TURKANA SMART SURVEYS PRELIMINARY REPORT 27 th June

TURKANA SMART SURVEYS PRELIMINARY REPORT 27 th June- 9 th July , 2012 Kabura Ndegwa-Nutrition Survey Consultant Nutri. Balance Consultancy Services

1. Background Information Turkana County lies in the Rift valley province in Kenya and is situated in the arid Northwestern region of the country. It is situated in the northwestern region of Kenya, sharing international borders with Ethiopia, Sudan and Uganda and locally with Baringo, West Pokot and Samburu districts. The district has an estimated total population of 855, 399. Turkana County cover an area of 77, 000 km 2 (Turkana District; Kenya National Bureau of Statistics, May 2009). The area has in the recent past been divided into six districts and comprises of seventeen administrative divisions. The larger Turkana district is the second poorest district in Kenya with poverty levels of approximately 20% above the national average. Turkana is constrained by the harsh environment, remoteness coupled with the poor infrastructure and low access to essential services in addition to other underlying causes of poverty that are experienced elsewhere in Kenya. It is classified among the Arid and semi arid lands (ASAL). Turkana consists mostly of low-lying plains with isolated mountains and hill ranges and receives unreliable and erratic rainfall of less than 100 mm annually. The rainfall pattern is unreliable and erratic. There are two rainfall seasons, the long rains occurring between April and July and the short rains between October and November. Warm and hot climate with temperatures ranging between 33◦C and 40◦C characterise the County. Being an ASAL district, Turkana is a drought prone area that experiences frequent, successive and prolonged drought and cattle rustling which leads to heavy losses of lives and livestock. According to Arid land resource management project (ALRMP), the County has four main livelihood zones. Nearly 60% of the population is considered pastoral, 20% agro pastoral, 12% fisher folks and 8% are in the urban/peri-urban formal and informal employments. Turkana district requires continuous surveillance of nutrition situation due to its vulnerability to adverse climatic conditions such as drought and flooding.

Map of Turkana County-Study Area

2. 2. 1 Rationale for conducting the surveys Survey justification The nutrition survey conducted in Dec 2011 showed a decrease in levels of malnutrition for the six districts as compared to the May 2011 results. Despite this significant progress, continued focus on sustaining recovery in Turkana and across the Arid and Semi. Arid Lands will be required if these gains are to be maintained(UNOCHA Horn of Africa Situation Report no. 27, 16 December 2011). In the light of this health and nutrition partners in Turkana propose to conduct nutrition surveys covering the 6 districts in Turkana. The survey will seek to estimate the level of malnutrition among children 6 -59 months and will also estimate the coverage of nutrition programs.

2. 3 Timing of Surveys Start of the short rains Dry Season Jan Feb Mar Apr Start of Long Rains May June July Dry Cool Season Aug Sept Short Rains Oct Nov Dec Increase in quality and quantity of pasture and browse. Increase in milk production. Decrease in number of livestock young. Current surveys took place in the same season as 2011 surveys (April 2011). This makes them comparable (for nutrition surveillance)

2. 2 Overall objective of the survey • Turkana district surveys will be conducted to assess the nutritional status of children 6 -59 months of age. In addition, the survey will seek to establish infant and young child feeding practices among children 0 to 23. 9 months as well the nutritional status of women in the reproduction age (15 -49 years). • This will determine the extent and severity of malnutrition among children aged 6 -59 months and analyze the possible factors contributing to malnutrition such as illnesses, child care practices, water & sanitation and food security and recommend food and non-food interventions • This assessment will constitute a nutrition surveillance system as well as provide information for the ongoing HINI programme.

