E; monitoring and evaluation of IYCF and IYCF-E; IYCF and IYCF-E survey and assessments; funding for IYCF and linking of IYCF and IYCF-E programming.

major highlights and way forwardThere is evidence1 showing that optimal IYCF reduces risk of mortality and malnutrition, prevents illness, growth faltering and poor child development and death. However when this is not or is imperfectly achieved in non-emergencies it becomes extra hard in emergencies.

It was further observed that globally, there has been very little improvement in rate of exclusive breastfeeding (EBF) since 1990 and it remains below 40%; Quality of complementary feeding (minimum acceptable diet) remains generally very poor and frequently correlates with high stunting rates. Most countries lack national monitoring systems for IYCF interventions23.

In addition, IYCF-E is often missing or is implemented ad hoc in an emergency response: Often, IYCF programme staff do not have the required skills to tackle the specific IYCF-E needs and the response approaches tend not to focus on additional or special needs of infant and child caregivers in emergencies. IYCF and IYCF-E are strongly linked and inter-related whereby the success of the IYCF-E will depend on the status of IYCF in non-emergency situation. The workshop concluded that protecting and promoting appropriate infant and young child feeding is critical to saving lives, and that strengthening IYCF outside of emergencies is essential to reducing the loss of life when disasters strike. For Somalia, there is a need to improve non-emergency and emergency IYCF programming; build capacity for IYCF and IYCF-E staff, document and disseminate results/impact of IYCF intervention through various channels including publication in peer reviewed journals and impact research; and learn from successful programmes such as CMAM on how to accelerate IYCF initiatives; Advocacy on IYCF at various levels including among donors is required. On donor advocacy, the participants drafted a letter to be sent to various donors calling for donors’ support to ensure that IYCF becomes an essential component of humanitarian action as well as development investments.

1 Lancet Child Survival series 2003 & UNICEF database 2012, from DHS, MICS and national surveys2 A composite indicator representing the proportion of children who meet the minimum recommended dietary and diversity and feeding frequency3 UNICEF. IyCF Programming status: Results of 2010-2011 assessment of key action for comprehensive IyCF programmes in 65 contries

Workshop participants

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5. urBAN NuTriTiON SiTuATiON

northwest urbanResults of the nutrition assessments conducted in July 2012 in the urban centers in Northwest region indicate a sustained Serious nutrition situation among the urban population in Awdal region with a GAM rate of 14.9% (11.8-18.7) and among the Sool region urban with GAM rate of 13.6% (8.7-20.7) since Deyr ‘11/12. Nutrition situation among the urban population in Togdheer region has deteriorated from Alert in Deyr ‘ 11/12 to Serious with a GAM rate of 14.7% (10.5-20.3). Among the urban populations in W. Galbeed and Sanaag regions, a sustained Alert nutrition situation with a GAM rates of 5.2% (3.7-7.3) and 8.1% (5.7-11.3) respectively is recorded.

northeast urbanThe nutrition situation among the urban populations in the northeast regions is either sustained or has deteriorated from the situation in the Deyr ‘11/12. Nutrition assessments conducted in July 2012 in the urban areas of bari region recorded a GAM rate of 16.5% (13.4-20.2) and a SAM rate of 3.4% (2.4-5.0), indicating a Critical nutrition situation and a deterioration from the Serious situation with GAM and SAM rates of 11.8% (9.1-15.1) and 2.1% (1.3-3.4) respectively, in December 2011. In Nugal region, a GAM and a SAM rate of 12.6% (10.1-15.7) and 1.8% (0.9-3.4) were recorded respectively, indicating a sustained Serious nutrition situation to the Deyr ‘11/12 GAM and SAM rates of 11.3% (9.1-13.9) and 3.8% (2.5-5.9).

central urbanIn Central Somalia urban, the nutrition situation is Critical both in Galgadud and Mudug regions. Nutrition assessments

conducted in July 2012 recorded • GAM rate of 15.2% (8.4-25.8) and SAM rate of 2.0%

(0.8-5.0) in Galgadud and a • GAM rate of 17.4% (13.7-21.8) and SAM rate of 3.7%

(2.5-5.6) in Mudug region. In December 2011, MUAC assessments conducted in the urban centres had classified Galgadud and Mudug regions as likely Very Critical with 19.2% acute malnutrition (MUAC<12.5/oedema) rate, thus indicating a likely improvement in the current situation. In Mudug, the findings indicate a deterioration from Serious phase in December 2011 when GAM and SAM rates of 14.9% (11.7-18.7) and 4.15 (2.4-6.9) were recorded respectively.

Mogadishu urbanIn July 2012, FSNAU and partners conducted a repeat nutrition and food security assessments in Mogadishu Town among the urban and the IDP population, as a way of closely monitoring the nutrition and food security situation in the town. The survey results of the urban population reported GAM and SAM rates of 10.8% (8.3-13.9) and 1.5% (0.7-3.0) respectively, the results indicate a sustained Serious nutrition situation among the Mogadishu urban population. The 90 days retrospective crude and under five death rates remain elevated at 1.23 (0.81-1.85) and 1.54 (0.82-2.85) respectively, indicating a Critical situation according to UNICEF classification, although a slight improvement was noted from results in April 2012. For details refer to Banadir regional surveys.

table 23: Summary of urban Assessment findings: northwest and northeast regions – Post Gu ‘12

Population Assessed GAM WHO SAM WHO MUAC<12.5 cm MUAC<11.5

cmOverallMorbidity

Estimated Nutrition Situation

NORTH WEST REGIONS

Awdal 14.9 (11.8-18.7) 1.9 (1.0-3.5) 3.5 (2.0-6.0) 0.9 (0.3-3.1) 7.9 (1.3-14.4) Serious Sustained

W. Galbeed 5.2 (3.7-7.3) 0.5 (0.1-1.9) 0.9 (0.3-3.0) 0 8.6 (5.8-11.5) Alert-Sustained

Togdheer 14.7 (10.5-20.3) 3.0 (1.4-6.5) 6.4 (3.9-10.4) 1.8 (0.9-3.7) 25.4 (20.2-30.6) Serious-Deteriorated from Alert

Sool 13.6 (8.7-20.7) 2.0 (0.9-4.4) 12.4 (8.7-17.3) 4.0 (2.1-7.4) 21.0 (16.0-26.0) Serious-Sustained

Sanaag 8.1 (5.7-11.3) 0.7 (0.2-2.1) 5.2 (2.8-9.6) 0.9 (0.3-2.3) 24.1 (19.2-29.1) Alert -SustainedNORTH EAST REGIONS

Bari (N=656) 16.5 (13.4-20.2) 3.4 (2.4- 5.0) 7.3 (4.5-10.1) 2.1 (0.7-3.6) 28.8 (24.2-33.5) Critical-deterioration from serious

Nugal (N=676) 12.6 (10.1-15.7) 1.8 (0.9- 3.4) 4.7 (2.7-6.8) 1.0 (0.1-2.0) 19.1 (11.4-26.8) Serious -Sustained

Galgadud (N=457) 15.2 (8.4-25.8) 2.0 (0.8- 5.0) 7.7 (1.8-13.5) 2.2 (0.0-4.8) - Critical-- improvement from likely Very Critical.

Mudug (N=620) 17.4 (13.7-21.8) 3.7 (2.5-5.6) 9.0 (5.0-13.1) 2.4 (1.0-3.9) - Critical- deterioration from Serious

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6. PLAuSiBiLiTy ChECKS

Guidance for use of the Plausibility checks digit preference dP for weight and height: Indicates how accurately children were weighed and when done correctly there shouldn’t be any digit preference. This normally occurs when enumerators round to the nearest cm/kg or half cm/kg. The signs; +, ++, +++ indicate if there was any DP for a number and if it was, mild, moderate or severe, respectively. Digit Preference scores for weight and hight are graded as; (0-5 Excellent,> 5-10 Good, >10-20 Accept and > 20 Problematic)

Standard deviation (Sd) of WhZ: Indicates whether there was a substantial random error in measurements. In a normal distribution the SD is equal to +1, but should lie between 0.8 and 1.2 Z score. SD increases as the proportion of erroneous results in the data set increases.

