FSNAU Nutrition Update for Somalia - Preliminary findings from 2016 Gu season nutrition surveys among Internally Displaced Persons (IDPs) in Somalia

Issued: July 5, 2016

Key Highlights

As part of Gu 2016 assessment plan, FSNAU and partners working in Somalia conducted integrated Nutrition and Food security assessments among the 12 Internally Displaced Person (IDP) settlements across Somalia from May 28th to June 3rd 2016. A total of 7 683 children (6-59 months) and 3 710 of women in the reproductive age group (15-49 years) were taken from 4 520 households. The objective of the assessments was to monitor the nutrition situation of these vulnerable IDP population groups as part of FSNAU’s biannual surveillance activities. The Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology was used for the assessment. Sampling was based on Probability Proportionate to Size (PPS)  two stage cluster sampling procedure for all assessments except Qardho and Dhusamareeb where exhaustive sampling was used.

Mortality survey was collected at the household level retrospectively within 90 days recall period. While other contextual factors on food security, WATSAN, household and child diversity, maternal health and nutrition data were collected at every Nth Household (skip pattern at every odd numbered household). Household variables such as (anthropometric and all other contextual indicators) and mortality were entered using EPI info soft 3.5.4 and ENA SMART software (July 9th, 2015 version) respectively. For quality assurance, supervisors’ would export EPI info file having anthropometric dataset to ENA software and were able to gauge  quality of data and survey team performance on a daily basis using ENA SMART software plausibility parameters.

Acute malnutrition in children 6-59 months is a direct outcome indicator of recent changes in nutritional status and sickness.

Critical levels of Global Acute Malnutrition (GAM rate ≥15 %) were observed among six IDPs of 12 surveyed during Gu 2016 assessment. These are Dhobley, Baidoa and Dolow IDPs in South-Central regions and Garowe, Bosasso and Galkayo in Northeast region. It is also of a concern to note that nutrition situation in three of these IDPs (Dolow, Garowe & Galkayo) is sustained as Critical since last two years. Serious GAM levels (10-14.9%) were also recorded among IDPs in Mogadishu, Kismayo and Dhusamareb in South Central region, Qardho IDPs (Northeast) and Hargeisa IDPs (Northwest). Alert level of GAM (5-9.9 %) was seen only among Burao IDPs in the Northwest.

Since Gu 2015, a drastic deterioration in nutrition assessment is noted in Bossaso IDP located in Northeast region while malnutrition prevalence in Dobley IDP in South Central region showed an improvement from a GAM of 20.7 percent to 17.7 percent. However, the change in prevalence was not statistically significant and it remained as critical in terms of the burden of wasting prevalence. 
The mortality survey took place the same time while anthropometric data from each selected households were being collected. Household selection for mortality also followed the same principles of second stage household selection procedure for anthropometry. In most of the IDP’s located in the Northeast and South Central, modified EPI methodology was adopted while for those IDP’s in the Northwest, a simple random sampling procedure was adopted.  A total of 4 939 households were sampled for mortality survey. 90 days prior to this assessment, there were a total of 544 people registered as in-migration, 741 people registered as out-migration, 293 new birth and 88 deaths. Out of the total 88 deaths, 44 were children under five where the highest number of deaths registered came from IDP’s situated in Mogadishu, Kismayo Qardho and Bossaso. 

The current IDP assessment also looked into other public health indicators such as immunization coverage for measles and supplementation of Vitamin A within a six month recall period among the 12 IDP settlements. Measles coverage and vitamin A supplementation was the lowest in for IDP’s residing in Mogadishu, Dhobley and Dhusamareb. However, coverage estimate was only calculated by asking or taking mothers recall and hence may not represent true estimate.

Results of Gu 2016 assessment suggest that the total absolute number of children affected with Global acute malnutrition and severe wasting among the displaced population were 18 750 and 4 080 respectively. This represents a 18.7 percent increase in GAM cases when compared to Deyr 2015 but only 2.2 percent increment from Gu 2015 findings. The burden of 2016 SAM cases, however, showed an increment by 31.6 percent when compared to Deyr 2015 but only 4.6 percent compared to Gu 2015.

Conclusion:
The current nutrition situation in the Northeast IDPs residing in Bossaso, Garowe and Galkayo is considered as alarming with Critical levels of malnutrition while a Serious situation in Qardho. The findings also show high morbidity rates which indicate a direct effect on the nutrition status of the children.

IDP’s nutritional status located in Baidoa and Dhobley has deteriorated from Serious (Deyr 2015) to critical levels while Kismayo IDPs nutritional status remained Serious since Deyr 2015. In Mogadishu, the current malnutrition prevalence was categorized as serious. Nevertheless, continuous arrival of new IDPs as a result of the on-going Government eviction plans, limited interventions in the Afgoye corridor, high morbidity, low immunization coverage (<40%), outbreak of unconfirmed Chikungunya (clinical signs like dengue fever) might further worsen the current nutritional situation.

