Summary Findings of Cross-Sectional Nutrition Surveys Northern Nigeria, September 2012

I. INTRODUCTION

Anthropometric and retrospective mortality survey was conducted in eight states of Northern Nigeria from 28th August to 5th October 2012. A cross-sectional survey design with two stage cluster sampling method was used. The survey was conducted in Borno, Jigawa, Kano, Katsina, Kebbi, Sokoto, Yobe and Zamfara states. The main objectives of the survey were to determine the nutritional status of children under-five years and women 15-49 years. Data were collected from a total of 4,583 households, 7,566 children under-five years of age and 6,043 women of reproductive age. Three local government areas were excluded at sampling stage from Borno state for security reasons, hence the results is not representative of the whole state.

2. RESULTS Compared to results of nutrition survey conducted in the same period last year, higher prevalence of severe acute malnutrition were reported in 2.1. Child Nutritional Status Kano, Kebbi and Sokoto states whereas the prevalence in Katsina state is The nutritional status of children was analyzed using WHO child decreased. growth standard. Prevalence of global acute malnutrition (WHZ and/or bilateral edema) results are as shown in figure 1 below. Table 1: Prevalence of global and severe acute malnutrition in children 6 to 59 months of age by state (WHZ WHO 2006 & MUAC WHO/ UNICEF 2009) Acute Malnutrition WHZ Acute Malnutrition MUAC Survey Global Severe Global Severe Domain N Acute Acute N Acute Acute Malnutrition Malnutrition Malnutrition Malnutrition Borno 662 10.6 2.7 682 9.5 3.4 (7.9,14.1) (1.7,4.4) (7.2,12.5) (2.2,5.2) Jigawa 817 11.5 2.6 822 13.3 3.6 (9.6,13.7) (1.6,4.1) (10.6,16.4) (2.3,5.7) Kano 838 9.2 2.3 875 9.9 2.4 (7.2,11.6) (1.2,4.2) (7.6,12.8) (1.2,4.6) Katsina 944 12.8 1.6 958 12.3 2.6 (10.3,15.9) (0.8,3.2) (9.7,15.5) (1.5,4.4) Kebbi 812 11 2 832 14.3 4.6 (9.1,13.1) (1.3,2.9) (11.4,17.8) (3.0,6.8 ) Sokoto 891 16.2 4.4 910 18.4 6.8 (14.1,18.5) (3.3,5.8) (15.3,21.9) (5.0,9.3) Yobe 756 10.2 2.2 767 8.6 2 (7.7,13.4) (1.3,3.7) (6.6,11.2) (1.1,3.4) Zamfara 871 11.1 1.7 888 14.8 5.1 Figure 1: Global acute malnutrition (WHZ and/or bilateral edema) (8.8,14.1) (1.0,2.8) 11.8,18.3) (3.4,7.6) and confidence intervals by states. Note: results in brackets are 95% confidence intervals

The prevalence of global acute malnutrition was found above 10 Stunting, or low height for age, generally occurs before age two and is percent in all surveyed states, except Kano. This shows that the caused by long-term insufficient nutrient intake and frequent infections. magnitude of the problem is considerable. The highest and lowest Its effects are largely irreversible which includes delayed motor develop- prevalence of global acute malnutrition according to WHZ-score ment, impaired cognitive function and poor school performance. were reported in Sokoto and Kano states at 16.2% and 9.2% re- spectively. The highest and lowest prevalence of severe acute mal- Underweight, or low weight for age , is a composite measure for stunt- nutrition according to WHZ-score were reported in Sokoto at ing and wasting. Prevalence of stunting or chronic malnutrition and un- 4.4% and in Katsina at 1.6%. derweight are shown in table 2 below.

Note: According to WHZ, Global Acute Malnutrition (GAM) is <-2SD and Severe Acute Malnutrition (SAM) is <-3 SD. Estimate of global and severe acute malnutrition includes bilateral edema cases. Mid upper arm circumference (MUAC) used <125mm and <115mm as cut off for global and severe acute malnutrition. Stunting is defined as HAZ <-2SD and severe stunting is HAZ<-3SD and Underweight is defined as WAZ <-2SD and severe underweight is WAZ <-3SD. Table 2: Prevalence of overall and severe chronic malnutrition (Height- Acute malnutrition, underweight and stunting reached peak within for-Age) and Underweight (Weight-for-Age) in children 0 to 59 months the first two years of life as shown in figure 2 above. This is a widely of age by states (WHO 2006) accepted pattern of onset and peak of malnutrition.