Skewness of WhZ: This is a measure of degree of asymmetry of the data around the mean. A normal distribution is symmetrical and has zero skewness and should lie between +1 or -1. Positive skewness indicates a long right tail and negative skewness indicates a long left tail.

kurtosis of WhZ: This demonstrates the relative peakedeness or flatness compared to a normal distribution. The normal distribution has zero kurtosis and surveys should lie between +1 and -1. Positive kurtosis indicates a peaked distribution while negative indicates a flat one.

Percent of flag: Flags are measurement that are highly unlikely to occur in nature and are therefore highlighted by the software. These incoherent measurements should be corrected or discarded prior to analysis, 0% flags is ideal but should be less that 2-3% of children measured.

Age distribution: This al lows for a v iew of the representativeness of the sample, and should be similar to the distribution within the population. Age bias is of particular concern for anthropometry. As younger aged (6-29) children are more likely to be malnourished than the older age group (30-59), this means under representation of the younger age group may give a lower prevalence than the actual one and vice versa. The age ratio allows a view of this relationship and should fall between 0.78 and 1.18 with an ideal falling around 1.0.

Sex ratio: Allows a view of the representativeness of the sample and should be similar to the distribution within the population. This should not vary too much from the expected sex ratio and should fall between 0.8 and 1.2.

Poisson distribution: Tests if cases are randomly distributed or aggregated over the clusters by calculation of the Index of Dispersion (ID) and comparison with the Poisson distribution.

Table 23 provides a summary of findings on plausibility checks for nutrition assessments conducted in the Gu ’12.

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table 26: Summary of nutrition Assessments (April - July 2012)

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Affected region/livelihood Participating

Agencies

date of nutrition Survey

Sample Size

GAM based on Who 2006<-2 Z scores or oedema(%)

SAM based onWho 2006 <-3 Z scores/oedema (%)

Mean WhZ oedema

cdr/10,000/day

u5dr /10,000/day

northern regions

1. Guban/West Golis

(Large sample cluster survey)

FSNAU , UNICEF, MOHL.SRCS,SDRA AID ORGANIZATION

July,2012 58821.7

(17.9-26.1)5.6

(3.7-7.9) -1.06±1.15 0 0.24(0.11-0.53)

0.45 (0.10-1.89)

2.East Golis/Gebi karkar (Large sample cluster survey) July,2012 504 13.6

(10.5-17.5)

2.6 (1.5-4.5) -0.69±1.14 0.2

0.18 (0.06-0.49)

0.36 (0.09-1.52)

3. Sool Plateau (Large sample cluster survey) July,2012 748

11.3 (9.3-13.8)

1.7(0.9-3.0) -0.67±1.08 0 0.12

(0.05-0.31) 0.40

(0.13-1.24)

4.Hawd Livelihood zone (Large sample cluster survey) July,2012 410

16.7 (11.5-23.5)

4.2 (2.3-76) -0.90±1.14 0 0.26

(0.09-0.75) 0.47

(0.11-1.95)

5.North West Agro pastoral (Large sample cluster survey)

July ,2012 451 13.5 (10.3-17.3)

1.1 (0.5-2.6) -0.68±1.60

0.00.21

(0.05-79) 0.36 (0.09-1.52)

6.Nugal Valley (Large sample cluster survey)

July ,2012 619

20.1 (16.5-5.24.3)

5.4 (3.9-7.5) -0.96±1.19 0.2 0.04

(0.01-0.32) 0.19

(0.02-1.46)

7. East Golis/Karkar Gaagab Dharror (Large sample cluster survey)

July ‘12 57513.9

(10.8-17.6) 4.1

(2.6-6.5) -0.89 ±1.08 0.00.11

(0.03-0.34) 0.15

(0.02-1.18)

8.Coastal Deeh(Large sample cluster survey) June 2012 385 12.8

(8.7-18.4) 3.5

(1.7-6.8) -0.77 ±1.09 0.3 0.56 (0.27-1.14)

1.34 (0.73-2.44)

Northern IDPs9. Garowe IDPs(Large sample cluster survey) May,2012 821

19.2 (15.9–23.1)

4.7 (3.2 –6.8) -0.97 ±1.15 0.2

0.43 (0.25-0.75)

0.59 (0.25-0.75)

10. bossaso IDPs(Large sample cluster survey)

May,2012 89918.7

(15.7-22.1) 3.9

(2.8-5.4) -1.06 ±1.05 0.2 0.33 (0.15-0.73)

0.61 (0.28-1.32)

11. Galkayo IDPs(Large sample cluster survey) May,2012 997

19.2 (16.1-22.8)

4.1 (3.0-5.6) -1.04 ±1.11 0.2 0.22

(0.11-0.43) 0.62

(0.27-1.44)

12.burao IDPs (Large sample cluster survey)

July 2012 51718.4

(14.7-22.7) 4.3

(2.6-6.9) -0.93±1.13 0.6 0.5 (0.28-0.88)

1.01 (0.36-2.80)

13.Hargeisa IDPs(Large Sample cluster survey)

July 2012 497 12.0 (9.2-15.0)

2.9 (1.7-4.8) -0.61±1.17 0.4 0.14

(0.03-0.61) 0.21

(0.03-1.65)

14. berbera IDPs (Large sample cluster survey)

July 2012 517 16.3 (13.6-19.3)

3.5(2.1-5.6) -0.94±1.06 0 0.49

(1.4-8.7)

0.74 (0.28-1.97)

15. Qardho IDPs(Small sample IDPs) May,2012 198

21.7 (16.8-27.6)

5.6(3.3-9.2) -0.83 ±1.37 0.5

central regions


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Summary of nutrition Assessments (April - July 2012) continued

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16.Dhusamareb IDPs(Small sample IDPs)

FSNAU, UNICEF, SRCS MOH

May 2012 20022.0

(16.1-29.3) 5.0

(2.5-9.8) 0.5 - -

17. Hawd Pastoral(Large sample cluster survey)

June 2012 81611.2

(8.9-14.0) 1.8

(0.9-3.4) -0.71 ±1.06 0.00.38

(0.19-0.76) 0.50

(0.18-1.36)

18. Addun Pastoral(Large sample cluster survey)

June 2012 701 14.5 (11.1 –18.9)

2.4 (1.3-4.3) -0.79 ±1.13 0.3

0.48 (0.25-0.92)

0.58 (0.19-1.76)

19. Cowpea belt(Large sample cluster survey)

June 2012 1174 16.0 -1.01 ±1.60 0.76

(0.48 –1.22) 1.46

(0.86 -2.48)

Shabelle regions 20.Mogadishu Town(Large sample cluster survey)

July 2012 67610.8

(8.3-13.9) 1.5

(0.7-3.0) -0.44 ± 1.16 0.4 1.23 (0.81-1.85)

1.54 (0.82-2.85)

21..Mogadishu IDP(Large sample cluster survey) FSNAU,

UNICEF, COSV, MERCy USA, IINTERSOS, SRCS, ZAMZAM, MUSLIM AID

July 2012 6709.6

(7.1-13.0) 1.8(1.0-3.2) -0.57 ±1.08 0.1 1.41

(0.99-2.02) 2.81

(1.82-4.33)

22. beletweyne district(Large sample cluster survey)

