FSNAU Bi-Monthly Nutrition Update, April 2015 FSNAU FSNAU Food Security and Nutrition Analysis Unit - April 2015

FoodG USe 2c0u1r5it yN Autcrcietisosn M Aasps easnsdm Feinetl dc oMveornaigtoer iinn gS oLmocaaltiaion Data OVERVIEW

Acute Malnutrition trends based on data from Health FacilitiesGulf o(January-Marchf Aden 2015) DJIBOUTI ¹#! suggest deterioration in nutrition situation in Hiran region (Bulo Burte, Beletweyne Awdal ! districts), Banadir region and among Riverine livelihoods in and SShabelleanag regionsBari Woq. Galbeed ! ! Deyr 2014/15 assessment had identified Bay Agropastoral, all Gu 2015 FNutritionoodG USe ¹2c#0u!1r5it yN Au Assessmenttcrcietisosn M Aasps easnsdm Feinetl dc oMCoverageveornaigtoer iinn gS oLmocaal tiPlanaion Dat afor Somalia Togdheer livelihoods among Gedo region (Pastoral, Agropastoral and Sool

Gulf of A#den ¹ #! #! Riverine) as well as Beletweyne district in Hiran region as well as DJIBOUTI ¹ ¹ Nugal livelihoods: Hawd Central and Coastal Deeh Central as hot spots Awdal ! Sanag Bari Woq. Galbeed for acute malnutrition in South Central Somalia. The nutrition ! ! ¹#! ETHIOPIA Togdheer situation observed during Deyr 2014/15 was also projected to be ! Sool sustained during February – April 2015. ¹# ¹#! Nugal ! Health facility data on acute malnutrition for the first quarter of ETHIOPIA ! Galgadud 2015 shows a deterioration in nutrition situation among Riverine Mudug Bakol ! livelihoods of Gedo and Shabelle region and in urban districts! of # Hiran ¹ Galgadud Beletweyne and Bulo Burte in Hiran region as well as in Banadir Bakol ! ¹# Hiran region (Table 1). Deterioration in nutrition situation in Bulo-Burte ! Gedo M. Shabelle ! can be attributed to worsening food insecurity due to continued Bay Gedo M. Shabelle Bay and a significant increase in the price of food items. In other Ban!#adir ¹ Ban!#adir L. Shabelle ¹ areas, prices are stable, or show seasonal increases and there are L. Shabelle NutritioNnut raitisons easssmesmenentt coovvereargae ge A

A M. Juba M. Juba Y Y N E

N Rural Livelihoods no major changes in security conditions. Deterioration in nutrition K E Ru!ral LIDiPvelihoods K ! situation in these livelihoods appears to be associated with ! IDP ! L. Ju¹b#a ¹# Urban ! morbidity: cases of Measles, Malaria and Acute Watery DiarrhoeaL. Juba ¹# # (AWD) reported among Shabelle Riverine cases of Measles, Acute! ± ¹ Urban

30 15 0 30 60 90 120 respiratory infections (ARI) and AWD reported by MCH centres in Kilomete rs Zam Zam and Hamar Weyne in Banadir region. Lack of nutrition ±

30 15 0 30 60 90 120 supplies to treat malnourished children was reported by Banadir HospitalKilomete rs which is the largest referral hospital in South Central Zone. Due to volatile security situation in and around Shabelle valley and increased displacement and population movement to and from the newly liberated towns, further deterioration in nutrition situation is expected among urban poor and displaced people in Banadir region. Moreover, even though the 2015 Gu (April - June)rains might improve pasture and milk availability in the area, it is vital to keep a watch over the riverine areas in Gedo region and Shabelle which are vulnerable to flooding. Health facilities among Hawd central, Addun central, Cowpea and Coastal Deeh also show sustained prevalence of Critical levels of acute malnutrition.

In North East, Health facilities in livelihoods of Sool and East Golis/Kakaar show deterioration in nutrition situation while others report strable nutrition situation.

Deterioration in nutrition situation among Northwest Agro pastoral from acceptable (<5%) to Alert (5- <10%) and among Northwest IDPs was projected for the period February-April 2015. However increasing malnutrition trends (>15%) seen in health facilities among urban areas (Central Burao) in Northwest is unexpected.

The 2015 Gu seasonal countrywide nutrition assessment will be conducted from May to July 2015 (see map above).

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Table 1: Trends of Acutely Malnourished Children in Somalia during January to March 2015 based on data from Health Facilities

SERIOUS ALERT Moderate (10 to CRITICAL VERY CRITICAL ACCEPTABLE Livelihood / Low proportion <15%) and stable High (> 15%) and High (> 15%) and V. low (<5%) HIS TRENDS- (5 to <10%) and or low (5 to <10%) stable proportion in increasing proportion in the Preceding 3 months stable trend in the but increasing the preceding proportion in the preceding 3mths relative to ≥ 2 yr preceding 3mths proportion in the 3mths relative to preceding 3mths relative to >2yr seasonal trend relative to >2yr preceding 3mths >2yr seasonal relative to >2yr seasonal trends seasonal trends relative to >2yr trends seasonal trends seasonal trends SOUTH CENTRAL REGION Cowpea Addun CENTRAL Coastal Deeh Hawd Pastoral GEDO Riverine Agro pastoral Pastoral JUBA Juba Riverine Agro pastoral Shabelle SHABELLE Shabelle Riverine Agropastoral Beletweyne HIRAN Bulo burte Mogadishu Urban BANADIR

Bay Agro pastoral Pastoral BAY /BAKOOL Bakool Agropastoral NORTH WEST Agro pastoral W Golis/Guban Hargeisa urban E Golis Livelihood IDPs Burao Urban Hawd Berbera Urban Borama urban NORTH EAST Hawd Addun Nugal Valley Livelihood Sool Plateau E Golis and Karkar Coastal Deeh Bosaso Town NUTRITION SITUATION IN NORTHWEST REGIONS