2. 2 Specific Objectives 1. 2. 3. 4. 5. 6. 7. Determine the prevalence of acute malnutrition among under five year olds children, pregnant and lactating women Estimate coverage of the current High Impact Nutrition interventions in the districts Determine the Infant and Young Child Feeding Practices (IYCF) among children 0 -23 months of age Investigate household food security and food consumption practices. To estimate crude and under-five mortality rates. Estimate morbidity rates of children below five years Determine the proportion of households with access to safe water and sanitation

3. Survey Methodology 3. 1 Survey sampling Two-stage cluster sampling was applied to randomly identify clusters with the probability of being selected proportional to the population size(PPS) in each cluster. All villages that were accessible by road and will be included in the sample selection. Those currently inaccessible(due to insecurity) were excluded from sampling frame. The required sample size was calculated on the nutritional status of children under five for the children 6 -59 months sample, Infant and Young Child (IYCF)feeding practices for the children 0 -23. 9 month sample and on the CMR for the household sample

Summary of parameters considered for sample size calculation & actual outcome of survey below: Survey Turkana Central Actual Sample of of 0 -5. 9 m IYCF Anthropo agemetry group Children # of HH to # of HH for Sample size for anthro. visit mortality considered In each cluster # of househol clusters ds/ cluster 215 426 451 12 595 554 595 16 38 224 541 719 - - - 670 - 37 Turkana South Actual 200 411 439 12 590 319 590 16 38 248 563 704 - - - 647 - 38 Turkana North Actual 197 413 467 595 543 595 16 38 234 498 678 12/13(2 clusters) - - - 666 - 37 212 430 431 12 599 544 599 16 38 220 479 632 - - - 632 - 36 Turkana West Actual [1] Number of households to be visited from anthropometry sample

Turkana Surveys (July 2012)-Plausibility Checks Acceptable Indicator Comments values/range CENTRAL SOUTH NORTH WEST Digit preference - weight <10 6 4 4 5 Excellent Digit preference - height <10 4 10 7 8 Good WHZ ( Standard Deviation) 0. 8 -1. 2 0. 93 1. 02 1. 04 1. 07 Excellent WHZ (Skewness) -1 to +1 0. 09 -0. 09 0. 01 0. 15 Excellent WHZ (Kurtosis) -1 to +1 -0. 10 0. 04 -0. 13 -0. 07 Excellent Percent of flags WFH <3% 1. 5% 1. 1% 1. 5% 2. 4% Excellent Percent of flags HFA <10% 3. 6% 5. 7% 8. 0% 6. 7% Good Percent of flags WFA <5% 0. 8% 1. 1% 1. 4% 2. 8% Excellent Age distribution (%) Group 1 6 -17 mo 20%-25% 29. 3% 32. 4% 27. 8% 28. 3% Problematic (Excess) Group 2 18 -29 mo 20%-25% 25. 6% 24. 7% 24. 9% Group 3 30 -41 mo 20%-25% 22. 0% 24. 7% 20. 2% 1. 24. 5% Skewed Poisson: Acceptable(Upper Limit) Pockets of malnutrition(previously un 25. 8% Acceptable surveyed areas Group 4 42 -53 mo 20%-25% 17. 8% 13. 3% 19. 6% 14. 4% Problematic(Deficient) Group 5 54 -59 mo Around 10% 5. 3% 5. 4% 7. 5% 7. 0% Problematic(Deficient) Age Ratio : G 1+G 2/G 3+G 4+G 5 Around 1. 0 1. 22 1. 31 1. 12 Large ‘Younger’ group Sex Ratio 0. 8 -1. 2 1. 1 1. 2 0. 9 12% 13% 12% Acceptable (Data quality distorted by skewed age ratio) General acceptability 2. Excess of boys

Population Age-Sex pyramids Turkana North 54 -59 42 -53 30 -41 % female % male 18 -29 Age Class Turkana Central 30 -41 % female % male 18 -29 6 -17 -20 -10 0 Percent 10 20 -15 -10 -5 0 Percent 5 10 15 Bottom-heavy pyramids Turkana West 54 -59 42 -53 30 -41 % female % male 18 -29 6 -17 Age Class Turkana South 30 -41 % female % male 18 -29 6 -17 -20 -10 0 Percent 10 20 -10 Less children in older age categories 0 Percent 10 20