July 2012 62816.6

(11.7-22.9) 3.3(1.7-6.3) -0.86 ±1.14 0

0.8 (0.53-1.22)

2.32 (1.30-4.11)

23. Mataban district(Large sample cluster survey)

July 2012 48016.7

(13.2-20.8) 4.2

(2.3-7.3) -0.91± 1.12 0.40.99

(0.70-1.41) 4.50

(3.02-6.64)

Juba Regions24. Juba Pastoral(Large sample cluster survey)

FSNAU , UNICEF AFREC, WVI, MERCy USA, SRCS, MERCy USA,SAF, EIRG,APD, JUbA FOUNDATION, WRRS, JCC, MVDO, PCDDO, ICDA, AMA-Uk

July,2012 525 15.8 (11.8-20.7)

2.1 (1.0-4.4) -0.78±1.09 1.5 0.44

(0.20-0.99) 0.81

(0.29-2.27)

25.Juba Agropastoral(Large sample cluster survey) July,2012 773 25.1

(22.2-28.3)

5.8 (4.4-7.7) -1.16±1.2 0.8 0.25

(0.07-0.88) 0.85

(0.41-1.78)

26.Juba Riverine(Large sample cluster survey)

July,2012 817 21.1 (17.7-24.8)

6.6 (5.0-8.7) -1.19±1.06 0.7 0.20

(0.11-0.42) 1.16

(0.57-2.32)

27.kismayu IDP(Large sample cluster survey)

July,2012 711 28.0(24.6-31.6)

8.2(5.7-11.7) -1.45±0.92 2.7

0.27 (0.13-0.55)

1.71 (1.08-2.71)

28.Dhobley(Exhaustive) July,2012 781 22 7.6 0.95 ±1.19 2.0 0.32 0.96

Gedo region29. North Gedo Dawo Pastoral(Large sample cluster survey)

June’12 69428.4

(23.0-34.5) 6.2 (4.4-8.7)

-1.30 ± 1.11

0.7 0.59 (0.35-1.01)

1.36 (0.77-2.36)

30. North Gedo Riverine(Large sample cluster survey)

June’12 75722.5

(19.2-26.1)6.1

(4.3-8.5) -1.16 ±1.11 00.2

(0.11-42.0) 1.6

(0.57-2.32)

31.Dolo IDPs(Large sample cluster survey)

June’12 974 25.9 7.5 -1.26 ±1.2 0.8 0.60 0.80

bay bakool region

32.bay Agro pastoral (Large sample cluster survey)

July, 2012 889 20.4 (16.7-24.5)

6.9 (5.0-9.4) -1.08 ±1.09 1.0

( 0.3-1.7) 1.40

(0.93-2.10) 2.70

(1.86-3.89)

33.bakool Pastoral(Large sample cluster survey)

July, 2012 72726.2

(20.6-32.8 5.7

(3.6- 9.1) -1.35±1.030.5

(0.01-1.1)0.31

(0.15-0.61) 0.86

(0.43-1.73)

34.baidoa IDPs(Large sample cluster survey)

July, 2012 85815.5

(11.6-20.4) 5.1 ( 3.1-8.5)

-0.76±1.16 1.7 0.42 (0.27-0.66)

1.52 (0.91-2.53)


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7.1 Progression of Estimated Nutrition Situation Deyr ‘08 /’09 - Gu ‘12

Deyr ‘08/09

Deyr ‘09/10

Gu ‘09

Gu ‘10


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nutrition ASSESSMEnt houSEhold QuEStionnAirE, Gu 2012- PAStorAl

household number ______ date_______________ team number ______ cluster number ________ cluster name _______________________ district: __________Q1-7 characteristics of household

Q1. Household size1 : (i) Today__________ (ii) In the last 30 days_______ Q2. Number of children less than 5 years

(0-59 months) Today: ______

Q3a. Household head: 1=Male 2=Female

Q3b. Marital status of caregiver: 1=Married & staying with spouse 2=Married but not stayed with spouse for 6 months or more 3=Widow/

widower 4=Divorced 5=Never married

Q3c. Highest level of mother’s/caregiver’s education: 0=None 1= Primary/Intermediary 2= Secondary 3= Tertiary

(college/university)

Q4a .How long has this household lived in this locality? 1= Resident 2= IDP<6 Months 3=IDP >6 months 4=Returnee (within the

last 6 months) 5=Refugee 6=Migrant

b. Are you hosting any recently (in the last 6 months) internally displaced persons? 0= No 1= yes

c. If yes, Number of persons ________

Q5. How many mosquito nets does the household have? 0=none 1=one 2=two

3=three 4= 4 or more

Q6. What was the source of the net? 1= NGO 2=Health Centre 3= Purchase

Q7. What is the household’s main source of income? 1= Animal & animal product sales 2= Crop sales/farming 3= Trade

4= Casual labor

5= Salaried/wage employment 6= Remittances 7=Self-Employment (Bush products/handicraft)

8=gifts/ zakat 9= Others, specify ________________Q8-15 feeding and immunization status of children aged 6 – 59 months in the household.

First Name

Date of Birth

-- /-- /--

Q8

Child Age(months)

(if child is more than 24 months old, skip to Q12)

Q9

Are you breast-feeding1 the child? (mention by name)

0= No 1=Yes

Q10How many times did you feed the child in the last 24 hours (besides breast milk)?0=Zero times1= 1 time2=2 times3 = 3 times4=-4 times5= 5 or more times

Q11

How many times did you feed the child with milk in the last 24 hours (besides breast milk)?

0=None1= 1 time2=2 times3=-3 times4= 4 times

5= 5 times or more

Q 12

Has child been provided with Vitamin A in the last 6 months?(show sample)0= No 1=Yes9=Don’t know

Q13Has child been immunized against measles2 in the last 6 months?0= No 1=Yes9=Don’t know

Q14

No of doses of polio vaccine given to the child orally?

0=none1=one2=two3=three or more9=Don’t know

Q15Does child have immunization card? 0= No 1=Yes

1

2

3

4

Q16-28 Anthropometry and morbidity for children aged 6 – 59 months in the household

1 Number of persons who live together and eat from the same pot

7.2 nutrition Assessment tools Post Gu ‘12

nutrition ASSESSMEnt houSEhold QuEStionnAirE, Gu 2012 Pastoral


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First Name

Q16a

Sex

1=Male2=Female

Q16b

Age

(month)

Q17

Weight (kg)

To the nearest tenth of

a kg

Q18

Height (cm)


a cm

Q19

Oedema

0= No 1=yes

Q20

MUAC(cm)


a cm

(≥6 mo)

Q21aDiarrhea3 in last two weeks

0= No 1=yes

Q21bIf yes in Q21a, for how many days did the child have diarrhea?

Q22Pneumonia (oof wareen/ wareento)4 in the last two weeks

0= No 1=yes

Q23

Fever5 in the last two weeks

0= No 1=yes

Q25Suspected Measles6 in last one month

0= No 1=yes9=Don’t know

Q26

Did the child sleep under a mosquito net last night?

0= No 1=yes

Q27

Where did you seek healthcare assistance when child was sick? (If yes in Q21 – 25)

0=No assistance sought1=Own medication2=Traditional healer3=Sheikh/Prayers4=Private Clinic/ Pharmacy5= Public health facility

Q28

Is the child currently registered in any feeding centres?

0= None1= SFP2= TFC/SC3= OTP4= Other

1

2

3

4

29a. Anthropometry (MuAc) for adult women of childbearing age (15-49 years) present at the household

Sno Name Age(years)

No of doses of Tetanus vaccine received

0= None1= One2= Two3=Three

MUAC(cm)

Physiological status

1= Pregnant

2= Lactating (infant <6months)

3 = N one o f t he above

Did the woman sleep under the mosquito net last night

0= No 1=yes

Is women currently registered in

0=None1=SFP (food)2 = M C H N ( F o o d a n d Vitamins)3=MCH - vitamins4=Other, (specify)

I l lness in last 14 days?

