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Northeast Nigeria Nutrition Sector Coordinator Simon Karanja: [email protected] Or Adamu Yerima: [email protected]

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Northeast Nigeria Nutrition Sector Coordinator Simon Karanja: Skaranja@Unicef.Org Or Adamu Yerima: Ayerima@Unicef.Org NURITION AND FOOD SECURITY SURVEILLANCE: NORTH EAST NIGERIA – EMERGENCY SURVEY NOVEMBER 2019 FINAL REPORT Acknowledgments This survey was carried out by the National Bureau of Statistics (NBS) in coordination with the National Population Commission (NPopC), the Federal Ministry of Health (FMOH), and the Nigeria Nutrition in Emergency Working Group (NiEWG). Financial support was provided by the Government of Nigeria, United Nations Children’s Fund (UNICEF), and the United Kingdom Agency for International Development (UKAID). Technical support was provided by the Centers for Disease Control and Prevention (CDC) and UNICEF through NBS. Additional information about this survey may be obtained by contacting UNICEF Nigeria or the Northeast Nigeria Nutrition Sector Coordinator Simon Karanja: [email protected] or Adamu Yerima: [email protected]. Executive Summary The Boko Haram conflict was declared to be a state of emergency at the beginning of 2012 by the government of Nigeria. In May 2013, the area under the state of emergency was extended to include all of Adamawa, Borno and Yobe states in North-eastern Nigeria. The insurgency and political violence had caused mass population displacement. According to the International Organization of Migration’s (IOM) August 2019 report, there were 1,483,566, 200,011 and 131,597 internally displaced persons (IDPs) in Borno, Adamawa and Yobe states respectively. Given the emergency situation as well as recently increases in access to newly liberated areas since the emergency declaration, a series of repeated surveys were organized with the primary objective of providing representative estimates for prevalence of acute malnutrition among children 6 to 59 months (by weight-for-height and MUAC), as well as mortality rate in North East Nigeria to inform the ongoing emergency response. Information on nutritional status of women of reproductive age, prevalence of common child health morbidities, access to health services and health status among children, and infant feeding. The first round of repeated surveys was conducted in October-November 2016, the second round in February-March 2017, the third round in July-August 2017, the fourth round in November-December 2017, the fifth round in April-May 2018 and the sixth round conducted jointly with WFP for both nutrition and food security (JANFSA) in October 2018, seventh round in May-June 2019. These surveys were carried out by the National Bureau of Statistics (NBS) in coordination with the National Population Commission (NPC), the Federal Ministry of Health (FMOH), and the Nigeria Nutrition in Emergency Working Group (NiEWG). Financial support was provided by the Government of Nigeria, United Nations Children’s Fund (UNICEF), and the United Kingdom Agency for International Aid (UKAID). Technical support was provided by the Centers for Disease Control and Prevention (CDC) and UNICEF through NBS. Methodology Cross-sectional household surveys were carried out using a two-stage cluster sampling design consistent with the SMART methodology. The survey area consisted of 65 LGAs within the three states of Adamawa, Borno and Yobe. The 65 LGAs were divided into 10 domains: 2 in Adamawa (North and South), 3 in Yobe (North, Central and South) and 5 in Borno state (North, South, Central, East, and MMC/Jere). Domains were created considering livelihood zones, geographic proximity and socio-cultural homogeneity1. Results are representative at the level of the domain, a grouping of LGAs. Clusters were selected using probability proportional to size (PPS) sampling. The primary sampling unit (PSU) for Yobe and Adamawa domains were based on Enumeration Areas (EAs) from the 2006 census frame. Estimated populations for each EA are 2019 populations projected from the 2006 census. Given recent large-scale population movement, an updated sampling frame was built for Borno. Population estimates from the August 2019 polio campaign micro plan as well as Village Tracking System population estimates by settlement were used for settlements2. 1 Famine Early Warning Systems Network (FEWSNET). Nigeria Livelihood Zones. 2014. Available at: http://www.fews.net/west-africa/nigeria/livelihood-zone-map/may-2014 2 Nigeria - DTM Round 28 Report (August 2019). Available at; https://displacement.iom.int/system/tdf/reports/Nigeria_DTM_Round_28_Report_August%202019.pdf?file=1&type=node &id=6616 Sample size was calculated to ensure adequate precision for estimates of global acute malnutrition (GAM) and crude mortality rate (CMR). A sample of 600 households, 30 clusters of 20 households, was selected per domain. Within selected clusters, all households were listed and selected using systematic random sampling. Enumerators received a four-days training including a full standardization and field test. Results Data collection took place between September 15 and October 22, 2019. Four of the LGAs in Borno (Abadam, Guzamala, Kukawa and