Nutrition & Food Security Surveillance Protocol, Nigeria, 2016

Evaluation and Lessons Learned
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1. Justification

Emergency conditions

The Boko Haram conflict was declared to be a state of emergency at the beginning of 2012 by the government. The impact on freedom of movement, livelihoods, markets, and humanitarian access have resulted in a severe food security and nutrition emergency North East Nigeria, Niger, Chad and Northern Cameroon.

The emergency is currently focused in Borno Yobe and Adamawa states. The insurgency and political violence in these states has caused population displacement, disruption in livelihoods, and acute food insecurity. According to the International Organization of Migration’s (IOM) June 2016 report, there are over 1.4 million, 159,445 and 111,671 internally displaced persons (IDPs) in Borno, Adamawa and Yobe states respectively

The most recent state level estimates of global acute malnutrition from the National Nutrition and Health Survey July to September 2015 found 10.9% (8.6, 13.7 95% CI) in Yobe, 11.5% (8.8, 14.9 95% CI) and in Borno 7.1% (5.0, 10.1 95% CI) in Adamawa. The results were not perfectly representative of Borno as there were inaccessible LGAs at the time of data collection. These conditions were poor but were not among the highest prevalence of GAM in the northern Nigeria. It is likely that there pockets of acute malnutrition at that time but intense political violence prevented humanitarian access.

Since the declaration of the nutrition emergency in April 2016, there have been small scale SMART and EFSA surveys conducted in Jere LGA Borno (April 2016), Jasuko LGA Yobe (May 2016), Gujba & Gulani LGAs Yobe (July 2016), Konduga LGA Borno (July 2016), Mondugo town (August 2016). Most surveys were not fully analysed or written up. The data were available for only two surveys. Digit preference negatively affected data quality for height, weight and MUAC in those data. Insufficient sample size caused mortality estimates to be supressed. Variation in sampling methods and survey implementation complicated comparisons across surveys. These small scale surveys conducted by several partners on an opportunistic basis do not allow a clear picture of conditions to be presented. Also the financial and human resources spent on unsystematic surveys and/or assessments prevents a more rational and effective use of limited emergency resources

Screening data were collected by NGO and UNICEF supported teams in Yobe and Borno states over the past four months (May to August 2016). Data on bilateral edema were also collected at most sites. While bilateral edema is rare in the Sahel, it is common to find about one case at OTP sites with an average of 50 cases across Northern Nigeria. The results of the screening show that the prevalence of SAM is much lower in sites where more exhaustive screening was conducted (over 5,000 children screened). In sites with smaller numbers of children screened the prevalence of SAM and GAM peaked at over 50% and 80%. There are some questions concerning data quality in these areas. It is evident in many of these cases with higher SAM and GAM estimates that the sample is not representative, but probably indicates a number of children who need preventive or treatment of acute malnutrition services.

Many local government areas in Yobe and Borno states are inaccessible due to the Boko Haram crisis. As these areas become accessible or populations are allowed out to join Internally Displaced Persons (IDP) camps, an immediate assessment of the nutrition conditions is needed. In these cases, exhaustive screening with MUAC is critical to identify the severity of conditions and assessment the number of children who need treatment for malnutrition and total number of persons needing emergency services.

There exists no one best method to implement and conduct nutrition surveillance.
Stakeholders correctly lack confidence in most sentinel site surveillance systems. Repeated nutrition surveys are methodologically sound but are not designed to quickly identify specific areas in crisis. Exhaustive screening of children’s MUAC can often suffer from sampling (non-exhaustive data collection) and data quality issues. Screening methods do not allow for assessment of change over time in emergency responses (unless specific planning is made in advance). Data from therapeutic feeding programs is an important source of information, but geographic coverage is not complete and admissions are based on a self-selected population seeking treatment for malnutrition.
In order to both quickly and accurately monitor and respond to the nutrition crisis conditions in the North East of Nigeria, UNICEF will:

  • Conduct repeated surveys every four months on standardized groupings of LGAs representing both emergency affected areas and livelihood zones. The groupings of LGAs represent populations between 750,000 and 2,500,000.

  • Emergency deployments of teams for exhaustive MUAC screening of children from 6-59 months in newly accessible areas and in coordination with Polio Eradication activities in North East Nigeria.

  • Triangulation with real-time CMAM programme and stocks data to ensure that all children diagnosed with SAM are receiving emergency therapeutic care.

Despite difficulties to access many LGAs in Yobe and Borno states, an intense multi-sector emergency response has been mounted since the beginning of 2016 when newly accessible areas were entered by government and humanitarian partners. The emergency response includes establishment of IDP camps, distribution of food and non-food items, WASH interventions, EPI and Polio and nutrition interventions.

The information collected through the nutrition surveillance will be used to improving coverage and quality of emergency lifesaving and sustaining services.