If yes, what illness? (use codes on the right)

If no, skip to 29b

Codes for adult illnesses

0= None

1= ARI2=Diarrheal3=Fever/Febrile4=Joint

5=Urinary tract infection (UTI)6=Pain in the chest7= Pain in lower abdomen/pelvis

8=Anemia9= Reproductive

10=Other, specify

1 Mother:

29b. Where do you usually seek health assistance when sick? 0=No assistance sought 1=Own medication 2=Traditional healer 3=Sheikh/Prayers 4=Private clinic/ Pharmacy 5= Public health facility

29c. If ‘No assistance’ in 28b, why? 1 = Too expensive 2 = Too far 3 = Not enough time 4 = Security concerns 5= Other, specify ……

30a. child dietary diversity

Please describe the foods (all meals and snacks) that the children (6-24 months) ate yesterday during the day and night, whether at home or outside the home. Start with the first food you ate yesterday morning. Record the respective codes to the foods mentioned. When a mixed dish is reported, ask about and tick all of the ingredients in their respective columns.

Write down all foods and drink mentioned. When composite dishes are mentioned, ask for the list of ingredients. The interviewers should establish whether the previous day and night was usual or normal for the households. If unusual- feasts, funerals or most members absent, then another day should be selected.

First Name Breakfast Snack Lunch Snack Dinner Snack

1.

When the respondent7 recall is complete, fill in the food groups based on the information recorded above. For any food groups not mentioned, ask the respondent if a food item from this group was consumed by the children.

If 6-24 months

Did the child (Name) consume food from any these food groups in the last 24 hours?8 0=No 1= Yes

Child 1 Child 2 Child 31. Cereals, roots and tubers (maize, ground maize, wheat, millet, rice, sorghum, spaghetti, bread, chapatti , macaroni,

canjera; white potatoes, cassava, arrowroot, white sweet potatoes, or foods made from these)

2. Legumes, nuts and seeds (cowpeas, beans, lentils , peanut, pumpkin seed, lentil seed, sunflower seed, wild nuts)

3. Milk and milk products (Fresh/fermented/powdered sheep, goat, cow or camel milk, Cheese (sour milk), condensed milk, yoghurt)

4. Flesh (meat, fish and poultry) products (fish, beef, lamb, goat, camel, wild game, such as Dik Dik, chicken, other birds such as guinea fowl and francolin)


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5. Eggs (eggs of chicken, or eggs of fowl)

6. Vitamin A rich fruits and vegetables (ripe mangoes, pawpaw, wild fruits such as gob, hobob, berde, isbandlays, kabla, coasta, red cactus fruit; yellow fleshed pumpkins, carrots, orange sweet potatoes, yellow cassava)

7. Other fruits and vegetables (banana, orange, apple, coconut, custard apple, dates, unripe mangoes, grapes, guava, wild fruits and 100% fruit juices; tomato, onion, squash, bell pepper, cabbage ,light green lettuce, white radish )

Q 30b. Total number of food groups consumed by each child

Q31a household food consumption & dietary diversity2: Please describe the foods (meals and snacks) that members of your household ate or drank yesterday during the day and night at home3. Start with the first food or drink of the morning. Include wild foods e.g. game meat, honey, fruits, vegetables, leaves.


Breakfast Snack Lunch Snack Dinner Snack

When the respondent9 recall is complete, fill in the food groups based on the information recorded above. For any food groups not mentioned, ask the respondent if a food item from this group was consumed

Any household member10

0=No 1= Yes 1. Cereals and cereal products (maize, ground maize, wheat, white wheat, wholemeal wheat, millet, rice, white grain sorghum, red sorghum

, spaghetti, bread, chapatti , macaroni, canjera)2. Milk and milk products (Fresh/fermented/powdered sheep, goat, cow or camel milk, Cheese (sour milk), condensed milk, yoghurt)3. Vitamin A rich vegetables and tubers (yellow fleshed pumpkins, carrots, orange sweet potatoes, yellow cassava) 4. Dark green leafy vegetables (amaranth, kale, spinach, , onion leaf, pumpkin leaves, cassava leaves, dark green lettuce)5. Other vegetables (tomato, onion, squash, bell pepper, cabbage ,light green lettuce, white radish )6. Vitamin A rich fruits (ripe mangoes, pawpaw, wild fruits such as gob, hobob, berde, isbandlays, kabla, coasta, red cactus frui,)

7. Other fruit (banana, orange, apple, coconut, custard apple, dates, unripe mangoes, grapes, guava, wild fruits and 100% fruit juices)8. Organ meat (liver, kidney, heart or other organ meat)9. Meat and Poultry (beef, lamb, goat, camel, wild game, such as Dik Dik, chicken, other birds such as guinea fowl and francolin)10. Eggs (eggs of chicken, or eggs of fowl)11. Fish (fresh or dried) and other seafood (shellfish)12. Legumes, nuts and seeds (cowpeas, beans, lentils , peanut, pumpkin seed, lentil seed, sunflower seed, wild nuts)13. White roots and tubers (white potatoes, cassava, arrowroot, white sweet potatoes, or foods made from roots)14. Oils and Fats (cooking fat or oil, ghee, butter, sesame oil, margarine)

15. Sweets (sugar, honey, sweetened soda and fruit drinks, chocolate biscuit, cakes,, candies, cookies, Sugar cane and sweet sorghum)16. Coffee, tea and Spices (coffee, tea, spices such as black pepper, cardamoms, cinnamon, ginger, nutmeg, cloves, salt. Condiments such

as ketchup, soy sauce, chilli sauce)Q 31b. Total number of food groups consumed?Q 31c. Did you or anyone in your household eat anything (meal or snack) OUTSIDE of the home yesterday

Q32 a. In the last three months, what is the main source in the household of these foods: i) Staple cereal? ____________ ii) Milk? _____________ (Use codes below)

1= Own production 2= Purchasing 3=Community Gifts/Donations 4= Food aid 5= Bartering 6= borrowing 7= Gathering

Q32b. How many times did you receive cereal food aid in the last 6 months? 0=never 1= once 2= twice 3=

three times 4= fourth 5= five times 6= six times or more

Q33 How many meals4 has the household had in the last 24 hours (from this time yesterday to now)? 0= none 1= One

2=Two 3= Three 4=Four + coping Strategies

Q 34. In the past 30 days, if there have been times when people did not have enough food or money to buy food, which of the following coping strategies did they use? (Select based on relevant livelihood system)

Pastoralist livelihood: Indicate type of Pastoralism practiced : 1= Nomadic/mobile 2= Sedentary/settled

In the past 30 days, if there have been times when you did not have enough food or money to buy food, how often has your household had to:

0=Never (zero times/week)1=Hardly at all (<1 times/ week)2=Once in a while (1-2 times/ week)3= Pretty often? (3-6 times/week)4=All the time (Every day)

a. Reduce home milk consumption and sell more of milk produced?b. Consume less preferred cereals

c. Borrow food on credit from another household (Aamah)?d. Reduce number of meals per day? e. Reduce the portion size/quantity consumed at meal times (Beekhaamis)?

f. Rely on food donations (gifts) from the clan/community (Kaalmo)?g. Consume weak un-saleable animals (caateysi)?2 FAO Household Dietary Diversity Tool3 Include foods prepared inside the home but consumed outside the home4 A meal refers to food served and eaten at one time (excluding snacks) and includes one of the three commonly known: - breakfast, lunch and supper/dinner


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i. Skip (go an) entire days without eating (Qadoodi)?j. Beg for food (Tuugsi/dawarsi)?k. Rely on hunting for food (ugaarsi)?