Marte) were determined by state level actors to be inaccessible at the time of this survey. All ten domains were accessible and all inaccessible areas in were excluded a priori. Prevalence of GAM in children 6 to 59 months was 11.3% in Yobe, 8.1% in Borno, and 7.2% in Adamawa. Prevalence of GAM exceeded the WHO Crisis Classification threshold for serious (10%) in all the domains in Yobe state (Central Yobe, Southern Borno, and Northern Yobe) and East Borno in Borno state. Prevalence of GAM was highest in Central Yobe both by weight-for-height and/or oedema (13.8%), and by MUAC (4.1%). Crude mortality was highest in Southern Adamawa 0.41 while under-five mortality rates was highest in both Northern Borno 1.02). Crude and under-five mortality rates remained below emergency threshold of 1 death / 10,000 people / day & 2 deaths in children under five / 10,000 children under five / day in any of the domains. By domain, crude mortality rate ranged from 0.2-0.41 total deaths / 10,000 people / day. Under five mortality rates ranged from 0.1 to 1.02 deaths in children under five / 10,000 children under five / day. Overall, data quality was excellent in all 10 domains according to SMART methodology classifications. Breastfeeding practices were assessed as a measure of infant and young child feeding (IYCF). The proportion of children who continued breastfeeding at one year was over 90% in all three states, but then steadily declined; continued breastfeeding at two years (assessed among children aged 20-23 months) ranged from 31.1 - 40.9% by state. Prevalence of acute among adolescent girls (15 to 19 years) was 29.5% and among adult women (20 to 49 years) was 5.9%. The rates of acute malnutrition is 5 times higher among the adolescent compared to the adult women. Recommendations: Based on the NFSS Round 8 findings, the following actions are recommended: Prevention: 1. UNICEF and WHO to continue support for SPHCDA to strengthen the routine provision of vitamin A and deworming through the EPI at health facilities, and in regular campaigns. UNICEF to assist in developing communication strategies to improve the uptake of vitamin A and deworming both in routine programming, and campaigns. 2. Health Sector to ensure 100% coverage of measles vaccination to ensure 100% herd immunity is achieved. 3. WHO, UNICEF and health sector partners to strengthen management of common childhood illnesses, such as diarrhoea, at accessible at the household level and primary health centers. 4. WFP to continue strengthening its ongoing humanitarian response (nutrition and food or cash assistance), which may be attributable in contributing to the documented decrease in acute malnutrition. Response: 5. Improve coverage of effective nutrition intervention e.g. targeting them in Mother to Mother Support groups, aimed at improving the nutritional status of adolescent girls. 6. Nutrition Sector partners to adopt tested and innovative methods to improve the coverage and quality of infant and young child feeding (IYCF), and use of micronutrient powder (MNP), including establishing Father-to-Father Groups, Mother-to-Mother Support Groups, Care Models, and engagement of Community Nutrition Mobilisers to distribute MNPs. Funding 7. Donors to support Nutrition Sector partners to scale-up nutrition prevention and treatment response in areas with persistent high levels of GAM including Central, Northern and Southern Yobe, and East Borno. Monitoring and Evaluation: 8. Nutrition Sector to plan and carry out systematic SMART methodology nutrition surveys in LGAs, and to seek donor funding for regularization of these surveys. Coordination: 9. OCHA to support the Nutrition Sector to involve the ISWG and specifically the WASH and Food Security in the planning, implementation, analysis, and dissemination of results. This is to ensure the SMART results are relevant to the other sectors. 10. OCHA to support the adoption of GAM results as a cross cutting outcome for all sectors. Table of Contents Acknowledgments i Executive Summary ii Table of Contents 5 List of Tables 7 List of Figures 8 List of Acronyms 9 1 Introduction 11 1.1 Justification 11 1.2 Objectives 12 2. Methodology 13 2.1 First Stage Sampling 13 2.2 Second Stage Sampling 14 2.3 Sample Size Calculation 14 2.4 Case Definitions and Inclusion Criteria 18 2.5 Training and Supervision 19 2.6 Data Analysis 20 3. Results 21 3.1 Final Sample and Data Quality 21 3.2 Anthropometric results: 24 3.2.1 Acute Malnutrition (WHZ and/or Bilateral Oedema) 25 3.2.2 Acute Malnutrition (MUAC) and/or Bilateral Oedema 28 3.2.3 Underweight 32 3.2.4 Chronic Malnutrition (Stunting) 34 3.3 Mortality results 37 3.4 Infant and Young Child Feeding 37 3.5 Child Health 44 3.5.1 Measles Vaccination Coverage 44 3.5.2 Diarrhoea, Oral Rehydration Therapy and Zinc Supplementation 47 3.5.3 Acute Respiratory Infection (ARI) and Treatment 49 3.5.4 Fever, Prevention of Malaria, and Antimalarial Treatment 51 3.6 Maternal Nutrition 56 3.6.1 Minimum Dietary Diversity for Women 58 3.7 Public Health Interventions that Prevents against Malnutrition 60 3.7.1 Deworming, Vitamin A and Micronutrient Powder (MNP) 60 3.7.2 Specialised Nutritious Foods 62 3.8 Water, Sanitation and Hygiene (WASH) 63 4.
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