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Nutrition in Crisis SituationsVol 15 December 2007 Summary of the nutrition survey results Notes on the survey methodologies Indicators and risk categories HighlightsSomalia—Displacement continues amid ongoing hostilities—Intensified fighting broke out in Mogadishu on October 27th, aggravating an already precarious humanitarian situation. According to UNHCR, an estimated 200,000 people fled the city in the two weeks following the new wave of violence, bringing the total displaced since February 2007 to 600,000. Food availability and access have been restricted throughout the country due to the rapid devaluation of the Somali shilling, increased transportation costs, and conflict related disruptions in commerce. Uncontrolled inflation has pushed prices for staple foods beyond the reach of many IDPs and poor households. Sudan—Floods and conflict threaten food security—Inter-ethnic clashes between Murle and Dinka groups in Jonglei State killed 34 people and wounded almost 100 people in November and early December. The full effect of the August 2007 floods is not yet clear. Some areas are expected to have a near-normal harvest, with food production adequate to fulfill household needs at least until February 2008. On the other hand, certain regions, such as the Nile-Sobat and Eastern Flood Plains zones, were harder hit and the most vulnerable were expected to start experiencing food shortages in October, although it is anticipated that they will at least partially recover once flood waters recede leaving behind a good water supply, pastures, and improved fishing. Attacks targeting humanitarian staff, as well as unchecked banditry, are hampering aid activities in all three states of Darfur. Major cities excepting, most agencies are forced to travel by helicopter, limiting what areas are accessible. Initial results of a joint U.N. and Government of National Unity (GNU) Emergency Food Security and Nutrition Assessment showed that the situation in Darfur rests quite serious. Central African Republic—Nutrition situation for refugees in Cameroon critical—The security situation has become increasingly volatile, especially in the northwestern part of the country. An estimated 299,000 people have been displaced since the beginning of 2007, including 79,000 who have fled to neighboring countries. Nutrition surveys conducted among Central African refugees in Cameroon reveal the prevalence of acute malnutrition to be above emergency levels. Niger—Grain harvest expected to be insufficient—Plentiful rainfall in August partially offset the early and abrupt end to the rainy season in September. It is still not entirely clear how the harvest will be affected, but it is generally expected that some areas will be negatively impacted with grain output predicted to be insufficient in nearly 1,500 villages. A GoN/joint nutrition survey found the country-wide prevalence of acute malnutrition to be 11.2% among children 6-59 months. However, wide regional disparities exist and many areas are still facing serious to critical nutrition situations. Bangladesh—Cyclone Sidr wreaks havoc—On November 15th a Category-4 Super Cyclone hit the Southwest coast of Bangladesh. Peak winds were recorded at up to 250 km/hour. The storm weakened as it travelled north and east through the country, but subsequent damage was reported in as many as 30 of Bangladesh's 64 districts, although the regions of Barisal and Khulna were the hardest hit. An estimated 7 million people were affected by the cyclone; of those, 2.7 million people required immediate life and livelihood saving intervention from external sources. Risk Factors affecting Nutrition in Selected SituationsSituations in the table below are classed into five categories relating to prevalence and or risk of malnutrition (I—very high risk/prevalence, II—high risk/prevalence, III—moderate risk/prevalence, IV—not at elevated risk/prevalence, V-unknown risk/prevalence; for further explanation see section "Indicators and classification" at the end of the report). The prevalence/risk is indirectly affected by both the underlying causes of malnutrition, relating to food security, public health environment and social environment, and the constraints limiting humanitarian response. These categories are summations of the causes of malnutrition and the humanitarian response, but should not be used in isolation to prescribe