Agro-pastoralists livelihood:



a. Shift from high priced cereal varieties to low price cereal varieties?

b. Shift from high quality cereals to low quality cereals (from osolo to obo)?

c. Borrow food on credit from shop (Deyn)?

d. Borrow food on credit from another household (Aamah)?

e. Reduce home milk consumption and sell more of milk produced?

f. Reduce the number of meals in a day by adults?

g. Stop all home milk consumption and sell all milk produced?

h. Rely on food donations (gifts) from the close relatives (Qaraabo)?

i. Rely on food donations (gifts) from the clan/community (Kaalmo)?j. Skip (go an) entire days without eating (Qadoodi)?

k. Community identified your household as in need of food and fives support? (Qaraan)l. Send household children to live or eat with relatives (elsewhere)?

WAtEr & SAnitAtion

Q35-36 Access to drinking water and sanitation facilities

Q35 What is the household’s main source of drinking water? Protected sources: 1 = Household connection 2 = Standpipe (Kiosk/Public tap/Taps connected to a storage tank)

3 = Protected Shallow well (covered with hand pump/motorized pump) 4 = Tanker 5 = Spring 6 = Bottled water 7 = Rooftop rainwater unprotected sources 8 = Berkads 9 = River/stream 10 = Dam/Pond (Balley) 11 = Open Shallow well 12 = other (specify) …

Q36 What type of toilet is used by most members of the household? 0 = No toilet is available (an open pit/open ground is used) 1 = Household latrine 2 = Communal/Public latrine 3 = Flush toilet

checked by Supervisor (Sign) ____________________________

(footnotes)1 Child having received breast milk either directly from the mothers or surrogate mother breast within the last 12 hours2 Measles immunization is a shot in the upper arm given to children after 6 months of age at health clinics or by mobile health teams3 Diarrhea is defined for a child having three or more loose or watery stools per day4 ARI asked as oof wareen or wareento. The three signs asked for are chest in-drawing, cough, rapid breathing/nasal flaring and fever5 Fever – The three signs to be looked for are periodic chills/shivering, fever, sweating and convulsions6 Measles (Jadeeco): a child with more than three of these signs– fever and, skin rash, runny nose or red eyes, and/or mouth infection, or chest infection7 Respondent refers to the person responsible for food preparation on the recall day. For the child, refer to the mother or caregiver8 WHO, 2008. Indicators for assessing infant and young child feeding practices: Conclusion of a consensus meeting held 6-8 November 2007 in Washington D.C., USA ;FANTA 2002 Summary Indicators for Infant and Child Feeding Practices; 9 Respondent refers to the person responsible for food preparation on the recall day. For the child, refer to the mother or caregiver10


household number ______ date_______________ team number ______ cluster number ________ cluster name _______________________ district: __________Q1-7 characteristics of household

Q1. Household size1 : (i) Today__________ (ii) In the last 30 days_______ Q2. Number of children less than 5 years

(0-59 months) Today: ______

Q3a. household head: 1=Male 2=Female

Q3b. Marital status of caregiver: 1=Married & staying with spouse 2=Married but not stayed with spouse for 6 months or more 3=Widow/

widower 4=Divorced 5=Never married

Q3c. Highest level of mother’s/caregiver’s education: 0=None 1= Primary/Intermediary 2= Secondary 3= Tertiary

(college/university)

Q4a .How long has this household lived in this locality? 1= Resident 2= IDP<6 Months 3=IDP >6 months 4=Returnee (within the

last 6 months) 5=Refugee 6=Migrant

b. Are you hosting any recently (in the last 6 months) internally displaced persons? 0= No 1= yes

c. If yes, Number of persons ________

Q5. How many mosquito nets does the household have? 0=none 1=one 2=two

3=three 4= 4 or more

Q6. What was the source of the net? 1= NGO 2=Health Centre 3= Purchase

Q7. What is the household’s main source of income? 1= Animal & animal product sales 2= Crop sales/farming 3= Trade

4= Casual labor

5= Salaried/wage employment 6= Remittances 7=Self-Employment (Bush products/handicraft)

8=gifts/ zakat 9= Others, specify ________________Q8-15 feeding and immunization status of children aged 6 – 59 months in the household.

First Name

Date of Birth

-- /-- /--

Q8

Child Age(months)

(if child is more than 24 months old, skip to Q12)

Q9

Are you breast-feeding1 the child? (mention by name)

0= No 1=Yes

Q10How many times did you feed the child in the last 24 hours (besides breast milk)?0=Zero times1= 1 time2=2 times3 = 3 times4=-4 times5= 5 or more times

Q11

How many times did you feed the child with milk in the last 24 hours (besides breast milk)?

0=None1= 1 time2=2 times3=-3 times4= 4 times

5= 5 times or more

Q 12

Has child been provided with Vitamin A in the last 6 months?(show sample)0= No 1=Yes9=Don’t know

Q13Has child been immunized against measles2 in the last 6 months?0= No 1=Yes9=Don’t know

Q14

No of doses of polio vaccine given to the child orally?

0=none1=one2=two3=three or more9=Don’t know

Q15Does child have immunization card? 0= No 1=Yes

1234Q16-27 Anthropometry and morbidity for children aged 6 – 59 months in the household

First Name

Q16a

Sex

1=Male2=Female

Q16b

Age

(month)

Q17

Weight (kg)

To the nearest

tenth of a kg

Q18

Height (cm)

To the nearest tenth of a cm

Q19

Oedema

0= No 1=yes

Q20

MUAC(cm)


a cm

(≥6 mo)

Q21Diarrhea3 in last two weeks

0= No 1=yes

Q22Pneumonia (oof wareen/ wareento)4 in the last two weeks

0= No 1=yes

Q23

Fever5 in the last two weeks

0= No 1=yes

Q24Suspected Measles6 in last one month

0= No 1=yes9=Don’t know

Q25

D i d t h e child sleep u n d e r a mosqui to n e t l a s t night?

0= No 1=yes

Q26

Where did you seek healthcare assistance when child was sick? (If yes in Q21 – 24)

0=No assistance sought1=Own medication2=Traditional healer3=Sheikh/Prayers4=Private Clinic/ Pharmacy5= Public health facility

Q27

Is the child currently registered in any feeding centres?

0= None1= SFP2= TFC/SC3= OTP4= Other

1 2

1 Number of persons who live together and eat from the same pot

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Sno Name Age(years)

No of doses of Tetanus vaccine received

0= None1= One2= Two3=Three

MUAC(cm)

Physiological status

1= Pregnant

2= Lactating (infant <6months)

3= None of the above

Did the woman sleep under the mosquito net last night

0= No 1=yes

Is women currently registered in

0=None1=SFP (food)2=MCHN (Food and Vitamins)3=MCH - vitamins4=Other, (specify)

Illness in last 14 days?

If yes, what illness?

If no, skip to 28c

Codes for adult illnesses

0= None

1= ARI2=Diarrheal3=Fever/Febrile4=Joint

5=Urinary tract infection (UTI)6=Pain in the chest7= Pain in lower abdomen/pelvis

8=Anemia9= Reproductive

10=Other, specify

1 Mother:

28b. Where do you seek health assistance when sick? 0=No assistance sought 1=Own medication 2=Traditional healer 3=Sheikh/Prayers 4=Private clinic/ Pharmacy 5= Public health facility

28c. If ‘No assistance’ in 28b, why? 1 = Too expensive 2 = Too far 3 = Not enough time 4 = Security concerns 5= Other, specify ……

29a. child dietary diversity

Please describe the foods (all meals and snacks) that the children (6-24 months) ate yesterday during the day and night, whether at home or outside the home. Start with the first food you ate yesterday morning. Record the respective codes to the foods mentioned. When a mixed dish is reported, ask about and tick all of the ingredients in their respective columns.