Chronic Malnutrition Underweight Protecting children from malnutrition especially during the first 1000 Survey days starting from conception to 24 months of life is critical for their Severe Under- Severe Domain N Stunting N future development. It is a window of opportunity to shape healthier Stunting weight underweight and more prosperous futures. Inadequate nutrition during the first Borno 735 32.2 9.9 745 31.3 7.9 two years of life may result in deficits in both physical and cognitive (26.6,38.4) (7.1,13.7) (26.6,36.4) (5.6,11.1) well-being which in turn may cause similar deficits in future genera- Jigawa 868 40.4 14.9 875 36.6 3.9 tions. (32.4,49.0) (10.8,20.0) (30.1,43.6) (5.8,13.5 ) Kano 929 27.4 6.6 886 29.6 3.5 2.2. Vitamin A Coverage (22.3,33.3) (4.0,10.5) (24.5,35.2) (2.1,5.6 ) Katsina 1051 30.7 7.1 1053 38.7 6.7 Provision of vitamin A supplements every six months can help pro- 24.2,38.1) (4.5,11.0 ) (31.5,46.3 ) (4.8,9.3 ) tect a child from death and disease associated with vitamin A defi- Kebbi 895 34.5 10.8 909 34.5 10.1 ciency. It is recognized as one the most cost-effective ways to im- 30.4,38.9) (8.1,14.4) (30.6,38.7) (8.0,12.8) prove child survival. Sokoto 984 39.6 13.3 993 40.7 12.3 35.1,44.3) (10.6,16.5) (36.8,44.7 ) (9.8,15.3 ) At national level, Maternal Newborn and Child Health Weeks Yobe 857 21.1 7 862 24.1 5.9 (MNCHW) held twice a year. Among other services during the pe- 14.6,29.5) (4.4,10.9) (17.8,31.9) (3.9,8.9 ) riod , provision of vitamin A supplements for children 6 to 59 month Zamfara 978 36.3 10.8 980 35.9 8.8 is one. For this reason, data were collected on Vitamin A supple- (1.7,41.2) (8.3,14.0) (32.1,40.0 ) (6.7,11.5 ) mentation to estimate the coverage during six months preceding the survey. Note: results in brackets are 95% confidence intervals Eighty six percent of children 6 - 59 months were reported to have The highest and lowest prevalence of stunting among children 0 to 59 received Vitamin A supplementation in Katsina state where as only months of age were found in Yobe and Jigawa states at 21% and 40% 19 percent of eligible children were supplemented with vitamin A in respectively. Sokoto state was found with the highest underweight chil- Yobe state. More effort should be done to improve the coverage in dren at 41% and Yobe with the lowest prevalence at 24%. states where the coverage were reported low.

Table 3: Vitamin A supplementation in children 6-59 months of age by survey domain

Survey Total Vitamin A Domain N (6 - 59 months of age) Borno 668 28.7 (25.3 - 32.2) Jigawa 788 81.6 (78.9 - 84.3) Kano 863 68.5 (65.4 - 71.6) Katasina 937 83.7 (81.3 - 86.0) Kebbi 821 30.5 (27.3 - 33.6) Sokoto 913 42.9 (39.7 - 46.2) Yobe 749 19.4 (16.5 - 22.2) Zamfara 882 32.3 (29.2 - 35.4) Figure 2: Trends of prevalence of GAM, Stunting, Underweight and Note: results in brackets are 95% confidence intervals MUAC<125mm by age in months

2.3 Mortality Mid Upper Arm Circumference (MUAC) was used to assess nutri- Eight months recall period was used to collect individual level data us- tional status of women of reproductive age and results are shown in ing January 1st as a reference point. The highest under-five death and table 5 above. The lowest and highest prevalence of under-nutrition crude mortality rates were found in Sokoto state at 1.07/10,000/ day (MUAC <221mm) were reported in Kebbi and Yobe states at 9% and 0.38/10,000/day respectively. and 16% consecutively.