Post Deyr 2014 nutrition analysis for Northwest Regions (Somaliland) showed an overall nutrition situation that has been steadily improving over the last five consecutive seasons. It was the first time ever that all the assessed livelihoods (10) reported Global Acute Malnutrition (GAM) prevalence below the emergency threshold (<15%)- no hot spots! In addition an Acceptable nutrition situation was recorded among (Northwest Agropastoral livelihood) for the first time in Somalia. Notable improvements were observed among Northwest Agropastoral, West Golis, Guban, Sool Plateau and the two IDP settlements of Burao and Berbera. Deterioration seen among two livelihoods of Nugal valley and East Golis (both from Alert to Serious) was not significant. Hawd pastoral, Sool urban and Hargeisa IDPs showed sustained nutrition situation since Gu 2014. The improvement in nutrition situation is attributed to favourable Deyr rains which also improved the food security situation. It was projected that this situation may not be sustained mainly because of the unpredictable weather patterns and seasonality.

2 FSNAU Bi-Monthly Nutrition Update, April 2015 FSNAU

Water shortage from Hawd and parts of Agro-pastoral areas is reported. In Hargeisa town there is a water crisis and cost of 200 litters has become 18,000/So shillings instead of 10,000/sh which makes it difficult for the poor urban and IDP’s to buy the required amount of water.

The health facility data in the last three months (Jan to March 2015) from all livelihoods indicate varied trends but generally showing stable nutrition situation with a few exceptions: E Golis/IDPs/Burao urban which show increasing trends of acute malnutrition (Table 2)

Table 2: Trends in Acute Malnutrition in Northwest Region of Somalia based on data from Health Facilities

Observations Livelihood Name of HIS visited Remarks Jan-March 2015 Aug-Oct 2014 July 2014 March 14 Agro 19.7% -High 19.6%- High and 9.6 % –low Improvement Odweyne 5.8% -low Pastoral stable Increased Fluctuating 8.3% –low and Haji Salah, Durugsi, 18.9% -High and 7.1 % –Low and 6.8% –low but Hawd decreasing Deterioration Balidhig Increasing stable Fluctuating Central Burao, Farah 21 % -High & 6% -Low & 7% -Low & Urban Omar, Dr Yusuf, Kenya, 8%-Low, stable Deterioration Increasing trend Sustained Sustained Dr. Allag 9.6 %-Low but 2.9%-Very low & Yirowe, Kosaar, Aden 13.2 %-High & 12.7%-Moderate Increasing Decreasing IDPs Deterioration Suleiman Increasing trend Fluctuating

Lughahya, Lowyado, Garbodadar, Boon, West Golis/ 5% -Very low and 23.7%-High 19.5 %-High & 15.1 %- High & Improvement Geerisa, Darbudhug, Guban Decreasing Sustained Fluctuating Decreasing Mandera, Harirad, Abdikadir Gebiley, Dilla, Allaybaday, 7.8%-Low & 8.7%-Low & 7.6%-Low & 7.7%-Low & Agro-pastoral Sustained Idhanka, Qolijeed Sustained Decreasing Decreasing sustained Sheik nur, ayaha, 15.6 %-High & 6.2%-Low but 7.0%-Low & 11.6 %-Moderate IDP’s Jamalyae,Dami, Deterioration Fluctuating Stable Decreasing & Fluctuating Statehouse

Hargeisa, Borama and 6.0%-Low & 11.4%- Moderate & 6%-Low & 5.6%-Low & Urban Improved Berbera Sustained Fluctuating Decreasing Decreasing

Salahlay, Bali-Gubadle, 5%-Very low & 24.2%-High & 11.1%-Moderate & 5.8%-Low & Hawd Improved Adadlay, Bali-Abane Stable Fluctuating Decreasing Decreasing

10-15% -Moderate >10% Moderate but >10%) –Moderate & >10% - Moderate East Golis Hadaftimo, Badhan Sustained but increasing increasing stable & increasing.

HAWD: Post Deyr 2014/15 assessment showed Figure 1: Malnutrition trend for Hawd MCH (2014-2015) Alert levels of GAM (8.9%) were sustained since 25.0 Gu 2014 (7.6 %). However, SAM prevalence (1.2 22.0

%) increased compared to six months ago (Gu 20.0 18.9 2014) Seasonally, Hawd has remained stable due 14.8 14.7 14.0 15.0 13.2 to livestock in-migration which ensures that even 12.1 12.7 12.8 10.4 10.3 during dry season, milk availability remains average. 9.8 9.4 10.0 However, current HIS trends show increasing trends 7.1 in acute malnutrition as illustrated in the Figure 1. 5.0 This has been attributed to measles and diarrhoea 0.0 outbreak reported in parts of Togdheer region. 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2015 2014 2 per. Mov. Avg. (2015) 2 per. Mov. Avg. (2014)

3 FSNAU FSNAU Bi-Monthly Nutrition Update, April 2015

Northwest Urban

Although no assessments were conducted in the urban areas of Togdheer region in the last two seasons, the latest health facility data ( Jan-Mar 2015) has revealed increasing malnutrition trends (Figure 2). The drastic increase in acute malnutrition is likely attributed to limited humanitarian activities in the urban centres. Reports from the field has cited reduced humanitarian activities including indefinite postponement of UNICEF run Child Health days (CHD) in Burao town. The urban poor have also been affected by unstable household food security situation.