First Name Breakfast Snack Lunch Snack Dinner Snack

1.

When the respondent7 recall is complete, fill in the food groups based on the information recorded above. For any food groups not mentioned, ask the respondent if a food item from this group was consumed by the children.

If 6-24 months

Did the child (Name) consume food from any these food groups in the last 24 hours?8 0=No 1= Yes

Child 1 Child 2 Child 3

1. Cereals, roots and tubers (maize, ground maize, wheat, millet, rice, sorghum, spaghetti, bread, chapatti , macaroni, canjera; white potatoes, cassava, arrowroot, white sweet potatoes, or foods made from these)


3. Milk and milk products (Fresh/fermented/powdered sheep, goat, cow or camel milk, Cheese (sour milk), condensed milk, yoghurt)

4. Flesh (meat, fish and poultry) products (fish, beef, lamb, goat, camel, wild game, such as Dik Dik, chicken, other birds such as guinea fowl and francolin)

5. Eggs (eggs of chicken, or eggs of fowl)

6. Vitamin A rich fruits and vegetables (ripe mangoes, pawpaw, wild fruits such as gob, hobob, berde, isbandlays, kabla, coasta, red cactus fruit; yellow fleshed pumpkins, carrots, orange sweet potatoes, yellow cassava)

7. Other fruits and vegetables (banana, orange, apple, coconut, custard apple, dates, unripe mangoes, grapes, guava, wild fruits and 100% fruit juices; tomato, onion, squash, bell pepper, cabbage ,light green lettuce, white radish )

Q 29b. Total number of food groups consumed by each child

Q30a household food consumption & dietary diversity2: Please describe the foods (meals and snacks) that members of your household ate or drank yesterday during the day and night at home3. Start with the first food or drink of the morning. Include wild foods e.g. game meat, honey, fruits, vegetables, leaves.


2 FAO Household Dietary Diversity Tool3 Include foods prepared inside the home but consumed outside the home


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When the respondent9 recall is complete, fill in the food groups based on the information recorded above. For any food groups not mentioned, ask the respondent if a food item from this group was consumed

Any household member10

0=No 1= Yes 1. Cereals and cereal products (maize, ground maize, wheat, white wheat, wholemeal wheat, millet, rice, white grain

sorghum, red sorghum , spaghetti, bread, chapatti , macaroni, canjera)2. Milk and milk products (Fresh/fermented/powdered sheep, goat, cow or camel milk, Cheese (sour milk), condensed

milk, yoghurt)3. Vitamin A rich vegetables and tubers (yellow fleshed pumpkins, carrots, orange sweet potatoes, yellow cassava)

4. Dark green leafy vegetables (amaranth, kale, spinach, , onion leaf, pumpkin leaves, cassava leaves, dark green lettuce)

5. Other vegetables (tomato, onion, squash, bell pepper, cabbage ,light green lettuce, white radish )

6. Vitamin A rich fruits (ripe mangoes, pawpaw, wild fruits such as gob, hobob, berde, isbandlays, kabla, coasta, red cactus frui,)

7. Other fruit (banana, orange, apple, coconut, custard apple, dates, unripe mangoes, grapes, guava, wild fruits and 100% fruit juices)

8. Organ meat (liver, kidney, heart or other organ meat)9. Meat and Poultry (beef, lamb, goat, camel, wild game, such as Dik Dik, chicken, other birds such as guinea fowl and

francolin)10. Eggs (eggs of chicken, or eggs of fowl)

11. Fish (fresh or dried) and other seafood (shellfish)


13. White roots and tubers (white potatoes, cassava, arrowroot, white sweet potatoes, or foods made from roots)

14. Oils and Fats (cooking fat or oil, ghee, butter, sesame oil, margarine)15. Sweets (sugar, honey, sweetened soda and fruit drinks, chocolate biscuit, cakes,, candies, cookies, Sugar cane and

sweet sorghum)16. Coffee, tea and Spices (coffee, tea, spices such as black pepper, cardamoms, cinnamon, ginger, nutmeg, cloves, salt.

Condiments such as ketchup, soy sauce, chilli sauce)Q 30b. Total number of food groups consumed?Q 30c. Did you or anyone in your household eat anything (meal or snack) OUTSIDE of the home yesterday

Q31 a. In the last three months, what is the main source in the household of: i) Staple cereal? ____________ ii) Milk? ______________ (Use codes below)

1= Own production 2= Purchasing 3=Community Gifts/Donations 4= Food aid 5= Bartering 6= borrowing 7= Gathering

Q31b. How many times did you receive cereal food aid in the last 6 months? 0=never 1= once 2= twice 3= three

times 4= fourth 5= five times 6= six times or more

coping Strategies

Q 32. In the past 30 days, if there have been times when people did not have enough food or money to buy food, which of the following coping strategies did they use? (Select based on relevant livelihood system)

urban/idPs livelihood Group



a. Shift to less preferred (low quality, less expensive) foods (from osolo to obo)?

b. Limit the portion/quantity consumed in a meal (Beekhaamis)?c. Take fewer numbers of meals in a day?

d. Borrow food on credit from the shop/market (Deyn)?e. Borrow food on credit from another household (Aamah)?f. Restrict consumption of adults in order for small children to eat?

g. Rely on food donations from relatives (Qaraabo)?h. Rely on food donations from the clan/community (Kaalmo)?i. Seek or rely on food aid from humanitarian agencies?

j. Send household members to eat elsewhere? k. Beg for food (Tuugsi/dawarsi)?l. Skip entire days without eating (Qadoodi)?m. Consume spoilt or left-over foods


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Q33-38 Access to water (quality and quantity)

Q33 What is the household’s main source of drinking water? Protected sources: 1 = Household connection 2 = Standpipe (Kiosk/Public tap/Taps connected to a storage tank)

3 = Protected Shallow well (covered with hand pump/motorized pump) 4 = Tanker 5 = Spring 6 = Bottled water 7 = Rooftop rainwater unprotected sources 8 = Berkads 9 = River/stream 10 = Dam/Pond (Balley) 11 = Open Shallow well 12 = other (specify) …

Q34a If the household has no access to protected water sources (if the answer to Q33 is 8, 9, 10, 11 or 12), what is the main reason? 0 = Not Available 1 = Distance too far 2= Security Concerns 3 = Cannot afford 4 = Queuing time is too long 5 = Other reasons (specify)

Q34b If you get your water from a protected water source (if the answer to Q33 is 1, 2, 3, 4, 5, 6 or 7), How many days in the last year month were you NOT able to get water from the protected source 1= None 2 = 1-5 days 3 = >5 days

Q34c What was reason for not getting water? 1 = couldn’t afford 2 = source dried up 3 = machine broke down 4 = other, specify ____________

Q35a What is the average time taken per TRIP to and from the main water source (including waiting and collecting time)? 1 = Less than 30 minutes 2 = 30 to 60 minutes 3 = More than 1 hour

Q35b Most days (on average) how much water do you collect for the household

Jer i c an (20 liter)

J e r i c a n ( 5 liter)

Drum (200liters) Haan (local container with capacity of about 12.5 liters)

O t h e r container(specify)

Total No. of Liters

No. of containers

Q36 Is the water for drinking treated and/or chlorinated4 at the Household level? 0 = No 1 = yes

Q37 If yes, what is the method of treatment (select more than 1 option if applicable)? 1 = Boiling 2 = Chlorination 3 = Straining/filtering 4 = Decanting/letting it stand and settle 5 = Leaving the water out in the sun 6 = Other (specify)