Demographic Indicators for Turkana County (From Individual and HH mortality Data): Indicator Total HH Sample Total U 5 Sample Number of persons/HH Number of U 5/HH % of U 5 in the population Male CDR + Design Effect (D. E) Female CDR + Design Effect (D. E) Sex Ratio Joined Left Reason for leaving. Work/School Reason for leaving. Migration/pastoralism Reason for leaving. Instability/Insecurity Reason for leaving. Social/other Turkana Central 4275 972 6. 4 (± 2. 48) 1. 5 (± 0. 67) 22. 7% 2055 0. 89(0. 54 -1. 46) 1. 12 2133 1. 21 (0. 77 -1. 92) 1. 30 0. 96 63 205 51. 0% Turkana South Turkana North Turkana West 3506 1028 5. 4 (± 2. 01) 1. 6 (± 0. 69) 29. 3% 1887 1. 26 (0. 84 -1. 89) 1. 02 1783 0. 62 (0. 33 -1. 17) 1. 11 1. 06 78 324 27. 6% 3164 979 4. 8 (± 2. 28) 1. 5 (± 0. 81) 30. 9% 2007 1. 69 (1. 12 -2. 55) 1. 43 2042 0. 96 (0. 59 -1. 53) 1. 05 0. 98 70 378 24. 1% 3455 864 More than ¼ of population 5. 6 (± 2. 31) is U 5 in al zones 1. 4 (± 0. 83) 25. 0% 1800 1. 76 (1. 07 -2. 89) 1. 77 1941 0. 97 (0. 49 -1. 92) Larger 1. 92 female 0. 93 population linked with 63 high 221 migration 22. 2% 24. 8% 51. 0% 48. 7% 47. 3% 11. 1% 2. 0% 4. 1% 3. 4% 13. 1% 19. 5% 23. 3% 27. 1%

Turkana Survey Zones- Comparison of 2011 and 2012 GAM July 2012: 14. 3% GAM April 2011: 27. 8% SAM July 2012: 2. 1% SAM: April 2011: 6. 0% p-value= 0. 00 GAM July 2012: 15. 3% GAM April 2011: 37. 4% SAM July 2012: 2. 3% SAM: April 2011: 9. 4 p-value= 0. 00 GAM July 2012: 11. 6% GAM April 2011: 24. 4% SAM July 2012: 0. 7% SAM: April 2011: 4. 5% p-value= 0. 00 GAM July 2012: 17. 1% GAM April 2011: 33. 5% SAM July 2012: 4. 2% SAM April : 2011: 6. 8% p-value= 0. 00

Malnutrition and Mortality Rates- Turkana County Wasting (WHO 2006) TURKANA CENTRAL TURKANA SOUTH TURKANA NORTH TURKANA WEST N=704 N=691 N=655 N=615 Global Acute Malnutrition (GAM) 11. 6 % (9. 4 -14. 3 9 ) Severe Acute Malnutrition (SAM) 0. 7 % (0. 3 -1. 7 C. I. ) 4. 2 % (2. 7 - 6. 5) 2. 3 %(1. 3 - 4. 1) 2. 1 % (1. 2 - 3. 7) Crude Death Rate (CDR) 1. 04 (0. 73 -1. 48) 1. 05 (0. 75 -1. 47) 1. 51 (1. 10 -2. 08) 1. 38 (0. 82 -2. 31) Underfive Death Rate (U 5 DR) 1. 27 (0. 71 -2. 26) 0. 98 (0. 49 -1. 93) 1. 78 (1. 16 -2. 73) 1. 18 (0. 36 -3. 80) 17. 1 % (13. 7 - 21. 1) 15. 3 % (11. 7 - 19. 6) 14. 3 % (11. 4 - 17. 9)

Malnutrition and Mortality Rates- Turkana County Sex Boys Girls Turkana Central N=704 Prevalence of global malnutrition (<2 z-score and/or oedema) (57) 15. 7 % (12. 2 - 19. 8 C. I. ) Turkana South Turkana North Turkana West N=691 N=655 N=615 Prevalence of global malnutrition (<2 z-score and/or oedema) (70) 19. 3 % (15. 1 - 24. 3 C. I. ) Prevalence of global malnutrition (<2 z-score and/or oedema) (56) 15. 5 % (11. 7 - 20. 3 C. I. ) (25) 7. 4 % (4. 8 - 11. 2 C. I. ) (48) 14. 6 % (10. 3 - 20. 3 C. I. ) (44) 15. 0 % (10. 0 - 21. 7 C. I. ) Prevalence of global malnutrition (<2 z-score and/or oedema) (46) 15. 8 % (12. 2 - 20. 2 95% C. I. ) (42) 13. 0 % (8. 8 - 18. 7 95% C. I. )