Figure 2: Health Facility Malnutrition Trends for Northwest Urban (2014-2015) 25 2014 2014 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2014)

20 16.6 14.5 14.5 14.6 13.7 13.8 13.9 15 12.7 12.7 11.7 11.8

10

5

0.0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

IDPs in Togdheer Region

According to Post Deyr 2014/15 assessment results, Burao and Berbara indicated steady improvements in nutrition situation in the last 2 consecutive seasons. However, health facility collected for the last 3 months ( Figure 3), indicates increasing malnutrition trends among the displaced population in Burao. The aggravating factors are linked to unstable food security indicators, which include high but stable food prices, a contributing factor to food insecurity for majority of IDP households. These trends are consistent with the usual high cost of cereal prices which translate to limited consumption of nutrients which generally does not benefit poor families as they are too costly. Milk availability has also declined due to reduced pasture for livestock. This is as a result of the dry spell which is a key characteristic of the Jilaal season. This situation translated to high prices of milk and milk products in the markets, hence further compromising the household food security of the population and more so the poor in urban, as well as the displaced in settlement camps. The situation is further compounded by limited labour opportunities for the displaced populations hence diminished purchasing power.

Figure 3: Health Facility Malnutrition Trends for IDPs (2014-2015)

40.0 33.7 35.0 2015 2014 2 per. Mov. Avg. (2015)

30.0 27.2

25.0 19.9 20.0 17.1 17.3 17.0 14.3 15.0 13.2 12.4 9.9 8.7 9.7 10.0 5.2 5.3 5.0 0.0 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

CONCLUSION

The overall nutrition situation for most NE livelihoods show stable nutrition situation except Hawd, Urban Burao and IDP settlement in the Togdheer region where increase in acute malnutrition was noted. Close monitoring of both nutrition and food security indicators will continue until the Gu seasonal surveys are conducted which will provide a more comprehensive picture.

4 FSNAU Bi-Monthly Nutrition Update, April 2015 FSNAU

NUTRITION SITUATION IN NORTHEAST REGIONS

The health facility data trends in acute malnutrition in Northeast region of Somalia are summarized in Table 3. Deterioration in nutrition situation among livelihoods of Sool and E Golis/Karkar is noted.

Table 3: Trends in Acute Malnutrition in Northeast Region of Somalia based on data from Health Facilities Observations Livelihood Name of HIS visited Remarks Jan-March 2015 Aug-Oct 2014 May-July 2014 Kalabayr, Jalam, Sustained Burtinle, Hasbahalle, Moderate (10 to GAM was Moderate (10 to <15%) Moderate (10 to <15%) Hawd Bacadweyn <15%) and sustain sustained as and sustain and fluctuation Goldogob trends Critical since Harfo Deyr 2014/15 Sustained Godob Low proportion Low proportion (5 to Low proportion (5 to GAM was Ballibusle Addun (5 to <10%) and <10%) and increasing <10%) and decreasing sustained as Jerriban increasing trends trends trends Alert since Deyr Galkio 2013/14 Sustained GAM Sinujiif deteriorated in Low proportion Gambool Low proportion (5 to Low proportion (5 to Deyr 2014/15 Nugal Valley (5 to <10%) and Waaberi <10%) and stable trend <10%) and stable trend to Serious increasing trends Gargaar (11%) from Alert (7.9%) in Gu 2014 Sustained Qarhiss GAM improved Dangorayo Low proportion in Deyr 2014/15 Low proportion (5 to Sool Plateau Qardho (5 to <10%) and V. low (<5%) proportion to Alert (9.4%) <10%) and stable Rako increasing trends from serious Waaciye (12%) in Gu 2014 Deterioration GAM improved in Deyr 2014/15 Ufayn Moderate (10 to E Golis and Low proportion (5 to Low proportion (5 to to Serious Iskushuban <15%) and sustain Karkar <10%) but increasing <10%) and stable (10.4%) from Carmo trends Critical (15.8%) in Gu 2014

Improvement Eyl Low proportion High (> 15%) and stable High (> 15%) and GAM Sustained Coastal Deeh Beyla (5 to <10%) and proportion stable proportion as Serious since Hafum increasing trends Deyr 2013/14 Shabelle Bulo Ellay, 100-ka Low proportion Low (5 to <10%) but Low proportion (5 to Bosaso Town bush, Tuurjaale, Ugas (5 to <10%) but Sustained increasing <10%) and Yasin, Horseed, and increasing trends Isnino

Post Deyr 2014/15 integrated analysis of nutrition showed either sustained or improved nutrition situation in most of the livelihoods. Exceptions were Bosaso IDPs which deteriorated from Serious to Critical and Nugal valley from Alert to Serious. The Hagaa season (Jan –Mar 2015) was dry mostly, but during third week of March 2015 there were some localized rains in areas of Coastal Deeh, East Golis/Karkaar, Sool plateau and Hawd livelihood which helped relieve the stresses of Hagaa and improved water access. The health information systems (HIS) data from health facilities in Northeast Somalia are mostly consistent with the Jan–Mar 2015 projections- sustained/stable malnutrition trends in most of the livelihoods.

5 FSNAU FSNAU Bi-Monthly Nutrition Update, April 2015

Hawd: Nutrition situation among Hawd pastoral Figure 4: Health Facility Malnutrition Trends in Hawd Pastoral Livelihood Zone (2014-2015) livelihood was sustained as Critical in Deyr 2014. The current HIS trend is showing improvement in 25.0 22.8 nutrition situation to serious (>10 -<15%). This could be because main aggravating factors of critical 20.0 16.7 malnutrition level were high morbidity and no disease 15.6 14.8 14.1 14.3 14.2 outbreaks were reported during the period of Jan- 15.0 13.4 14.0 13.8 14.0 11.7 Mar 2015. 11.4 10.9 11.1 10.0 Nugal and Coastal Deeh: Nugal valley had deteriorated last Deyr 2014 from Alert to Serious 5.0 Proportion of malnourished children (%) while Coastal Deeh was sustained as Serious in 0.0 Deyr 2014. Both were projected to remain Serious. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec The current HIS results show improvement in nutrition situation to Alert for both Nugal Valley and Coastal 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015) Deeh, this could be because there was no major food security concerns or outbreak of diseases are reported in recent months.