Q38 Does the family pay for drinking water? 0 = No 1 = yes

Q39-40 Sanitation and hygiene (access and quality)

Q39a What type of toilet is used by most members of the household? 0 = No toilet is available (an open pit/open ground is used) 1 = Household latrine 2 = Communal/Public latrine 3 = Flush toilet

Q39b If the answer to Q39a is 0, what is the main reason? 1 = Pastoral/ frequent movements 2 = Lack resources to construct 3 = Lack of space to construct 4 = Don’ t see the need 9 = Don’t know

Q39c If the answer to Q39a is 1,2 or 3 , how many households share/use the same toilet? 1= One 2= 2 to 3 3= 4 to 9 4= 10 or more 9 = Don’t know

Q40 When you wash your hands, what substance do you use for hand washing? 0= None (only with water) 1= Soap/Shampoo 2= Sand 3= Ash 4= Plant extracts

Q41 Have you been exposed to information on correct personal hygiene and sanitation practices in the last 3 months? (select more than 1 option if applicable) 0= No 1= yes via mass media 2= yes via printed media 3 = ye s v i a i n t e r p e r s o n a l communication 4= yes via group meetings

checked by Supervisor (Sign) ____________________________

(footnotes)1 Child having received breast milk either directly from the mothers or surrogate mother breast within the last 12 hours2 Measles immunization is a shot in the upper arm given to children after 6 months of age at health clinics or by mobile health teams3 Diarrhea is defined for a child having three or more loose or watery stools per day4 ARI asked as oof wareen or wareento. The three signs asked for are chest in-drawing, cough, rapid breathing/nasal flaring and fever5 Fever – The three signs to be looked for are periodic chills/shivering, fever, sweating and convulsions6 Measles (Jadeeco): a child with more than three of these signs– fever and, skin rash, runny nose or red eyes, and/or mouth infection, or chest infection7 Respondent refers to the person responsible for food preparation on the recall day. For the child, refer to the mother or caregiver8 WHO, 2008. Indicators for assessing infant and young child feeding practices: Conclusion of a consensus meeting held 6-8 November 2007 in Washington D.C., USA

;FANTA 2002 Summary Indicators for Infant and Child Feeding Practices; 9 Respondent refers to the person responsible for food preparation on the recall day. For the child, refer to the mother or caregiver

4 Chlorinated water should have a characteristic taste and smell


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Date______________ Team No:___ Cluster No. ___ Cluster Name____________________ Town_______________ Region ________

SNo HouseholdNumber Child No.

Sex:

1=Male2=Female

Age(Months) Weight

(kg)Height(cm)

Oedema1= Yes2=No

MUAC(cm)

Illness in past 14 days? 0 =No

If Yes specify1= Diarrhoea2=Pneumonia3=Malaria 4=Measles

7.4 urban rapid Assessment record form - Gu 2012


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Household No ___ date_______________ team No ___ cluster No ______ cluster Name _______ enumerator ________

No. 1: First Name2: Sex (1=M; 2=F)

3: Age (yrs)

4: Born since __ / 3/ 2012

5: Arrived since __ / 3/ 2012

6: Reason for leaving

7: Cause of death

a) How many members are present in this household now? List them.

b) How many members have left this household (out migrants) since Mar __, 2012? List them

c) Do you have any member of the household who has died since Mar __, 2012? List them

codesReason for migration Cause of death

1= Civil Insecurity 6= Hospitalised 2= Food Insecurity 7= In boarding school3= Employment 8= Grazing/herding4=Divorce/ Married away 9= Other, specify5=Visiting

1= Diarrhoea2= Fever3= Measles4= Breathing Difficulty5= Malnutrition/Hunger

6= Violence/Physical injuries7= Pregnancy/Birth complications8= Other, specify (e.g. still birth)

Summary*

Total U5

Current HH Members

Arrivals during the Recall period

Number who have left during Recall period

Births during recall

Deaths during recall period* For Supervisor Only


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rapid nutrition Assessment formdate: _____________ district: ________________ livelihood: __________________ cluster name: _________________ cluster no. __ team no. ___

HouseholdNumber

Women aged 15-49 yrs Children aged 6-59 months

Physiological Status:1=Pregnant2=Lactating3=Not pregnant/ lactating

MUAC (cm) [for Woman]

Child No.

Sex: 1=Male2=Female

Age(Months) Weight

(kg)Height (cm)

Edema

1= Yes2=No

MUAC(cm)

Illness in past 14 days?

No = 0If Yes, specify (indicate ALL that apply) 1

1=Diarrhoea2=Pneumonia3=Fever4= Measles

Vaccination in the last 6 months

No = 0If Yes, specify (indicate ALL that apply)1=Polio 2=Vitamin A supp3=Measles2

Registered in feeding centre?

0=None1=SFP2=TFC/SC3=OTP

(footnotes)

1 Diarrhea is defined for a child having three or more loose or watery stools per day; Pneumonia asked as oof wareen or wareento. The three signs asked for are chest in-drawing, cough, rapid breathing/nasal flaring and fever; Fever – The three signs to be looked for are periodic chills/shivering, fever, sweating and convulsions; Measles (Jadeeco): a child with more than three of these signs– fever and, skin rash, runny nose or red eyes, and/or mouth infection, or chest infection2 Measles immunization is a shot in the upper arm given to children after 6 months of age at health clinics or by mobile health teams

7.7 SouthErn idPS And urbAn QuEStionnAirE - July 2012


7.8 Somalia livelihood Zones

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8. GloSSAry of tErMS

Anthropometry The technique that deals with the measurements of the size, height, weight, and proportions of the human body.

baseline data baseline data represent the situation before or at the beginning of a program or intervention. Survey data may be compared to baseline data if defined criteria for comparison are met (e.g., similar methods and coverage)

bias Anything other than sampling error which causes the survey result to differ from the actual population prevalence or rate.

chronic Malnutrition Chronic malnutrition is an indicator of nutritional status over time. Chronically malnourished children are shorter (stunted) than their comparable age group.

cluster Sampling Cluster sampling requires the division of the population into smaller geographical units, e.g. villages or neighbourhoods. In a first step, survey organizers select a defined number of units among all geographical units. In a second and sometimes third step, households are selected within the units using simple random sampling, systematic random sampling, or the modified EPI method.

Confidence interval When sampling is used, any figure derived from the data is an estimate of the actual value and is subject to sampling errors, i.e., there is a risk that the result obtained is not exactly equal to the actual value. The estimated prevalence coming out of a sample is therefore accompanied by a confidence interval, a range of values within which the actual value of the entire population is likely to be included. This value is generally 95% in nutrition and mortality surveys. This means that we can be 95% confident that the true prevalence lies within the given range.

crude mortality rate (cMr) Mortality rate from all causes of death for a population (Number of deaths during a specified period /number of persons at risk of dying during that period) X time period.

cut-off points The point on a nutritional index used to classify or screen individuals’ anthropometric status.

design Effect (dE) Cluster sampling results in greater statistical variance (see definition below) than simple random sampling because health outcomes tend to be more similar within than between geographical units (see cluster sampling). To compensate for the resulting loss in precision, the sample size calculated for simple random sampling must be multiplied by a factor called “design effect”; A measure of how evenly or unevenly the outcome (for example wasting, stunting, or mortality) is distributed in the population being sampled.

Global Acute Malnutrition (GAM) GA M in c l udes a l l children suffering from moderate and severe acute malnutrition; percent of children under 5 who have low

weight-for-height measured by -2 z-scores and with or without oedema.