the necessary response. J Adequate K Mixed L Inadequate Greater Horn of AfricaEthiopiaDespite better than average rains in many parts of the country and predictions for an overall improved food security situation, 8 million people face chronic food insecurity and are dependent on food and cash assistance from the GoE, while an additional 1.3 million people are in need of emergency food assistance (FEWS, 10/07). In the Somali region, restrictions to trade and movement, coupled with recent flooding, have complicated humanitarian efforts to reach the most vulnerable. UN partners were coordinating activities, and at last count, 5,000 tonnes of food had been distributed to nearly 1 million people living in the 5 zones affected by military operations (OCHA, 19/11/07). It is anticipated that restrictions will soon be at least partially lifted, which in turn should improve access to markets and stimulate commerce. A series of surveys conducted in the Wolayta region of SNNPR by Concern in June 2007 revealed very low rates of acute malnutrition (figure 1), consistent with survey results from the same time last year (Concern, 06/07). Most of those interviewed described the December 2006 meher harvest as good and many reported that they still had reserve food stocks. Two other surveys by Concern in October 2007 in the South Wollo zone, Amhara region, show a more serious nutrition situation (figure 1). Over 1/3 of those included in the studies benefited from some type of food security initiative (Concern, 10/07). A UNHCR/joint survey of all refugee camps in May/June 2007 indicates that the nutrition situation, on the whole, has either improved or stayed the same as compared to this time last year. The prevalence of acute malnutrition ranged from 4%-13.5% in the 6 camps surveyed (UNHCR, 06/07) (table 1). The prevalence of anemia was found to be high among children under 5 and pregnant women and it was recommended that iron-fortified food be included in either the general ration or as a special supplement (table I). Figure I Results of nutrition surveys, Ethiopia, June-October 2007 (Concern)
TABLE I Prevalence of acute malnutrition and anemia, Ethiopian Refugee Camps, May-June 2007 (UNHCR, 07/07)
KenyaAs of November 2007, the short rainy season had begun throughout the country and the supply of maize was predicted to be enough to meet domestic demand in the coming months (FEWS, 11/07). Pastoralist regions in the northwest received early rainfall in October, providing much needed relief after poor rainfall earlier in the year. However, ongoing conflict in the area has closed both schools and markets, leaving the population vulnerable to food insecurity and malnutrition (FEWS, 11/07). Rains were late or sporadic in some parts of the country, notably the southeast and coastal marginal agricultural regions. Already stricken by prolonged drought, the food security situation is at risk of deteriorating further if adequate rainfall is not received (FEWS, 11/07). Nutrition surveys carried out by GTZ in August 2007 in the three Dadaab refugee camps in northern Kenya showed that the situation, while still serious, has markedly improved since similar surveys were carried out at the same time last year (figure 2). Mortality rates were all within acceptable range (GTZ, 08/07). Vaccination rates were high in all of the camps. At the same time, levels of anemia among both mothers and children were much higher than WHO recommended cut-offs, ranging between 52.0-62.4% (mothers) and 77.4-84.1% (children). Approximately 2/3 of survey participants reported consuming at least two meals per day. Figure 2 Results of nutrition surveys, Dadaab Refugee Camps, Kenya, August 2007 (GTZ/UNHCR, 08/07)
SomaliaIntensified fighting broke out in Mogadishu on October 27th, aggravating an already precarious humanitarian situation. According to UNHCR, an estimated 200,000 people fled the city in the two weeks following the new wave of violence, bringing the total displaced since February 2007 to 600,000 (UNHCR, 20/11/07). Many of those displaced left for areas surrounding the capital, most notably Middle and Lower Shabelle. Already suffering the compounded effects of prolonged drought, a failed Gu harvest, and economic instability, the regions are poorly equipped to cope with this latest influx of people. Heightened insecurity has also hampered humanitarian access to the population. Food availability and access have