Addun: Addun livelihood was sustained Alert phases since Gu 2014. The projection (Jan-Mar) was no change in nutrition situation and the current HIS results (Jan-Mar 2015) also show a decreasing trend. This is due to stable Food security situations and no reported diseases outbreaks.

East Golis and Sool Plateau: East Golis showed Figure 5: Health Facility Malnutrition Trends in East Golis/ improvement in nutrition situation from Critical to KarKaar Livelihood Zone (2014-2015) Serious during Deyr 2014 in East Golis and Sool 25.0 23.5 plateau from Serious to Alert. Same phases was 19.5 19.5 projected for both, and current HIS results (Jan- 20.0 Mar) also show Serious level (>10 - <15%) in 16.6 17.1 East Golis and Alert (>5 - <10%) in Sool Plateau. 15.0 12.2 10.6 10.8 11.1 9.9 9.8 9.4 10.0 Data from the health facilities (Jan-Mar 2015) in 7.7 7.9

Proportion of malnourished (%) 6.5

East Golis areas namely Ufeyn, Carmo, Calula 5.0 and Iskushuban record high proportion (>10%) of acutely malnourished children and fluctuating 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec trend, indicating a likely Serious situation (Figure

5). low numbers (<10%) of acutely malnourished 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015) children are recorded from the health facilities of Nugal valley (Sinujiif, Gambool and Waaberi) and Coastal Deeh (, Banderbayla and Eyl) in Jan-Mar 2015 but regarding the historical trends the situations are projected as likely Serious and stable compared to Deyr 2014/15 analysis. HIS data from the health facilities in Sool plateau (Qarhis, Dangaroyo, Rako and Waaciye MCHs) reported low numbers (<10%) of acutely malnourished children and declining trend, indicating stable nutrition situation of Alert phase and consistent to historical HIS results.

CONCLUSION

The Health Information system (HIS) results of January to March 2015 combined with the historical nutrition trends in NE suggest that the nutrition situation among livelihoods of Coastal Deeh, Nugal Valley and East Golis are expected to remain Serious until June 2015, while Addun and Sool plateau livelihoods are expected to be sustained as Alert. Hawd livelihood is projected to improve from Critical to Serious. There is no outbreak of diseases reported in Northeast during recent months The nutrition situation among IDPs in Northeast Somalia towns is unstable and likely to remain as Serious/Critical levels due to their vulnerability to food and health access problems.

6 FSNAU Bi-Monthly Nutrition Update, April 2015 FSNAU

NUTRITION SITUATION IN CENTRAL REGIONS

Deyr 2014/15 nutrition assessment showed deterioration in Coastal Deeh from Serious to Critical while Hawd and Addun livelihoods sustained Critical and Alert levels respectively. This nutrition situation was expected to be sustained during Feb –April 2015 as neither improvement nor deterioration was expected within the next three months. The health information systems (HIS) data from health facilities in Central Somalia are mostly very high, but consistent with the historical trends that usually MCHs in central were reporting .Current HIS trends (Table 4) suggest sustained nutrition situation. Due to security reasons, HIS Facilities among Cowpea belt and Coastal deeh livelihoods in central could not be reached.

Table 4: Trends in Acute Malnutrition in Central region of Somalia based on data from the Health Facilities Livelihood HIS Visited Mar-2015 Sept-2014 July-2014 Remarks Sustained Adaado High (>15%), High (> 15%) and High (> 15%) and Aduun GAM was sustained as Critical Dusomareb Stable stable stable since Deyr 2014/15 Sustained Galinzoor High (>15%), High (> 15%) and Hawd High (>15%) GAM was sustained as Alert Abudwaaq Stable stable since Deyr 2013/14

The Jilaal season (July-Sep ’15) was dry mostly, but recently (April 2015), Gu rains have started in some locations in Central, and is expected to improve the situation and relief the impacts of Hagaa season. There were no disease outbreaks reported in recent months, but during the health facility revisits cases of Pneumonia and fever were reported among Hawd and Addun livelihoods.

Hawd: Sustained Critical nutrition situation was seen Figure 6: Health Facility Malnutrition Trends in in Deyr 2014 among hawd livelihood was projected to Hawd Livelihood Zone of Central Areas (2014-2015) 70.0 64.7 64.6 remain the same and this is reflected by the current HIS 63.5 63.8 63.0 60.8 61.4 60.0 57.7 trends. The nutrition situation seen is consistent with the 56.2 54.7 55.3 51.8 historical HIS trends. Data from health facilities in Hawd 50.0 49.1 48.8 47.6 livelihood (Abudwak and Gelinsoor) also indicate very high 40.0 (>30%) but stable levels of acute malnutrition. Though no 30.0 diseases outbreaks were reported recently, the conflict in Guricel has resulted displacements and may negatively 20.0

affect the nutrition status. Figure 6 shows HIS trends (Jan- Proportion (%) acutely malnourished 10.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Mar 2015) for MCHs in Hawd. 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Axis Title 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015) Addun: During Deyr 2014/15 analysis results of Addun livelihood indicated sustained Alert level of malnutrition with projection of no change in nutrition situation (Jan-Mar). This is reflected by the HIS trend of Addun livelihood which show high (>15%) but stable trends of acute malnutrition. Data from the health facilities (Jan-Mar’15) among Addun pastoral areas of Central Somalia (Dhusamareb and Addado) showed very high (>30%) of acute malnourished children which suggest a sustained Critical nutrition situation.