Growth Monitoring Observation of a child growth over time by periodic assessment of his/her weight-for-height or weight-for-age.

household A group of persons who live together and eat from the same pot (i.e. the HEA definition)

kwashiorkor Sign of severe malnutrition characterized by bilateral oedema.

Malnutrition State in which the physical function of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance process such as growth, pregnancy, lactation, physical work, and resisting and recovering from disease.

Morbidity A condition related to a disease or illness.

oedema An accumulation of excessive extra cellular fluid in the body; a distinguishing characteristic of kwashiorkor when bilateral. All children with nutritional oedema are classified as severely malnourished.

outcome Wasting and mortality are examples of outcomes measured in surveys.

Prevalence Proportion of a population with a disease or condition of interest at a designated time.

P-value If you want to know whether there is a significant difference between two survey estimates, frequently a statistical test is applied and a P value calculated. The P value is the probability that the two estimates differ by chance or sampling error.

recall period A defined period in the past used to calculate estimated mortality and/or morbidity rates.

reference Population The NCHS (1977) and WHO (2006) reference values are based on two large surveys of healthy children, whose measurements represent an international reference for deriving an individual’s anthropometric status.

Sample A subset of the total population that should be selected at random to guarantee a representation of the total population.

Sample size The size of the sample calculated based on objectives of the survey and statistical considerations.

Sampling error Sampling error is the degree to which a sample might differ from the whole target population, e.g., how well it represents a target population or total population. Sampling error can be quantified (e.g., in a confidence interval).

Sampling frame The list of all the ultimate sampling units from which the sample is selected.

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Sampling interval The sampling interval is the total number of sampling units in the population divided by the desired sample size.

Sampling unit The unit that is selected during the process of sampling; depending on the sampling process the sampling unit can be a person, household, cluster, district, etc.

Severe Acute Malnutrition (SAM) SAM includes all children suffering from severe malnutrition; percent of children under 5 who have low weight-for-height measured by -3 z-scores and with or without oedema.

Simple random Sampling The process in which each sampling unit is selected at random one at a time from a list of all the sampling units in the population.

Stunting (chronic malnutrition) Growth failure in a child that occurs over a slow cumulative process as a result of inadequate nutrition and/or repeated infections; stunted children are short for their age and may look younger than their actual age; it is not possible to reverse stunting; measured by the height-for-age index.

Systematic random Sampling (SrS) A methodology which selects a sampling unit at random, then selects every nth household thereafter, where ‘n’ equals the sampling interval.

underweight Percentage of children under the age of five with weight-for-age below -2SD from median weight-for-age of reference population.

urban town/center (based on UNDP definition/Pre-War definition): The regional capital and all the district capitals. These urban areas had most of the social amenities such as schools, mosques, district hospitals, markets, etc. Moreover, there was a greater prospect of the visible presence of some sort of local government or administrative structures in the regional and district capitals.

Wasting (1) Growth failure as a result of recent rapid weight loss or failure to gain weight; wasted children are extremely thin; readily reversible once condition improve; wasting is measured by the weight-for-height index.

Wasting (2) Percentage of children under the age of five suffering from moderate or severe wasting (below minus two standard deviations from median weight-for-height of reference population). Wasting differs from acute malnutrition because it does not take into consideration the presence/absence of oedema.

Z-score Score expressed as a deviation from the mean value in terms of standard deviation units; the term is used in analyzing continuous variables such as heights and weights of a sample.

AcknoWlEdGEMEntS

report writing: - FSNAU Nutrition TeamAbukar yusuf Nur - Nutrition AnalystLouise Masese-Mwirigi - Nutrition AnalystJoseph Waweru - Nutrition AnalystMohamed borle - Nutrition AnalystElijah Odundo - Nutrition Data Analyst/biostatisticianTom Oguta - Senior Nutrition AnalystAhono busili - Nutrition Team Manager

data collection and support in report writing - FSNAU field team

nutrition cluster response piece Leo Matunga - Nutrition Cluster CoordinatorPenina Muli - Nutrition Cluster Support Officer

Special contributionsTamara Nanitashvili -Officer-in-Charge, FSNAUAnne bush - Nutrition Technical Advisor Abdi Roble - Deputy Food Security Technical Manager

design and publishingBarasa Sindani - Design and Publications OfficerCatherine kimani - Graphics Assistant

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The Information Management Process Gathering & processing• FSNAUhasauniquenetworkof32specialistsalloverSomalia,whoassessthenutritionandfoodsecuritysituation

regularlyand120enumeratorsthroughoutthecountry,whoprovidearichsourceofinformationtoensureagoodcoverageofdata.

• Nutritiondata isprocessedandanalyzedusing theStatisticalPackage forSocialSciences (SPSS), EPInfo/ENAandSTATAsoftwareformeta-analysis.

• FSNAUdeveloped the IntegratedPhaseClassification (IPC), a setofprotocols for consolidatingand summarizingsituationalanalysis.Themappingtoolprovidesacommonclassificationsystemforfoodsecuritythatdrawsfromthestrengthsofexistingclassificationsystemsandintegratesthemwithsupportingtoolsforanalysisandcommunicationoffoodinsecurity.

• Foodsecurityinformationisgatheredthroughrapidassessmentsaswellasmonthlymonitoringofmarketprices,climate,cropandlivestocksituations.

• BaselinelivelihoodanalysisisconductedusinganexpandedHouseholdEconomyApproach(HEA).• The IntegratedDatabase System (IDS), anonline repositoryon FSNAU’sofficialwebsitewww.fsnau.org, provides

a web-based user interface for data query, data import and export facilities from and intoMS Excel, graphing,spreadsheetmanagementandeditfunctions.

Validation of Analysis• Quality control of nutrition data is done using the automated plausibility checks function in ENA software. The

parameterstestedinclude;missing/flaggeddata,agedistribution,kurtosis,digitpreference,skewnessandoverallsexratio.

• Quality control of food security data is done through exploratory and trend analysis of the different variablesincluding checks for completeness/missing data,market price consistency, seasonal and pattern trends, groundtruthingandtriangulationofdatawithstaffandotherpartneragencies,andsecondarydatasuchassatelitteimagery,internationalmarketprices,FSNAUbaselinedata,etc.

• Beforethelaunchofthebiannualseasonalassessmentresults(GuandDeyr),twoseparateday-longvettingmeetingsareheldcomprisingofmajortechnicalorganizationsandagenciesinSomalia’sFoodSecurityandNutritionclusters.TheteamcriticallyreviewstheanalysispresentedbyFSNAUandchallengestheoverallanalysiswherenecessary.Thisisanopportunitytosharethedetailedanalysis,whichisoftennotpossibleduringshorterpresentationsorinthebriefs.

Products and Dissemination • A broad range of FSNAU information products include, monthly, quarterly and biannual reports on food and

livelihoodinsecurity,markets,climateandnutrition,whicharedistributedbothinprintanddigitalformatsincludingPowerPointpresentationsanddownloadablefileavailableontheFSNAUsite.

• Feedbackmeetingswith key audiences enableus to evaluate the effectivenessof our informationproducts.Weconstantlyrefineourinformationtomakesureitiseasilyunderstandabletoourdifferentaudiences.

• FSNAUhasalsodevelopedathreeyearintegratedcommunicationstrategytoensurethatitsinformationproductsaremadeavailableinwaysappropriatetodifferentaudiencesincluding,donors,aidanddevelopmentagencies,themedia,Somaliaauthoritiesandthegeneralpublic.

United Nations Somalia, Ngecha Road Campus Box1230,VillageMarket,Nairobi,Kenya

Tel:+254-(0)20-4000000/500,Cell:+254-(0)722202146/(0)733-616881Fax:+254-20-4000555Email:[email protected]

Website:www.fsnau.org

fsnau technical series report post gu 2012 nutrition analysis

Documents