been restricted throughout the country due to the rapid devaluation of the Somali shilling, increased transportation costs, and conflict related disruptions in commerce. Uncontrolled inflation has pushed prices for staple foods beyond the reach of many IDPs and poor households (FEWS, 11/07). In addition, this year's Deyr rainy season has so far been irregular, with some areas receiving near-normal quantities and others receiving little or no rain. Parts of central Somalia are already signalling lower than average rainfall patterns, which is of particular concern as it is host to an increasing number of IDPs. If the current trend continues, the overall food security situation is likely to deteriorate even further throughout the country. Nutrition situation in Shabelles remains alarming Two nutrition surveys conducted in early November show that the nutrition situation in the Shabelle regions continues to be critical, with the prevalence of acute malnutrition ranging between 14.0-17.6% (FSAU, 19/11/07) (table 2). These figures are comparable to the prevalence found in surveys done in May 2007 (NICS 14). The first detailed nutrition survey to be conducted among recently displaced persons in Afgoye and Merka, towns just outside of Mogadishu, also found elevated rates of malnutrition. The proportion of those severely malnourished was especially high, at 3.2% (FSAU, 19/11/07) (table 2). Pockets on malnutrition still exist in North While the situation in the North of the country is considered more stable, there are still some areas of concern. Hundreds of displaced families from Sool arrived in NE Puntland at the end of October after being overrun by forces loyal to the self-declared republic of Somaliland. Many were said to be in urgent need of food, shelter, clean water, and medicines (IRIN, 25/10/07). Nutrition surveys conducted in Somaliland among IDPs and returnees in Hargesia, Burao, and Berbera indicate that the situation remains more or less unchanged from surveys conducted at the same time last year. It should be noted that the prevalence of acute malnutrition in both Burao and Berbera are above emergency thresholds (figure 3). Inadequate infant and child feeding practices, as well as water and sanitation services, were identified as needing improvement. Stable but worrying situation in Bakool and Central Regions A nutrition survey conducted in Wajid town and surrounding areas, Bakool region, show serious levels of malnutrition, although these results are similar to those found in the last survey conducted in February (FSAU, Oct/Nov 07) (table 2) . Hawd and Addun pastoral livelihood, spanning from Galgadud and Madug to southern Nugul regions, were surveyed in November 2007 and the results revealed a critical nutrition situation (table 2). The prevalence of acute malnutrition was found to be 15.9% (12.8-18.9) and 17.2% (14.1-20.5) respectively, which are slightly higher than earlier data from sentinel sites and rapid assessments suggested (FSAU, Oct/Nov 07). People were found to have access to a diverse range of foods, in part due to wide scale food distributions. However, access to clean water and sanitation facilities were poor, immunization rates low, and health services inadequate. Table 2 Results of Nutrition Surveys, Somalia, 2007 (FSAU, 09/07; FSAU 10-11/07)
Figure 3 Results of Nutrition Surveys, Somalia, 2007 (FSAU, 09/07)
Overall Irregular rains, economic instability, and continued insecurity are exacerbating an already precarious humanitarian situation. SudanInter-ethnic clashes between Murle and Dinka groups in Jonglei State killed 34 people and wounded almost 100 people in November and early December 2007. Following a confrontation in an MSF-compound in Bor on November 29, 2007 that left 4 civilians dead and another wounded, humanitarian staff were evacuated to Juba. As a result of the fighting, UNHCR temporarily suspended repatriation efforts in the area (USAID, 12/07). The full effect of the August 2007 floods is not yet clear. Some areas are expected to have a near-normal harvest, with food production adequate to fulfill household needs at least until February 2008 (FEWS, 11/07). On the other hand, certain regions, such as the Nile-Sobat and Eastern Flood Plains zones, were harder hit. The most vulnerable were expected to start experiencing food shortages in October, although it is anticipated that they will at least partially recover once flood waters