Cowpea and Coastal: During Deyr 2014/15 assessment Cowpea belt showed an improvement from Serious to Alert. During Feb –April 2015 Cowpea belt was expected to deteriorate based on historical trends and limited access to health care/humanitarian support. Data from health facilities in Coastal deeh and cowpea belt is not available due to security but based on historical nutrition trends of malnutrition, the nutrition situation in coastal deeh and cowpea belt livelihoods are expected to be Serious until June 2015,

CONCLUSION: In summary the nutrition situation of Hawd is projected to remain Critical due to morbidities reported (but not outbreak) and displacements in Guriel, while Addun pastoral livelihood is expected to remain Alert, and Coastal deeh and Cowpea belt are projected to be Serious.

The nutrition situation among IDPs in Central Somalia towns is unstable and likely to remain in Serious/Critical levels due to their vulnerability to food and health access problems.

7 FSNAU FSNAU Bi-Monthly Nutrition Update, April 2015

NUTRITION SITUATION IN JUBA REGIONS

Post Deyr 2014/15 assessments among Dhobley and Kismayo IDPs in Juba region showed a significant improvement (p<0.001) in nutrition situation - from Critical levels to Serious (11%) and Alert (8.5%) respectively. Dhobley IDPs recorded critical levels of CDR (1.25/10000/day) and a Serious levels of U5MR (1.55/10000/day). The CDR had deteriorated since Gu 2014 (0.46) and Deyr 2013 (0.40), the main underlying causes were diarrhea (23%), malaria (18.6%) and pneumonia (18.6%).

Because of insecurity, no nutrition assessments could be done among different livelihoods of Juba. The health facility data from all livelihoods in Juba for the period (Jan- Mar 2015) indicates sustained high malnutrition trends with high proportion of malnourished children (>15%) among pastoral (Figure 7) and Agropastoral (Figure 8) livelihoods.

Figure 7: Health Facility Malnutrition trends in Juba Figure 8: Health Facility Malnutrition trends in Juba Pastoral MCHs (2014-2015) Agropastoral MCHs (2014-2015)

50 50

45 45 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015) 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015) 40 40

35 35 31.2 29.1 30 30 27.8 28.3 27 26.1 25 25.8 23.8 23.8 23.4 23.8 23.1 23.3 25 23.4 22.8 25 22.1 21.7 22.1 22.3 21 19.2 20 18.8 20 18.6 20 17.6 15.3 14.8 13.9 15 15 12.7 Proportion of malnourished children

Proportion of malnourished children 10 10

5 5

0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Figure 9: Health Facility Malnutrition trends in Juba Post Deyr assessment (2014/15) reports that Food Riverine MCHs (2014-2015)

Security situation remains unchanged since post-Gu 50 2014 in most livelihoods except Juba riverine which show 45 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015) deterioration from Stressed (IPC Phase 2) to Crisis (IPC 40 35 Phase 3). HIS trends (Jan-Mar 2015- Figure 9) among 29.7 30 29 26.3 26.4 27 27.2 Juba Riverine show a stable or slight improvement with 25 22.8 23.1 low proportion of malnourished children (<15%). 20 15.4 15.7 16.2 15 13.9 11.5 12.2 9.2 10

NUTRITION SITUATION IN BAKOOL REGION Proportion of malnourished children 5

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Improvement in the food security situation for all rural livelihoods in Bay and Bakool regions was noted during Post Deyr 2014/15 assessment. These improvements are mainly attributed to high access of milk, low morbidity, food distribution to families with malnourished children and as well as to cash for voucher. Deyr 2014/15 assessment among Bakool pastoral showed an improvement in both GAM and SAM from Critical levels to Serious (12.3%) and Alert (1.5%) respectively. Current HIS data (Jan- Mar 2015) from Bakool pastoral health facilities shows critical (>15 %) but stable trend of acute Malnutrition even though the nutrition assessments conducted in Deyr 2014 recorded an improvement ((Figure 10). Figure 10: Health Facility Malnutrition trends in Figure 11: Health Facility Malnutrition trends in Bakool pastoral MCHs, Bakool – (2014-2015) Bakool Agro-pastoral MCHs,Bakool – (2014-2015)

75.0 75.0

65.0 65.0 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015) 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015)

55.0 55.0

45.6 41.9 41.9 45.0 45.0 41.7 41.7 40.4 39.7 39.8 40.4 39.7 39.8 38.1 38.1 38.1 36.3 36.2 36.3 36.2 33.9 34.6 33.8 33.9 33.7 35.0 32.4 35.0 31.7 30.9 29.7 26.8 25.1 24.6 25.0 25.0

15.0 Proportion of malnourished children 15.0

5.0 5.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

8 FSNAU Bi-Monthly Nutrition Update, April 2015 FSNAU

Due to insecurity, nutrition assessment among Bakool agro-pastoral could not be conducted .The HIS data among Bakool agro pastoral (Jan- Mar 2015) shows high (>15%) but stable proportion of acute malnourished children (Figure 11). Poor rain performances in Deyr 2014, high morbidity and as well as poor water and sanitation facilities could be responsible for these high proportions of acute malnourished children seen among health facilities in Bakool Agro pastoral. Figure 12: Health Facility Malnutrition trends in Bay NUTRITION SITUATION IN BAY REGION Agro-pastoral MCHs (2014-2015) 50.0 47.2 44.4 42.5 39.4 40.4 40.0 38.8 38.4 36.5 Post-Deyr 2014 results of nutrition assessments 34.2 33.1 32.7 30.4 29.8 conducted among Bay Agro-pastoral show Critical 30.0 levels (19%) of acute malnutrition, which are sustained 23.6 20.0 since Gu 2012, and increase in SAM prevalence (5.5%) compared to Gu 2014 (3.7%). Even Baidoa IDPs showed 10.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 deterioration in GAM prevalence to Critical (15.3%) in Proportion of malnourished children 0.0 Deyr 2014/15 compared to Serious (12.9%) GAM in Gu Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014. -10.0 2015 2014 2 per. Mov. Avg. (2015) 2 per. Mov. Avg. (2014) (Source:DHO , BRH, DMO and BMO) The data collected from the health facilities Bay agro-pastoral livelihood for the last three months (Jan- Mar 2015) shows a high (>15%)but stable trend of acutely malnourished children (Figure 12). Sustained high levels of acute malnutrition in Bay region are mainly linked to high morbidity rates, insecurity situation, and limited access to health services, poor water and sanitation facilities as well as poor infant and young feeding practices.