It’s also worth to note that IDP access to and coverage of vital public health programs such as routine immunization and Vitamin A supplementation were the lowest in Mogadishu, Dhobley, Baidoa in the South central zones and Dhusamareb in the North East zone. The measles coverage in Dhusamareb and Mogadishu was 20.0 percent and 27.8 percent respectively. Consequently, any measles outbreak where these IDP reside will further escalate the morbidity and mortality rate found from the current assessment. Interventions that helps to improve access and provision of health services are crucial in order to rehabilitate the acutely malnourished children and prevent further deterioration.

Recommendations: 

In light of the current preliminary findings, FSNAU puts forward the following recommendations:
 

• Scale up of existing Community Management of Acute Malnutrition (CMAM) programs to contain and arrest critical levels of acute malnutrition (where wasting prevalence is the highest or sustained as critical for many seasons) for those IDP’s located in Bossaso, Garowe, Galkayo, Dobley, Baidoa and Dolow.
• Scale up the existing preventive health programs (routine vaccination program and vitamin A supplementation) in IDP’s that have registered high levels of stunting, underweight and under five death rate (U5DR) i.e. Kismayo, Dobley, Baidoa, Garowe, Bossaso).
• Coverage of measles immunization and vitamin A was observed to be significantly below WHO target. Mop-up campaigns should be conducted to raise the coverage to reach the targets. Assessments are needed to determine the true coverage rates following immunization campaigns, and to identify the reasons for low coverage.
• For IDPs in Dolow and Mogadishu recommendations from the recent Nutrition Casual Analysis (NCA) on addressing underlying causes should be implemented.
• Similar NCA should be conducted for IDPs that have persistently high levels of acute malnutrition (Bossaso, Garowe, Galkayo, Dobley, Baidoa) in order to help inform the design of program interventions aimed at addressing the underlying causes of acute malnutrition in these populations.

NUTRITION SITUATION AMONG IDPs IN NORTHWEST REGION

Hargeisa IDP: IDP’s in Hargeisa registered GAM prevalence of 12.0 percent and SAM prevalence of 1.9 percent in Gu 2016 which indicate a sustained Serious nutrition situation in the last 12 months. These trends typically indicate sustained serious level of malnutrition among Hargeisa IDPs.

Burao IDP: the GAM prevalence in Burao was 7.0 percent and SAM prevalence of 0.4 percent indicating Alert nutrition situation reflecting sustained nutrition situation since Deyr 2014/15. 

The Crude and under five death rates in Buroa IDPs are within the Acceptable WHO/UNICEF levels of <0.5 and <1/10 000/day respectively. This reflect a stable mortality levels since Gu 2013.

Morbidity remains to be a key driver of malnutrition in Somalia due to suboptimal provision of health services even among the IDP population. Morbidity levels in two weeks prior to the assessment ranged from 7.0 percent in Burao IDP to 10.8 percent in Hargeisa IDPs. (Annex 6). These indicate a reduction in the reported morbidity in Hargeisa but a slight increase in Burao from 2.9 percent reported in Deyr 2015.

NUTRITION SITUATION AMONG IDPs IN NORTHEAST AND CENTRAL REGIONS

Bosaso IDPs: Gu 2016 nutrition assessment in Bosaso IDPs showed a significant deterioration (p<0.01) in nutrition situation with Critical levels of both GAM (19.8%) and SAM (4.3%) compared to Critical levels of GAM (16.8%) and Serious SAM (2.9%) reported in Deyr 2015 assessment.

Qardho IDPs: There has been stable nutrition situation in Qardho IDPs for the last four seasons. A total of 546 children aged 6-59 months anthropometry measurement during Gu 2016 showed a Serious level of GAM (12.6%) and Alert level of SAM (1.9%). In Deyr 2015, similar nutrition situation among Qardho IDPS was recorded with a 10.4% level of GAM (Serious) and 1.1percent level of SAM (Alert).

Garowe IDPs: 570 children aged 6-59 months were surveyed among IDP’s of Garowe. The findings showed Critical levels of acute malnutrition (GAM 20.0%) and (SAM 4.3%) in Gu 2016. The malnutrition level has sustained as Critical since Deyr 2015 (GAM 19.5%) and (SAM 3.8%). High morbidity levels (46.0%) have also been recorded in Gu 2016 assessment. Similar results of morbidity seen in previous seasons of Deyr 2015 (41.3%) and Gu 2015 (46.8%), which can be among the contributing factors of persisting Critical malnutrition level.
 
Galkacyo IDPs: A total of 707 children aged 6 -59 months were surveyed among IDP’s of Galkacyo.  The result showed sustained Critical nutrition situation GAM (16.9%) and SAM (3.1%) during Gu 2016 nutrition assessment. The current GAM and SAM however, has slightly deteriorated when compared to Deyr 2015 GAM (16.5%) and SAM (1.7%). 

Morbidity trends of Galkayo IDPs showed a higher prevalence during the Gu season than in Deyr which normally has a lower rate by comparison. The current morbidity levels showed a higher (36.7%) morbidity rate as compared to Deyr 2015 (24.6%) among children who reported as sick two weeks prior of assessment. The same trend was also observed for Gu’ 2015 (35.9%) as compared to Deyr 2014 (23.2%), signaling higher morbidity in Gu season than in Deyr among IDPs located in Galkayo.