Emergency levels are experienced when the mortality figures double Data from all the eight states were used to calculate the level of mal- the sub-Saharan Africa baseline and no state reached that level. nutrition among adolescent and older women. As illustrated in figure 3 below the highest levels of malnutrition based on MUAC among Table 4: Crude mortality rate and under-five death rate by state women of reproductive age is among adolescents as compared to the older women. The difference is statistically significant. Similar Crude mortality rate Under-five death rate Survey Domain (10,000/day) (10,000/day) findings were reported in the previous 4 nutrition surveys conducted Borno 0.1 0.3 in the area. [0.05, 0.20] [0.12, 0.74] Jigawa 0.13 0.51 [0.07, 0.24] [0.26, 0.98] Kano 0.12 0.28 [0.06, 0.22] [0.13, 0.60] Katsina 0.17 0.5 [0.01, 0.31] [0.26, 0.97] Kebbi 0.31 0.68 [0.21, 0.46] [0.37, 1.22] Sokoto 0.38 1.07 [0.26, 0.55] [0.69, 1.65] Yobe 0.05 0.14 [0.02, 0.12] [0.05, 0.44] Zamfara 0.27 0.84 [0.17, 0.44] [0.55, 1.28] Note: results in brackets are 95% confidence intervals 2.4 Women Nutritional Status Adequate nutrition is especially critical for women because inadequate Figure 3: Percent of women with acute malnutrition ( MUAC nutrition causes damage not only on women's own health but also on <221mm) by age in groups

the health of their children and development of next generation.

Table 5: Acute malnutrition according to MUAC in women of repro- ductive age by state Fourteen percent of adolescent women 15 to 19 years of age were reported pregnant, despite the high risk of malnutrition observed in Survey Domain Total N Low MUAC (<221mm) this age group. Borno 618 10 (7.7 - 12.4) Percent 25 Jigawa 731 15.3 22.0 (12.7 - 17.9) 19.6 19.6 Kano 733 13.4 20 16.0 (10.9 - 15.8) 14.3 Katsina 776 14.2 15 (11.7 - 16.6) 10.2 Kebbi 715 8.8 10 (6.7 - 10.9) 4.0 Sokoto 725 14.5 5 (11.9 - 17.1) Yobe 694 16.1 0 (13.4 - 18.9) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group Zamfara 789 12 N=1,053 (9.8 - 14.3) Note: results in brackets are 95% confidence intervals Figure 4: Percent of women pregnant by age groups

Note: Low MUAC is defined as <221 mm 2.5 Water and Sanitation 3. Conclusion and recommendations

Access to improved dinking water ranged from 15% to 74% across 1. Seven out of eight states surveyed were found to have prevalence of the surveyed states. Five of the eight surveyed states had lower global acute malnutrition (GAM) above 10 percent. An estimated access to improved drinking water compared to sub-Saharan Africa 261,049 new cases of severe acute malnutrition (SAM) is expected across average of 61%. the eight surveyed states in the coming one year.

The highest and lowest access to improved sanitation facility were This is considered as very high caseload and worth immediate attention, reported in Yobe and Kano states at 6% and 24% well below sub hence provision of nutritional support for children under the age of five Saharan African countries average of 30%. years should continue. It is also recommended to expand coverage of the program to reach more children. Table 6: Access to improved drinking water and sanitation facility by state II. Acute malnutrition, underweight and stunting reached peak in the first two years of life. This is an accepted pattern and is documented from Survey Total Access to improved Total Access to improved Domain N drinking water N sanitation facility different studies. Majority of childhood damages occurs during this pe- riod and are irreversible. Therefore, in addition to therapeutic feeding Borno 569 38 561 7.3 programs it is recommended to support partners to improve infant and (34.0- 42.0) (5.2 - 9.5) Jigawa 566 73.7 484 20.2 young child feeding practice in the area.

(70.0 - 77.3) (16.7 - 23.8) III. Access to improved drinking water and sanitation facility were found Kano 547 63.6 556 23.9 (59.6 - 67.7) (20.4 - 27.5) very low in most of the surveyed states. It is commended to improve Katasina 559 35.4 561 19.1 access to safe drinking water and improved sanitation facility in the area. (31.5 - 39.4) (15.8 - 22.3) Kebbi 572 14.9 567 6.7 Contact Details: (11.9 - 17.8) (4.6 - 8.8) National Bureau of Statistics Sokoto 556 22.1 561 10.9 Isiaka Olarewaju (Deputy Director) - [email protected] (18.7 - 25.6) (8.3 - 13.5) - [email protected] Yobe 553 66.9 546 6.4 (63.0 - 70.8) (4.4 - 8.5) Zamfara 570 42.3 567 7.9 UNICEF (38.2 - 46.3) (5.7 - 10.2) Stanley Chitekwe (Chief of Nutrition) - [email protected] Total 4,492 4,403 Bamidele Omotola (Nutrition Specialist) - [email protected] Isiaka Alo (Nutriiton Specialist) - [email protected] Note: results in brackets are 95% confidence intervals Robert Johnston (Nutrition Specialist-WCARO) [email protected] Assaye Tolla (Consultant) – [email protected]