NUTRITION SITUATION IN HIRAN REGION

Post Deyr 2014/15 nutrition assessment in Beletweyne Figure 13: Health Facility Malnutrition trends in district showed Critical levels of acute malnutrition (17.3 Beletweyne Urban Bundoweyn data (2014-2015) % GAM) which are sustained as critical since Gu 2012. 40.0 2014 2015 2 per. Mov. Avg. (2015) 2 per. Mov. Avg. (2014) 36.1 An increase in SAM prevalence to Critical levels (4.2%) 35.2 35.0 33.4 33.4 32.3 33.1 from Serious levels (3.5% and 3.6%) since in Gu 2014 31.0 30.0 28.3 27.8 and Deyr 2013 was also noted. This was a contrast to 25.2 25.0 21.6 20.9 the food security situation which was reported to have 20.1 20.0

14.5 15.1 improved in all rural livelihoods of Hiran region during 15.0

Post Deyr 2014/15 assessment. The health facilities 10.0

data from Beletweyne and Bulo burte Districts for the 5.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 last three months (Jan- Mar 2015) indicates very critical 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec nutrition situation with high and increasing trend of acute malnutrition (>30%),

NUTRITION SITUATION IN SHABELLE REGIONS Figure 14: Health Facility Malnutrition Trends in The post Gu 2014 season integrated nutrition situation Shabelle Riverine MCHs (2014-2015) analysis indicate Serious level of acute malnutrition in 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015)

58.9 the Agro-pastoral and Alert levels in the Riverine areas of 60.0 Shabelle regions which indicated improvements since Gu 55.0 51.8 50.0 48.1 45.0 2014. The nutrition situation was projected to deteriorate 39.9 39.9 40.0 38.6 due to the measles outbreaks in the area. 34.2 33.0 35.0 29.7 27.1 28.1 30.0 26.9 27.2 25.0 23.3 Recent HIS data collected from health facilities for the 20.0 month of January to March 2015, shows deterioration 15.0 Proportion of malnourished children 10.0 in nutrition situation and increasing (>30%) trends of 5.0 0.0 malnourished under-five children seen at the clinics in Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec riverine (Figure 14). This increase could also be due to (Source: IINTERSOS/Swiss-Kalmo) 9 FSNAU FSNAU Bi-Monthly Nutrition Update, April 2015 increased outreach activities in region Figure 15: Health Facility Malnutrition Trends in which attracted more admission and better coverage in Shabelle Agropastoral MCHs 2015 the new sites. There were also case of malaria Acute 60.0 2014 2015 2 per. Mov. Avg. (2014) 2 per. Mov. Avg. (2015) Watery Diarrhoea and measles reported. 50.0

39.1 40.0 Agro pastoral livelihood area of the Shabelle region 34.8 34.3 33.5 27.8 29.3 shows an improvement with decreasing trends in acute 30.0 27.8 28.3 24.6 23.8 24.4 23.7 malnutrition in last two months (Figure 15). Recent 20.6 21.2 19.0 field reports indicate increased cases of Acute Watery 20.0 Proportion of malnourished children

Diarrhoea (AWD) which is a normal seasonal trend 10.0 during the dry seasons of Jilaal. With already limited 0.0 health services in the area, concerns are that the situation Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec may worsen and may be compounded by suspension of (Source: Swiss-kalmo) humanitarian agencies, including those in health and nutrition.

Moreover, even though the coming Gu rains might improve pasture and milk availability in the area, it is vital to keep a watch over the riverine areas which are vulnerable to shocks especially flooding.

NUTRITION SITUATION IN BANADIR

The nutrition situation in Banadir during Deyr’2014/15 assessments was classified as Alert (9.7% GAM), showing improvement from Serious levels (10.1% GAM) recorded in Gu 2014 with a projection that the situation would likely be sustained. The Health Information System (HIS) indicated High (> 15%) and fluctuating trends of malnutrition in Banadir region (Table 5).

Table 5: Acute Malnutrition Situation in Banadir Region based on data from Health Facilities MCH CENTERS HIS Trends- Jan- Mar, 2015 REMARKS Zam Zam High > 15% and increasing Reported cases of measles Waberi High> 10 % and fluctuating No major out breaks Hamar weyne High >15 % and increasing Poor sanitation, ARI and AWD cases Hamar Jab Jab < 15% and decreasing No major out breaks Medina

The current HIS data (Jan-Mar 2015) from most of the Figure 16: Health Facility Malnutrition Trends in Health facilities in Banadir regions (Figure 16) shows Mogadishu MCHs (2014-2015) deterioration in nutrition situation with hhigh but stable 70.0