recede leaving behind a good water supply, pastures, and improved fishing. However, the food security outlook was less optimistic for Bieh county. In addition to extensive flooding, it is also troubled by poor infrastructure, low market access, and continual loss of assets, mainly cattle theft by rival clans. An outbreak of Rift Valley fever was reported in the states of White Nile, Sennar, and Gazeera in mid-October. According to WHO, 436 human cases, including 161 deaths, had been confirmed as of November 21, 2007. As the disease also affects animals, the outbreak could have potential consequences for those whose livelihoods depend on livestock and every effort was being made to contain the epidemic (WHO, 11/07). AAH-US conducted a survey in Nyirol county, Jonglei State, in September 2007, which showed the nutrition situation to be critical (table 3). The local situation during the survey was perturbed by both insecurity and flooding. The survey team reported that most of the farms they observed had suffered some kind of flood damage. As 86.7% of those surveyed reported private production as their main source of food, the loss of crops is sure to have an impact (AAH-US, 09/07). Surface runoff and rain water were cited as the main source of water for the majority of the population and no latrines were observed in any of the households surveyed . Table 3, Prevalence of Acute Malnutrition , South Sudan (AAH-US, 09/07; ACF-F, 10/07)
A nutrition survey was also done in Bentiu and Rob Kona towns in October 2007, this one by ACF-F (table 3). The prevalence of malnutrition was 20.5% (C.I. 17.0-24.6), a figure not statistically different from prior ACF surveys conducted during similar periods (ACF-F, 10/07). The majority of the population reported buying their food from the market, although some vulnerable households were still receiving targeted food aid through WFP food-for-rehabilitation programs. The average duration of exclusive breastfeeding was given as 3.6 months. Darfur Attacks targeting humanitarian staff, as well as unchecked banditry, are hampering aid activities in all three states of Darfur. Major cities excepting, most agencies are forced to travel by helicopter, limiting what areas are accessible (USAID, 20/12/07). Coordination of humanitarian programs in IDP camps continued to be a challenge in 2007 (USAID, 20/12/07). Kalma camp in South Darfur has been without a coordinating agency for over one year, and there has never been an agency in Gereida, Darfur's largest camp which hosts over 120,000 people. The Spanish Red Cross will give up direction of Abu Shok and Zam Zam camps in North Darfur in the coming months after the Sudanese Red Crescent failed to renew their contract. Initial results of a joint U.N. and GNU Emergency Food Security and Nutrition Assessment showed that the situation in Darfur rests quite serious (USAID, 20/12/07). A full 70% of people affected by the conflict were estimated to be food insecure and fewer people were able to plant and harvest crops in 2007 as compared to 2006. In addition, acute malnutrition rates have climbed over 3% since the last assessment in 2006 from 12.9% to 16.1% and at the same time, nutrition program coverage dipped negligibly from 14.2% to 13%. Results from nutrition surveys conducted by Tear Fund and Relief International revealed that the situation is even more critical in some areas (UNICEF, 08/07) (figure 4). Figure 4 Results of Nutrition Surveys, Darfur, 2007 (UNICEF, 08/07)
Overall High levels of acute malnutrition persist in Darfur and parts of South Sudan. Flooding in the South and ongoing conflict in Darfur pose important threats to food security. West Africa
NigerPlentiful rainfall in August partially offset the early and abrupt end to the rainy season in September. It is still not entirely clear how the harvest will be affected, but it is generally expected that some areas will be negatively impacted with grain output predicted to be insufficient in nearly 1,500 villages (FEWS, 09/07). While worrisome, this estimate is considerably lower than last year, when almost 4,000 villages experienced grain shortfalls. Market prices, which are lower than last year and the 5-year average for the same time of year, reflect the adequacy of current grain stocks. The August rains also replenished valuable watering holes in pastoralist zones, thus providing better access for livestock. With good pasture, the condition of