A.1. Prevalence of Protein Energy Malnutrition
In Malawi, national DHS (Demographic Health Surveys) conducted in 2000 showed that 49% of children aged 0-59 months are chronically malnourished - meaning that they are too short for their age or stunted. The proportion of children who are stunted is 25 times the level expected in a healthy, well-nourished population. Acute malnutrition, manifested by wasting which results in children being too thin for their height, is 5.5% (<-2 SD weight for height) (note: this figure does not include oedema and consequently not directly comparable with the surveys using the national nutrition survey guidelines and may therefore be an underestimation of global acute malnutrition rates). The rate of under-nutrition in Malawi (measured as an index of weight for age) was found to be 25.4%.
The above data was compiled from surveys conducted in 2000, between July and November, considered a "normal" year for Malawi in terms of harvests, weather and economic stability. It is therefore clear that chronic malnutrition was a serious problem in Malawi even before the current food insecurity situation arose. The 2000 survey indicates that in the best part of a normal year Malawi had at least 110,000 children who were suffering from acute malnutrition. Acute malnutrition, or wasting, is an indicator of rapid weight loss associated with food shortages. Of these 110,000 children, roughly 24,000 cases are, in a normal year, severely malnourished. With the current food crisis, the expected number of children with acute malnutrition could rise to 300,000. Of these potential malnourished cases, approximately 40,000 children under five will be severely malnourished.
The strategy to address the projected high prevalence of wasting in Malawi must focus on relief food distribution, selective feeding programmes and associated food security, water and sanitation and health programmes. Most importantly stunting and under-nutrition rates require a long-term programme that addresses the underlying and basic causes of malnutrition. The current emergency programme could greatly contribute to reduction in the rates of acute malnutrition, but will not address the longer-term solutions to chronic malnutrition. However the present emergency programme is designed to provide longer term solutions to the residual problem of treatment of acute malnutrition within the Malawian Health System.
A.2. Micronutrient Deficiencies and Coverage of Supplementation Programmes
In Malawi, 49% of the households with children under five years of age use salt that has adequate levels of iodine. Coverage in the Northern part of the country seems to be higher than coverage in the Central and South, which is attributed to entry of non-iodized salt from the country through neighboring Mozambique. There have been calls for legislation to control the import of non-iodized salt.
Four percent of all women who have given birth in the previous five years reported having some form of night blindness during their last pregnancy. 41.7% of mothers received vitamin A supplements within a month of delivery (DHS 2000). The coverage of Vitamin A among children under five years old in Malawi was 65.3% during the 2000 survey. A more recent countrywide survey (to be published in November) reports 59.7% of pre-school children and 97.1% of pregnant women low or deficient serum retinol levels (vitamin A). At least 2/3 of women in Malawi were reported to have received iron supplements, but only 17% have received a complete dosage, meaning that compliance is very low. In the unpublished survey 72.3% of pre-school children and 17.1% of pregnant women were reported to be anaemic. Measles vaccination coverage is an impressive 84%, but the program must be accelerated to reach 100%.
In Malawi, 63% of mothers exclusively breastfeed infants during the first four months but only 12% at 6 months, while 93% of mothers introduce complementary foods from six to nine months. The current food insecurity will affect care practices, due to the increased workloads of women as they search of food. The lack of adequate food also means that children are not getting the quality and quantity of food required for healthy growth. This is clearly demonstrated in the surveys conducted in the most affected of Malawi during the period of the current food insecurity.
A.3. Previous Nutrition Surveys in Malawi in Selected Districts
Oxfam GB conducted a nutrition survey in Thyolo and Mulange districts in March 2002, and the prevalence of global acute malnutrition (GAM) in the two districts was 7.2% (4.8-9.6) and 6.2% (4.0-8.4) respectively. Crude mortality rate was found to be 1.14/10,000/day and 1.7/10,000/day in Thyolo and Mulange respectively, while the under-five mortality rate is 1.68/10,000/day and 2.7/10,000/day respectively. These levels are high according to SPHERE standards and indicate a precarious situation. The results probably reflected the fact that the data was retrospective on the 3 months prior to the survey, which correspond to the peak of the lean season.
Save the Children Fund UK conducted surveys in Salima and Mchinji three times at intervals of three to six months. The first survey was conducted in December 2001, towards the beginning of the hunger gap, and showed a prevalence of wasting of 10.2% in Mchinji and 6.6% in Salima. The second survey completed in March, towards the end of the hunger gap, shows a prevalence of wasting at 12.5 % in Mchinji and 19% in Salima. In the latest survey conducted in June 2002, a reduction in malnutrition was observed in both districts, where wasting was recorded at 9.7% in Salima and 7% in Mchinji. This slight improvement was attributed to the harvest of maize plus the supplementary and therapeutic feeding programs and general ration distribution implemented by Save the Children Fund (with support from UNICEF and the World Food Programme). Although these rates do not represent a crisis situation, the rates are slightly higher that the rates of wasting found in the national surveys two years ago
World Vision International conducted two surveys in Nayuchi and Kiyunga agricultural development project (ADP) in Machinga district. The first survey occurred in October 2001, and covered Nayuchi ADP alone. The second survey was conducted in January-February 2002, during the peak of the hunger gap, and included a follow-up in Nayuchi ADP and a new survey in Kunyinga ADP. In the October survey, 6.8% global acute malnutrition rate was recorded, while global acute malnutrition in the January-February survey was 4.1% and 4.2 % in Nayuchi and Kunyinda respectively. Although this survey was conducted during the peak of the hunger gap, the prevalence of malnutrition was at an acceptable level during the second survey.
A review of the surveys completed thus far indicates that the situation seems to be worst in the central region, followed by the southern region. There are also indications from the June survey that the hunger gap will start early this year, because by June the rates of malnutrition observed in Salima and Mchinji are abnormally elevated in light of the recent harvest and relief interventions. Rates of severe forms of acute malnutrition, manifested by oedema (which is associated with high mortality rate), were also found to be high among children under five years old.
A.4. Admissions at the Nutrition Rehabilitation Centers
In Malawi, there are over 90 Nutrition Rehabilitation Units (NRUs) that care for severely malnourished children. Because these structures already exist, the plan during this emergency is to improve the services provided in these NRUs by upgrading the centers structurally and functionally. The Government of Malawi, UNICEF and NGO partners also plan to provide appropriate food and systematic treatments that will promote quick recovery and reduce the length of stay in the NRU.
An assessment of 82 NRUs has been completed. This assessment shows that during a normal year, an NRU can admit an average of 19 patients. However, in January 2001 average NRU admissions peaked at 50 children, while six NRUs admitted over 80 children. Nationally, NRUs have the capacity for about 4,500-6000 malnourished children per month. The number of severely malnourished children, based on the past levels of malnutrition, is over 25,000 children in normal years and expected to be up to 40,000 this year.
As these NRUs cannot handle all the cases of severely malnourished children, the need to have an effective supplementary feeding programme to reduce severe malnutrition at community levels cannot be over-emphasized. NRUs and supplementary feeding programmes must also be complemented by a general ration distribution to ensure an adequate food supply at the household level - especially in the areas where high rates of malnutrition and high food deficits have been identified through the food security assessment. In addition the lack of capacity of the Government NRU system will mean that should the situation worsen as expected then additional capacity will have to be made probably supported by International NGO's.