Rapid Nutritional Assessment (RNA) on Flood-Affected

Populations

In

Awsi-Rasu and Gabi-Rasu IDP Sites

Afar Region

(13th – 18th October 2020)

Date of report: 25th October 2020

Joint Government and Humanitarian Partners Joint Regional Assessment Team

Afar Regional Health Bureau and DPFSPCO, WFP

Samara, Afar_ Introduction

According to the Afar Regional and NGO Joint Rapid Nutrition Assessment, the majority of IDPs (Internally Displaced Persons) are identified in Aysaita district (9,377 people). The demographic profile suggests that 54% of the displaced population are children, of which 7.9% are five (5) years old or younger. Although one-fourth of the IDPs (21%) live in host communities, there are still the majority of the IDPs (79%) that have settled in formal and informal sites, and sites/camp like settlements. In Aysaita district, 4 of these IDP sites have been identified.

Figure 1: Location of Assessment Woredas Map-flood affected areas in Afar

Aysaita

A scre ening exercise was conducted in the 3 Internally displaced people sites (IDP) in selected areas of Aysaita district between 13th and 15th October2020. While all screenings were conducted in the government managed sites/settlements, there were also some IDP out of the formal sites screened. Please note that IDP site in the newly accessible area/sultan-Alimirah was not captured by the Joint Regional Government and humanitarian partners assessment-RNA mission.

RNA Joint Assessment Team Composition, Awsi-Rasu Team No. List of Team Organization Role Remarks 1 KEDIR LAALE DPFPCO/ENCU ENCU Coordinator 2 NUR MOHAMMED DPFSPCO/WFP TSFP Coordinator 3 SELAMAWIT HAILU PIE Health and Nutrition Supervisor 4 MOHAMMED ABAGEZ RHB Nutrition Focal Person 5 HASSAN SCI CMAM -Supervisor 6 AYDAHIS ALI ABH/UNICEF Zonal Monitor

2. Objective The main purpose of conducting the rapid nutrition assessment is to assess nutrition situation, particularly to know the total number of children and PLW affected/displaced as well as the proportion of malnourished individuals over the total number of IDP sites and health status of the worst affected flooding Woredas of Awsi-Rasu and Gabi-Rasu in order to verify whether flagged areas of concern obtained from the Regional early warning reports are actually affected and displaced population/areas and to see the need for conducting a standard emergency nutrition survey and trigger an immediate response.

2.1 Specific Objective a) To estimate nutritional status of children 6-59 months of age using Middle Upper Arm Circumference (MUAC) and Oedema in the selected flood affected Woredas of ; b) To estimate nutritional status of Pregnant and Lactating Women (PLW) using MUAC measurement. c) To assess morbidity status of children aged 6-59 months; d) To assess the level of food insecurity situation of the affected /displaced population and identify possible foreseen scenarios including main aggravating factors; e) To assess environmental sanitation situation of the community in the affected Woredas, IDPs.

3. Methodology A total of six oriented health workers and three food security officers were deployed per each Woreda/IDP sites and over a three-day period conducted rapid nutrition assessment in all children aged 6 to 59 months and PLW using Mid Upper Arm Circumference (MUAC) tapes, children were also assessed for nutritional oedema. The assessment was employed by using the National Emergency Nutrition Coordination Unit /Disaster Prevention and Preparedness Agency (ENCU/DPPA, 2006) guideline. A purposive and two stage simple random sampling methods was used to determine IDPs and villages to carry out the assessment. The RNA exercise had purposively targeted in selected flood affected Woredas in Awsi-Rasu and Gabi-Rasu Woredas of the region. In this case, Aysaita and Afambo Woredas in Awsi-Rasu, and and Woredas in Gabi-Rasu was selected for the purpose this RNA assessment exercise. Three out of total IDP sites were identified as worst affected areas, and selected using the purposive sampling technique per each sampled Woreda.

As summarized in table 1 below, Focus Group discussion (FGD), Key Informant Interview (KII), MUAC screening and Transect walk were the main activities undertook to collect both primary and secondary data.

Table1: RNA main activities at Woreda and IDPs levels Study Location Major Activities Participants Woreda Briefing & planning meeting with - Woreda Health and Pastoral & Rural Woredas Officials in the 1st day of Development Offices, and Water resources Office; and Woreda Administrators 4 KII Kebele Briefing & planning meeting HEW, Health Officer and kebele Administrator (flood affected) 3 KII IDP Site 2 FGD Men and Women Groups 1 MUAC Screening Children 6-59 months old and PLW (15-49 years aged) 1 Transect Walk The entire IDP sites per each Woreda