Dhusamareb IDP: Acceptable nutrition situation (10.1% GAM) and (1.9% SAM) was shown after 382 children were assessed from IDP’s of Dhusamareb. Deyr 2015 showed Serious (10.9% GAM) and Alert (1.6% SAM), however many of the other indicators including stunting and underweight show significant improvement (P<0.01) compared to the previous season of Deyr 2015 assessments.

The current nutrition situation for IDP’s located in the Northeast IDPs indicates nutritional deterioration or critical level of severe acute malnutrition in Bossaso, Garowe and Galkayo IDPs and with a serious level of malnutrition in Qardho IDP.  The findings also showed high morbidity rates which affects negatively the health and nutrition status of the children under-fives. Health facility data compiled from many of the regions in North from January to June indicated high admission rates of Malaria, Acute Respiratory Infections (ARI) and measles outbreak. Interventions to improve access and provision of health services are crucial in order to rehabilitate the acutely malnourished children and prevent further deterioration.

NUTRITION SITUATION AMONG IDPs IN SOUTH CENTRAL REGION

Mogadishu IDPs: Results of Gu 2016 assessment of IDP’s in Mogadishu registered a GAM prevalence of 14.7 percent and SAM prevalence of 3.5 percent which indicate a sustained serious level of acute malnutrition since Deyr 2014/15.

The crude and under five death rates reported were 0.33 /10 000/day and 0.99 /10 000/day respectively in the Mogadishu IDPs, indicating acceptable according to WHO classification, and an improvement from the reported doubling Serious level of under- five death rates (1.50/10 000/day) in Deyr 2015 and (1.36) in Gu 2015. Main causes of under-five death reported was fever, Diarrhoea and acute respiratory infection (ARI).

No major outbreaks of communicable disease were reported during this period but high morbidity rate of 44.6 percent as compared to last year Deyr 2015 of 29.7 percent.

The current Mogadishu IDPs evictions, high morbidity, low immunization coverage (<40%), outbreak of unconfirmed Chikungunya (clinical signs like dengue fever), limited interventions in the Afgoye corridor and arrival of new IDPs are likely to aggravate the nutrition situation.

Dolow IDPs: Critical level of malnutrition among Dolow IDPs has remained since Gu 2012. Gu 2016 assessment showed Critical prevalence for both GAM (21.8 %) and SAM (4.9%). The SAM prevalence observed in Gu 2016 is 4.9 percent lower when compared to Deyr 2015 of 6.1 percent suggesting decreasing trend in severe acute malnutrition.

Decrease in both Crude death rates (0.42) and under five death rates (0.45) suggesting Acceptable situation and an improvement from Gu 2015 when both Serious CDR and U5DR of 0.90/10 000/day and 1.20/10 000/day was recorded.

Morbidity rate 13.4 percent among Dolow IDPs in Gu 2016 is lower when compared to 24.3 percent observed during Gu 2015 or 36.9 percent noted in Deyr 2014/15. High morbidity, Low Immunization coverage, can be attributed to the sustained critical malnutrition situation observed among IDPs of Dolow.

Dhobley IDPs: Anthropometric measurement from 780 children aged 6-59 months revealed Global acute malnutrition of Critical level in Dhobley while SAM prevalence was 3.6 percent. This indicates that there was a deterioration from serious to Critical levels in nutrition situation from Deyr 2015 (14.0% GAM).

Alert level of crude death rate (CDR) with (0.60 /10 000/day) and under five death rate (U5DR) with (0.51/10 000/day) was recorded during the 90 days recall retrospective survey in Gu 2016. 

The overall morbidity reported two weeks prior to the assessment shows sustained high levels (24.6%) in Gu 2016 when compared to Deyr 2015 (39.6 %).

Baidoa IDP: Anthropometric measurement from 762 children aged 6-59 months indicated a Critical nutrition situation (18.0 % GAM) with SAM prevalence of 4.3 percent (Critical). This shows deterioration from Serious level in Deyr 2015 (14.5%).  Acceptable levels were recorded for both CDR and under five death rates (0.25/10 000/day) retrospectively during Gu 2016.

The overall morbidity reported two weeks prior to the assessment shows deterioration (37.4%) in Gu 2016 when compared to Deyr 2015 (24.2%)

Kismayo IDPs: the prevalence of GAM for IDP’s in Kismayo was 14.5 percent i.e. serious however having Critical levels of SAM 4.4 percent. Serious level of malnutrition prevalence has sustained since Gu 2015.

Acceptable levels of CDR (0.51/10 000/day) but a Serious levels of U5DR (1.4/10 000/day) were recorded in Kismayo IDPs in Gu 2016. In terms of CDR, the situation has remained as alert level since Deyr 2015.
The current morbidity which stood as 28.1 percent has not significantly decreased from the one that was reported in Deyr 2015 (27.6%).

Click this link to access the full Update in pdf format: FSNAU Nutrition Update, June 2016