60.0 levels of acute malnutrition (> 20%) . No nutrition supplies 2015 2014 2 per. Mov. Avg. (2015) are reported by Banadir Hospital which is the largest 50.0 referral hospital in South Central Zone. This is why 40.0 acute malnutrition cases have increased. The hospital 30.0 28.5 27.9 27.9 25.4 21.5 20.3 management is considering suspension of interventions 19.5 18.3 20.0 16.9 16.6 14.9 Proportion of malnourished children 11.1 11.3 if no supplies are received. This will lead to further 9.4 10.0 8.6 deterioration in health and nutrition situation in Banadir. 0.0 Jul Oct Apr Jan Jun Feb Mar Dec Aug Nov May Sept ACF: The admission trend form there feeding centre are as follows Jan 1190, Feb 1397 and March 1167. They extended Mobile activity in the corridor to Lafole area after more camps in TABELAHA (Km 8) moved to Lafole area where there have been huge eviction of IDPs going in Mogadishu by the land lords the other IDPS have newly settled .Due to volatile security situation in and around Shabelle valley and most of the newly liberated towns have led to increased displacement and population movement from the affected areas in to Mogadishu with poor living condition. This is a cause of concern with low humanitarian support targeted towards the urban poor and the IDP’s and highlights the need for close monitoring. Recent field reports indicates increased cases of Acute Watery Diarrhoea (AWD), measles, malaria and ARI in most of the facilities as reported by WHO Banadir CSR surveillance. 10 FSNAU Bi-Monthly Nutrition Update, April 2015 FSNAU

NUTRITION SITUATION IN GEDO

Critical nutrition situation (GAM >15%) was recorded Figure 17: Health Facility Malnutrition Trends in among various livelihoods of Gedo region during Post Deyr Gedo Pastoral MCHs (2014-2015) 2014/15 assessment. Deyr 2014/15 also recorded high 60.0 levels of morbidity among pastoral (27.1), Agro pastoral 50.0 2015 2014

(21.6%) and Riverine livelihoods (20.9%) communities 40.0 33.5 29.5 which combined with limited availability/access to health 29.3 30.0 27.6 26.4 26.2 22.5 services in the region are the key aggravating factors for 22.3 22.7 18.7 17.7 20.0 17.8 15.8 high prevalence of acute malnutrition observed in these 13.3

livelihoods. The food security situation was classified as Proportion of Children malnourished 10.0 Stressed (IPC Phase 2). 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Figure 18: Health Facility Malnutrition Trends in Figure 19: Health Facility Malnutrition Trends in Gedo Agropastoral MCHs (2014-2015) Gedo Riverine MCHs (2014-2015)

60.0 80.0

70.0 50.0 2015 2014

2015 2014 60.0 40.0 37.7 50.0

28.7 30.0 27.5 27.9 40.0 25.3 23.8 24.1 23.9 33.5 22.1 21.5 19.8 19.5 19.9 30.0 27.1 26.6 25.1 25.5 25.1 20.0 18.1 22.7 23.0 23.3 19.1 21.2 21.6

Proportion of Children malnourished 20.0 18.1 17.3 Proportion of Children Malnourished 10.0 10.0

0.0 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

The health facility data for Jan-March 2015 (Table 6) from Gedo Pastoral livelihoods shows a sustained nutrition situation with high (>15%) but stable trend of acute malnourished children. The Agropastoral livelihood show high (>20%) but a decreasing trends while Riverine livelihood shows an increasing trend of acute malnourished children.

Table 6: Health Facility trends in Acute Malnutrition in Gedo Regions of Somalia based on data from Health Facilities Observations Livelihood Name of Health facilities Remarks Jan-Mar 2015 Aug-Oct 2014 May-Jul 2014 SRCS Elwak, >15% and Moderate (10 to Gedo pastoral Belet-hawa, >15% and stable Sustained decreasing <15%) Dollow AMA bardera, >15% and >15% and High (> 15%) and Deterioration Gedo Riverine HIRDA increasing increasing t decreasing Measles Gedo Agro HIRDDA MCH High (> 15%) and High (> 15%) and High (> 15%) and Improved pastoral Luuq Trocaire Decreasing increasing decreasing

CONCLUSION

Gu average rains have already started in early April, 2015. Overall improvement in nutrition situation is expected among all the livelihoods if season performs well. No outbreaks of disease are reported with exception of measles cases in Bardera and Burdhubo districts area. Routine Immunization activities are normally done at MCHs in North Gedo with few outreach programs but in South Gedo region immunization is limited to major MHCs because of limited access.

11 FSNAU FSNAU Bi-Monthly Nutrition Update, April 2015

RAPID NUTRITION ASSESSMENT (MUAC) IN BULO BURTE URBAN, HIRAN REGION, SOMALIA

Bulo Burte is one of the towns affected by trade disruptions and restricted population movement due to a siege on the town by insurgents. Table 7: FSNAU Cut-Off Points for Middle Upper Arm Circumference (MUAC) FSNAU Cut-Off Points for MUAC Based on Proportion of Acceptable Alert Serious Critical Very Critical Children (%) That Fall Under Each Category Less than 12.5% (Global Acute Malnutrition-GAM <5.0% 5.0-7.4% 7.5-10% 10.7-16.7% >16.7% MUAC) Less than 11.5% (Severe Acute Malnutrition-SAM <1.0% 1.0-1.6% 1.7-2.4% 2.5-4.0% >4.0% MUAC)

Results of the rapid MUAC assessment conducted in Bulo Burte in early April 2015 show prevalence of Very Critical levels of acute malnutrition: one out of three children the age of five are acutely malnourished (33% GAM-MUAC) and one out of five children under the age of five are severely malnourished (19 % SAM-MUAC) able(T 7).