Woreda Level: 3 KIIs were conducted with focal persons from Woreda health, pastoral and rural development offices and Woreda Administrator per a Woreda. 3 KII was conducted with flood affected Kebele administrators, and health extension workers. IDPs Level: Two FGDs with voluntary participants of young and elderly groups of men and women, drawn from the community, were parallel and independently conducted to gather qualitative information reflecting community perception and perspective of the overall health, nutrition and food security situation of the communities in the affected IDP/Woreda. In order to determine the nutritional status of children aged 6 - 59 months, nutritional assessments using MUAC and identification of oedema and PLW at household level (IDP sites) will be employed per sampled IDP/kebele. In some cases, if parents are not in a position to determine the exact age of the child, height are used as proxy indicator of age. Locally made measuring sticks were used to determine the height of the child. Children between 65 and 110 cm were included in the screening process. MUAC screening and oedema identification of children 6-59 months was carried out by the team moving from house to house and from one edge to the other end of the village/IDP sites to minimize bias. Thus, a total of 100 children per each IDP site/sub-kebele were measured using MUAC; and a minimum of 300 children and PLW were screened for their nutritional status in the three selected IDP sites per a Woreda. All children under five who are detected as severely malnourished were immediately referred to the nearby health facility using the referral slip form. Parallel to the MUAC and oedema measurement, physical observation of each IDP/village to assess various conditions of the flood affected community such as water, livestock, sanitation, hygiene were carried out using transect walks.

MUAC are registered according to the cut off points recommended by ENCU/DPPA (2006) guideline for malnutrition as outlined in the following table: Table 2: U5 Children MUAC screening results presentation format Indicator Category/ Nutritional Status Number Percentage Oedema = A Kwashiorkor A (A/N)*100 MUAC < 115 mm = B Severe Acute Malnutrition (SAM) B (B/N)*100 115≤ MUAC < 125 = C Moderate Acute Malnutrition (MAM) C (C/N)*100 MUAC ≥ 125 = D Normal D (D/N)*100 Total N Severe Acute Malnutrition (SAM) A+B (A+B)/N*100 Global Acute Malnutrition (GAM) A+B+C (A+B+C)/N*100

Classification of MUAC malnutrition in children 6-59 months (based WHO Classification 2007) MUAC reading classification Severity <125 mm Moderate and severe (Orange & Red MUAC) ≥115 mm and <125 mm Moderate (Orange MUAC) ---- MAM <115 mm Severe (Red MUAC) ---- SAM Oedema Severe

Awsi-Rasu Team-01_Arado IDP Site 15th October2020 4. Results Screening results with proportions of SAM and MAM Children (6-59 months aged) assessed in the four selected flood-affected Woredas of Awsi-Rasu and Gabi-Rasu using MUAC measurement are summarized in Table 4.1;

Table 4.1: Proportions of SAM and MAM Children (6-59 months) in Awsi-Rasu, October 2020 Awsi-Rasu Number of IDP sites assessed: 6 AYSAITA AFAMBO Number of % Number of % MUAC Category Children Children MUAC ≥ 125mm no oedema (Green MUAC) 201 50.3 128 59.5 MUAC < 125 mm no oedema (Orange & Red MUAC) 199 49.8 87 40.5 MUAC ≥ 115 mm & < 125 mm no oedema (Orange MUAC) 95 23.8 58 27.0 MUAC < 115 mm and/or oedema (Red MUAC) 104 26.0 29 13.5 Total children screened 400 100.0 215 100.0

Fig1: Proportions of SAM and MAM by age, based on Fig2: Proportions of SAM and MAM by age, based on

MUAC cut off's in Aysaita Woreda, October 2020 MUAC cut off's in Afambo Woreda, October 2020

Table 4.2: Proportions of SAM and MAM Children (6-59 months) in Gabi-Rasu, October 2020 Gabi-Rasu Number of IDP sites assessed: 6 AMIBARA GEWANE Number of % Number of % MUAC Category Children Children MUAC ≥ 125mm no oedema (Green MUAC) 200 66.7 205 68.3 MUAC < 125 mm no oedema (Orange & Red MUAC) 100 33.3 95 31.7 MUAC ≥ 115 mm & < 125 mm no oedema (Orange MUAC) 65 21.7 59 19.7 MUAC < 115 mm and/or oedema (Red MUAC) 35 11.7 36 12.0 Total children screened 300 100.0 300 100.0

Fig3: Proportions of SAM and MAM by age, based on MUAC Fig4: Proportions of SAM and MAM by age, based on cut off's in Amibara Woreda, October 2020 MUAC cut off's in Gewane Woreda, October 2020

As indicated in the figures above, a higher proportion of the children aged 6 - 17 months were more severely malnourished based on MUAC (<125mm) than the older children aged (30-59) months in all assessed Woredas IDPs IDP sites.