animals has improved, increasing their resale value (FEWS, 09/07). Nutrition situation still precarious is most parts of the country A GoN/joint nutrition survey conducted in April 2007 found the country-wide prevalence of acute malnutrition to be 11.2% (C.I. 10.1-12.4) among children 6-59 months (INS-N/joint, 09/07). However, wide regional disparities exist and many areas are still facing serious to critical nutrition situations (figure 5). Diffa and Agadez had the highest prevalence of acute malnutrition, with rates of 19.4% (C.I. 16.0-23.4) and 17.4% (C.I. 14.7-20.6) respectively, although the results from Agadez are not fully representative as certain areas could not be accessed during the survey due to insecurity. Severe malnutrition and mortality rates appeared to be under control (figure 5). Concern completed two nutrition surveys in the districts of Tahoua and Illela, Tahoua region in June 2007 (Concern, 06/07). Acute malnutrition was 12.7% (C.I. 10.1-15.3) in Tahoua district and 8.6% (C.I. 6.7-10.8) in Illela, rates that were both higher than that of 7.5% (C.I. 5.5-10.2) from the national survey done in Tahoua region at roughly the same time (table 4). It should be noted, however, that the confidence intervals of all three surveys overlapped. Figure 5 Results of National Nutrition Survey, Niger (INS-N/JOINT 06/07)
Additional surveys in rural areas of Zinder and Magaria, Zinder region were carried out by MSF-CH in July 2007. Results obtained were similar to those from surveys done in August 2006 and show that the nutrition situation remains worrisome (table 4). A MSF-B survey in the Dakoro health district of Maradi showed a serious nutrition situation, with a high prevalence of severe malnutrition (table 4). Mortality rates, however, were with acceptable ranges. Table 4 Result of Nutrition Surveys, Niger (CONCERN 06/07; MSF-CH, 07/07; MSF-B 04/07)
Central Africa
BurundiReports of banditry and harassment by FNL elements caused some NGOs to halt activities in rural Bujumbura, including an important nutrition survey scheduled for December 2007(OCHA, 02/12/07). Outbreaks of cholera were reported in Rumonge/Bururi province, as well as in the southern city of Mvugo in the Nyanza Lac commune. The first cases were reported on November 2nd and by early December, at least 132 confirmed cases were identified. No deaths were reported (OCHA, 02/12/07). Repatriation efforts continue and figures show that 38,681 refugees have returned to the country since the beginning of 2007, the overwhelming majority coming from Tanzania (OCHA, 02/12/07). Approximately 120,000 refugees are still in Tanzania awaiting return. The Tanzanian government has indicated that they will close all camps in 2008, pushing UNICEF and UNHCR to increase their capacity to integrate returnees. A new joint program by the two organizations aims to help construct houses for as many as 20,000 households as well as build 15 new schools and 15 new pre-schools (OCHA, 12/12/07). A UNICEF/GoB national nutrition survey was carried out in August 2007. Preliminary results indicate that the nutrition situation is generally under control and has improved since the last countrywide survey in 2005 (UNICEF, 10/07) (figure 6). Comparisons, however, should be made with caution as the two surveys were carried out at different periods of the year. Acute malnutrition rates ranged from 2.4% in Mwaro to 11.5% in Rutana. Figure 6 Results of Country Wide Nutrition Survey, Burundi (UNICEF/GoB, 08/07)
MSF-B conducted a nutrition survey in the district of Karuzi in April 2007 (MSF-B, 04/07). The results of the survey, while under emergency levels, nonetheless reveal a serious nutrition situation (table 5). Mortality rates were under control. At the time of the survey, MSF-B was in the process of handing over its nutrition activities to the MoH hospital. Table 5 Results of Nutrition Survey, Burundi (MSF-B 04/07)