Table 8: Summary of Nutrition Situation (Children 6-59 Months) All Boys Girls Indicator-MUAC n = 100 n = 53 n = 47 Prevalence of Global Acute Malnutrition(GAM-MUAC) n=33 n=16 n=17 (< 12.5 cm and/or oedema) 33.0% (25.3-41.8 95% CI) 30.2% (20.2-42.4 95% CI) 36.2% (21.5-54.0 95% CI) Prevalence of Severe Acute Malnutrition (SAM-MUAC) n=19 n=8 n=11 (< 11.5 cm and/or oedema) 19.0% ( 8.4-22.4 95% CI) 15.1% ( 8.6-25.1 95% CI) 23.4% (11.3-42.3 95% CI)

It was noted that prevalence of acute malnutrition is higher in girls (36.2%) compared to boys (30.2%). Similar trends were noted for prevalence of Odema which was higher in girls (6.4%) compared to boys (5.7%).

ODEDMA / KWASHIROKAR PREVALENCE

The prevalence of oedematous malnutrition (Kwashiorkor) is being reported separately. It is most common among children living in deprived circumstances who are exposed to infections and eat a monotonous diet deficient in protein, vitamins and minerals. Current rapid assessment shows six cases of bilateral oedema (Table 8).

Table 9: Prevalence of Oedema (Kwashirokar) in 6-59 month old children in Bulo Burte Indicator Number Percentage

Overall (n =100) 6 6.0%

Boys (n = 53) 3 5.7%

Girls (n = 47) 3 6.4%

Figure 20: Bulo Burte Urban Health Facilities Data (2014-2015)

2014 2015 2 per. Mov. Avg. (2014) 50.0 46.7 43.9 45.0 38.9 40.0 37.5 36.9 34.5 35.0 28.4 30.0 27.6 27.6 26.9 26.8 23.8 25.0 21.2

20.0 15.0 15.0 10.0 5.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

12 FSNAU Bi-Monthly Nutrition Update, April 2015 FSNAU

Data from health facilities in Bulo Burte also show sustained high level of acute malnutrition (>20%). The levels were much higher (36.8%) this quarter (Jan-March 2015) compared to the first quarter of 2014 (22.5%) [Figure 20].

There are currently increasing diarrhoea cases according to health professional there but no outbreaks reported in the area. The results of this assessment also show high morbidity (34%) among children under five. Majority (22%) of the children examined reported an episode of diarrhoea during the 14 days before the assessment while suspected measles was reported among four percent of the children (Table 9).

Table 10: Prevalence of Morbidity in 6-59 month children in the two weeks prior to interview (n=100) Number Percentage Diarrhoea 22 22 % Pneumonia 3 3 % Fever 5 5 % Suspected Measles 4 4 % Total 34 34 %

CONCLUSION AND RECOMMENDATIONS

The Very Critical nutrition situation in Bulo Burte town call for an urgent and sustained delivery of humanitarian assistance to the affected population. Ø There is need for sustained nutrition assistance to treat the malnourished and supplement those at risk of malnutrition. Ø Health service provision is lacking in the area and the high morbidity found in this assessment and the rate of suspected measles call for urgent establishment of health facilities in the town. Ø In tandem with provision of urgent humanitarian assistance to the affected population, security conditions permitting, there is need to carryout other assessments and collect more information that enable comprehensive humanitarian planning

Details of Post Gu 2015 Nutrition Assessment (n=41)

Rural livelihood Urban livelihood IDPs Total SOUTH 1. Bakool Pastoral 1. Mogadishu Town 1. Mogadishu IDPs 2. Bay Agropastoral 2. Kismayo Town 2. Kismayo IDPs 3. N Gedo Pastoral 3. Dhobley IDPs 4. N Gedo Riverine 4. Baidoa IDPs 5. S Gedo Pastoral-MUAC 5. Dolow IDPs 6. S Gedo Agropastoral-MUAC 7. S Gedo Riverine-MUAC 19 8. Hiran pastoral- 9. Beletweyne District 10. Shabelle Agro pastoral 11. Shabelle Riverine 12. Juba Pastoral- Cattle 12 2 5 CENTRAL 1. Coastal Deeh Dhusamareb IDPs 5 2. Cow pea Belt 3. Hawd Pastoral 4. Addun Pastoral 4 1 NORTH EAST 1.Sool Plateau/ Nugal /Kakkar -cross cutting 1. Bari Region Urban 1. Bossaso IDPs 2.East Golis – cross cutting 2. Nugal Urban 2. Qardho IDPs 3.Coastal Deeh 3. Garowe IDPs 9 4. Galkayo IDPs 3 2 4 NORTHWEST 1. West Golis 1. Sool Urban 1. Hargeisa IDPs 2. Guban pastoral 2. Toghdeer urban 2. Burao IDPs 3. Hawd NW 3. Berbera IDPs 8 East Golis –cross cutting Sool Plateau/ Nugal /Kakkar -cross cutting 3 2 3 22 5 13 41 MONTHLY NUTRITION SURVEILLANCE-MUAC Bulo Burte Xuddur

13 FSNAU FSNAU Bi-Monthly Nutrition Update, April 2015

Recent publications and releases • FSNAU Post Deyr 2014/15 Food Security and Nutrition Technical Report, March, 2015 • FSNAU Post Deyr 2014 Nutrition Technical Report, March 2015 • FSNAU Post-Deyr 2014 Food Security and Nutrition Outlook (February to June 2015), February 2015 • FSNAU Climate Update, March 2015 • FSNAU Market Data Update, March 2015 • FSNAU Presentation of the key findings from the 2014/15 post-Deyr Seasonal Food Security and NutritionAssess - ment in somalia, January 2015 • FSNAU Technical Release, January 2015 NOTE: The above publications and releases are available on the FSNAU website: www.fsnau.org

Physical Address: United Nations Somalia, Ngecha Road Campus. Postal address: PO Box 1230, Village Market, Nairobi, Kenya Telephone: +254-20-4000500. Fax: +254 20 4000555, Comments and information related to nutrition: [email protected], Website: http://www.fsnau.org

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