Table 4.3: Screening results with proportions of SAM and MAM children by Sex and IDP sites

Oedema (Severely MUAC <11.5 cm MUAC 11.5 cm & <12.5 cm MUAC >=12.5 cm SAM MAM No. Aysaita Woreda Number of U Malnourished Children) (SAM) (MAM) (Normal) Proportion Proportion Children Screened Name of IDP Site Boys Girls Boys Girls Boys Girls Boys Girls 1 Mohammed Humad Primary School - - 31 36 22 19 50 42 200 33.5% 20.5% 2 Aysaita Teachers College (ATC) - - 11 12 12 10 35 20 100 23.0% 22.0% 3 Arado Primary School - - 4 10 18 14 27 27 100 14.0% 32.0% TOTAL 0 0 46 58 52 43 100 112 400 26.0% 23.8%

Oedema (Severely MUAC <11.5 cm MUAC 11.5 cm & <12.5 cm MUAC >12.5 cm SAM MAM No. Afambo Woreda Number of U Children Malnourished Children) (SAM) (MAM) (Normal) Proportion Proportion Screened Name of IDP Site Boys Girls Boys Girls Boys Girls Boys Girls 1 Fatuma Abdu Primary School - - 2 7 8 6 12 15 50 18.0% 28.0% 2 Gala'aluI school - - 3 2 8 8 26 18 65 7.7% 24.6% 3 Meego school - - 6 9 17 11 33 24 100 15.0% 28.0% TOTAL 0 0 11 18 33 25 71 57 215 13.5% 27.0%

Oedema (Severely MUAC <11.5 cm MUAC 11.5 cm & <12.5 cm MUAC >12.5 cm SAM MAM No. Amibara Woreda Number of U Children Malnourished Children) (SAM) (MAM) (Normal) Proportion Proportion Screened Name of IDP Site Boys Girls Boys Girls Boys Girls Boys Girls 1 Melka Werer IDP - - 1 7 7 10 46 29 100 8.0% 17.0% 2 BadahamoIDP - - 3 4 7 4 32 50 100 7.0% 11.0% 3 Serkahamo IDP - - 11 9 20 17 27 16 100 20.0% 37.0% TOTAL 0 0 15 20 34 31 105 95 300 11.7% 21.7%

Oedema (Severely MUAC <11.5 cm MUAC 11.5 cm & <12.5 cm MUAC >12.5 cm SAM MAM No. Gewane Woreda Number of U Children Malnourished Children) (SAM) (MAM) (Normal) Proportion Proportion Screened Name of IDP Site Boys Girls Boys Girls Boys Girls Boys Girls - - 1 Rifo IDP 7 9 14 10 21 39 100 16.0% 24.0% 2 Nina-tahiro School - - 3 11 15 5 47 19 100 14.0% 20.0% 3 Gewane Secondary School - - 3 3 9 6 43 36 100 6.0% 15.0% TOTAL 0 0 13 23 38 21 111 94 300 12.0% 19.7%

Table 4.4: Proportions of SAM and MAM based on MUAC cut off’s Malnutrition by Woreda, October 2020

➔ As indicated in table 4.4, highest proportion of under five children with SAM cases were found in Aysaita IDP sites as compared to the other Woredas IDPs assessed. A total of 104 cases out of 400 total screened children were severely malnourished (SAM) in Aysaita Woreda IDPs. ➔ The proportion of SAM cases were 26.0%, 13.5%, and 11.7% and 12.0% in Aysaita, Afambo, and Amibara and Gewane Woreda IDPs, respectively.

5. Discussion and Key Findings Nutritional Status: Absolute MUAC (measured in millimeters) is a globally recognized measure of acute malnutrition (WHO, 2007). In all screened IDP sites (October 2020), the proportion of under five children identified with SAM cases ranges from 14.0 to 33.5 per cent in Aysaita IDPs, SAM proportion rages from 7.7 to 18.0 per cent in Afambo IDPs , and 7.0 to 20.0 per cent and SAM proportion rages from 6.0 to 16.0 per cent in Gewane IDPs were severely acute malnourished as measured by absolute MUAC (MUAC <115 mm) in the above mentioned Districts IDP sites in Awsi-Rasu and Gabi-Rasu of Afar Region. Based on WHO classification, this situation classified as critical nutrition status with aggravating factors and categorized under critical public health classification, very high severe category indicating critical nutrition situation in the assessed Woredas/districts IDP sites of Awsi-Rasu and Gabi-Rasu.