Central African Republic/CameroonThe security situation in CAR has become increasingly volatile, especially in the northwestern part of the country. An estimated 299,000 people have been displaced since the beginning of 2007, including 79,000 who have fled to neighboring countries (UNICEF, 28/09/07). The deployment of MINURCAT, the U.N. force for Chad and Central African Republic, scheduled for November 2007, whose mandate is to protect civilians, was delayed due to lack of technical and material inputs (AI, 29/11/07). Two nutrition surveys were carried out by MSF-CH in August/September 2007 among Central African refugees living in Adamaoua and Eastern Province, Cameroon. The prevalence of acute malnutrition surpassed critical levels in each of the surveys (MSF-CH, 09/07) (table 6). Moreover, the U5MR in the Eastern Province survey was 5.1/10,000/day (C.I. 4.3-6.0), well beyond emergency levels; in Adamaoua, it was below the alert threshold. Table 6 Prevalence of Acute Malnutrition and Mortality Among CAR Refugees living in Cameroon (MSF-CH 08-09/07) (MSF-B 04/07)
Conflict Zones and Rebel or Population Movement, Central African Republic (HDPT, 12/07)
Democratic Republic of the CongoThe violence that began in North Kivu between the Forces Armées de la République Démocratique du Congo (FARDC) and Laurent Nkunda's forces in September 2007 has continued unabated. By mid-November OCHA had been able to confirm that at least 405,345 people were displaced in the region surrounding Goma (OCHA, 11/07). Humanitarian aid has been suspended in many areas due to the insecurity. In early December, the WFP was forced to halt all movements outside of Goma, postponing food distributions to as many as 335,000 IDPs (WFP, 12/07). ICRC reports to having treated numerous casualties of military clashes, including some civilians, and signal that rape, looting, and recruitment of child soldiers are on the rise (ICRC, 11/07). Cholera outbreak confirmed in South of country WHO reported 286 cases of cholera and 18 deaths (Case Fatality Rate 6.0%) in the southern city of Lubumbashi and its surrounding area during the month of October (WHO, 11/07). The primary explanation given for the elevated level of mortality was the lack of proper treatment centers within reasonable distance for those affected. High levels of severe acute malnutrition persist Nutrition surveys in Kinshasa, Orientale, Katanga, and Equateur provinces showed average to poor nutrition situation (figure 7), although it is important to note that severe malnutrition ranged from 1.5% to as high as 4.3%. The Kinshasa survey also measured the nutritional status of women and found BMI and iron supplementation levels to be acceptable (IPS/Joint, 04/07) (table 6). Figure 7 Results of nutrition surveys, DRC, 2007 (ISP/Pronanut, 04/07; COOPI, 10/07; GOAL, 05/07; AAH-US, 08/07)
Table 6 Women’s Nutritional Status, Kinshasa Province (ISP/JOINT 04/07)
AsiaBangladeshOn November 15th a Category-4 Super Cyclone hit the Southwest coast of Bangladesh. Peak winds were recorded at up to 250 km/hour. The storm weakened as it travelled north and east through the country, but subsequent damage has been reported in as many as 30 of Bangladesh's 64 districts, although Barisal and Khulna regions were the hardest hit (see map). An estimated 7 million people were affected by the cyclone (GoB, 26/11/07); of those, 2.7 million people required immediate life and livelihood saving intervention from external sources (UN, 2/11/07). The early warning system put in place by the Government of Bangladesh proved effective and has been credited with saving countless lives and decreasing destruction. Shelter, food, and cash for livelihoods support were identified as the priority needs for storm victims, followed closely by water and sanitation. The pre-positioning of essential drugs and medicines has made the task of providing health care to those in need much easier. Despite major infrastructure damage, the GoB, along with numerous International agencies and NGOs, were swift to implement relief activities. Food was distributed to those in need, including high energy biscuits for the most vulnerable and a 3-month supply of blended food for children (OCHA, 26/11/07). Temporary shelters were constructed until permanent structures can be rebuilt. The biggest challenge to rebuilding, however, will be the destruction done to livelihoods. At least 1.6 million acres of cropland was damaged and an important share of the rice harvest was affected (USAID, 28/11/07). Large numbers of livestock were killed and damage to the fishing industry is considerable. The FAO was planning a comprehensive food and livelihoods assessment for December in order to ascertain the full impact of the cyclone and to aid in the identification of priority steps for recovery. Areas Affected by Cyclone Sidr (UN, 22/11/07)
Abbreviations and acronyms
ReferencesGreater Horn of Africa
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