5.1 Nutrition ❖ The floods have had a significant negative impact on infant feeding practices and basic social access. approximately more than 60% of mothers report at the IDP community level that they have reduced breast feeding their children and about 35 % of mothers have stopped breast feeding since the flooding situation other related socio-economic impacts in Aysaita Woreda IDPs. ❖ Majority of the mothers/ Women reported that they do not have sufficient privacy and safety place to breast feeding their children in the IDP sites since the current IDP sites in Aysaita are overcrowded and inadequate space even for sleeping as well as high risky and vulnerable for transmission of COVI-19 Crisis. ❖ Most of the community in the IDPs and mothers with young children report having to reduce the complementary food given and shortage of complementary food items in the Aysaita IDP sites. ❖ Across all IDP sites visited in Aysaita including Afambo Woreda there were no provision of essential nutritional food and distribution of infant feeding supplies. These reports were the most dominant in Aysaita, Mohammed Humad IDP site and more than 50% of the interviewed communities reported in the visited IDP site. 5.2 Health ❖ Most of the IDP community members reported that didn’t get adequate health support to access health services and care from the District Hospital in Aysaita town, which is a big challenge for IDPs in need of immediate solution and response in Aysaita Woreda IDPs. ❖ Diarrhea, ARI/cough, Malaria, Typhoid-fever and skin diseases are the most common health concerns in the IDP communities, particularly for under five children and adult people in the visited IDP sites of Awsi-Rasu. 5.3 Environmental Conditions Sanitation ❖ According to the community interview through FGD, less than 25% of households had access to a toilet that was considered to be clean and in good working order in Aysaita Woreda IDPs. ❖ For men, women, boys and girls there has been a decrease in the use of shared latrines in the IDP sites (in the school compound as IDPs settled temporarily) and an increase in the use of communal latrines out of IDP sites and in defecating in the open field in Aysaita Woreda IDPs.

Environmental issues relating to public health in the IDPs ❖ 68% of households reported vectors, particularly mosquito around their houses in the IDP sites, Aysaita Woreda. ❖ Stagnant water remained where IDP people were living in all IDP sites assessed in Aysaita Woreda with exception of Aysaita Teaching College IDPs. The most stagnant water was observed in Mohammed Humad School’ IDP site. ❖ In all visited IDP sites of Aysaita Woreda, there was no one responsible for removing garbage from houses or shelters and waste disposal garbage was not available in the IDP compound, particularly Aysaita Woreda. 5.4 The top highest priorities for the IDP community in Aysaita/Afambo ❖ Adequate essential food items; and health care services; and clean drinking water and treatment; ❖ Conditional cash /finance assistance for daily life saving basic expenses and exchange ❖ Repair and rehabilitation; and NFI- material assistance ❖ Critical needs reported from the IDP Aysaita, particularly for temporary and long-term shelter solutions and the repair and rebuilding of their houses. ❖ Firewood support for cooking food at the IDP sites in Aysaita Woreda including Afambo IDPs.

Immediate shelter priorities ❖ House Materials to use for re-building and repair since schools are reopening ❖ Adequate Tent support per standards ❖ Temporary shelter with adequate space for sleeping and cooking purpose ❖ Conditional cash to purchase non-food items

6. Conclusions In all screened IDP sites the proportion of under five children identified with SAM cases ranges from 14.0 to 33.5 per cent in Aysaita IDPs, SAM proportion rages from 7.7 to 18.0 per cent in Afambo IDPs , and 7.0 to 20.0 per cent and SAM proportion rages from 6.0 to 16.0 per cent in Gewane IDPs were severely acute malnourished as measured by absolute MUAC (MUAC <115 mm) in the above mentioned Districts IDP sites in Awsi-Rasu and Gabi-Rasu of Afar Region. Based on WHO classification, this situation classified as critical nutrition status with aggravating factors and categorized under critical public health classification, very high severe category indicating critical nutrition situation in the assessed Woredas/districts IDP sites of Awsi-Rasu and Gabi-Rasu. Thus, this critical situation that is in need of immediate assistances in provision and distribution of essential food items, adequate clean water supply and health access and nutritional care, and special nutrition intervention are necessary in all the IDP sites assessed in Awsi-Rasu and Gabi-Rasu.

7. Recommendations and priorities

❖ Continue the existing food assistance program; and ensure nutrition program with quality and coverage of TFP and SFP, and IYCF activities), to treat severely- SAM cases and prevent the deterioration of moderately malnourished children; ❖ Provide adequate blanket feeding intervention for all children 6 – 23 months old. Immediately. ❖ Ensure full CMAM intervention and treatment of MAM and SAM, and IYCF activities. Within 2 weeks ❖ Initiate targeted and blanket IYCF activities for infants and children 0-23 months old. Immediately. ❖ Improvement of the clean water access in the flood affected Woredas. Immediately. ❖ Set up strong nutritional surveillance system with the woreda health and early warning structures in the flood affected Woredas IDP sites; Involve the Regional health Bureau and humanitarian partners for activities such as the detection, prevention and treatment of acute malnutrition being implemented routinely in the flood affected Woredas public health structures; ❖ Coordination of the different humanitarian actors working in health and nutrition, to provide immediate response and timely monitor the nutrition situation in the IDPs sites. ❖ Conduct standard SMART Nutrition Survey in one of the floods affected IDPs Woreda in Afar;