Turkana Central GAM and SAM decrease (Significant)

Malnutrition and Mortality Rates- Turkana County TURKANA CENTRAL TURKANA SOUTH TURKANA NORTH TURKANA WEST N=719 N=701 N=668 N=632 Severe under nutrition 1. 5 %(0. 9 - 2. 7) < 115 mm 2. 1 % (1. 1 - 4. 2) 1. 4% (0. 4 - 2. 6) 1. 9 % (1. 1 - 3. 2) Moderate ≥ 115–<125 mm 5. 6 % (3. 9 - 7. 8) 7. 1 % (5. 1 - 9. 9) 5. 8 % (4. 2 - 8. 1) 6. 0 %(4. 4 - 8. 1) Global Acute Malnutrition ≤ 125 mm 7. 1 % (5. 3 - 9. 5) 9. 3 % (6. 5 - 13. 0) 6. 5 % (4. 4 - 9. 5) 7. 9 % (6. 0 - 10. 4) Prevalence of Acute malnutrition MUAC

Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex Sex Boys Girls Turkana Central N=704 Prevalence of global malnutrition (<2 z-score and/or oedema) (57) 15. 7 % (12. 2 - 19. 8 C. I. ) Turkana South Turkana North Turkana West N=691 N=655 N=615 Prevalence of global malnutrition (<2 z-score and/or oedema) (70) 19. 3 % (15. 1 - 24. 3 C. I. ) Prevalence of global malnutrition (<2 z-score and/or oedema) (56) 15. 5 % (11. 7 - 20. 3 C. I. ) (25) 7. 4 % (4. 8 - 11. 2 C. I. ) (48) 14. 6 % (10. 3 - 20. 3 C. I. ) (44) 15. 0 % (10. 0 - 21. 7 C. I. ) Prevalence of global malnutrition (<2 z-score and/or oedema) (46) 15. 8 % (12. 2 - 20. 2 95% C. I. ) (42) 13. 0 % (8. 8 - 18. 7 95% C. I. ) Chi-square analysis indicates that there is no significant differences between the sexes in 3 surveys. Turkana Central showed a significant difference (p<0. 01) between the male and female sample. This suggests that overall, sex is not a risk factor for malnutrition levels.

Prevalence of acute malnutrition by age, based on weight-for-height zscores and/or oedema Turkana Central Age SAM (months) Turkana South Turkana North Turkana West MAM SAM (8)25. 8% (11)12. 5% (6)28. 6% (17)20. 7% (7)30. 4% MAM 6 -11 (1)9. 1% (15)19. 7% 12 -23 (5)45. 5% (5) 36. 8% (9)29. 0% (28)31. 8% (10)47. 6% (26)31. 7% (4)17. 4% 24 -35 (3)27. 3% (14)18. 4% (4)12. 9% (22)25. 0 % (3)14. 3% (13)15. 9% (3)13. 0% 36 -47 (2) 18. 2% (9) 11. 8% (6)19. 4% (15)17. 0% (2)9. 5% (14)17. 1% (4)17. 4% 48 -59 (0) 0. 0% (10)13. 2% (4)12. 9% (12)13. 6% (0)0. 0% (12)14. 6% (5)21. 7% (8)11. 1% Total (11)100% (76) 100% (31)100% (82)100. 0 % (72)100. 0% (88)100% (21)100. 0 % (23)100. 0 % (10)13. 9 % (28)38. 9 % (15)20. 8 % (11)15. 3% Chi-square analysis indicates that there is a significant difference (p<0. 01) between the younger (6 -23 m) and whole (24 -59) sample. This suggests that infant feeding practices are related to malnutrition levels.

Continued: Differences in GAM/SAM prevelance in younger and older age group GAM Zone SAM 6 -23 m p-value Inference (5)45. 5% >0. 05 Non-significant difference (14)45. 2% >0. 05 Non-significant difference 6 -23 m 24 -59 m Turkana Central (49)55. 7% (39)44. 3% (6)54. 5% Turkana South (56)46. 7% (64)53. 3% Turkana North (60)56. 6% (46)43. 4% (16)76. 2% (5)23. 8% >0. 05 Non-significant difference Turkana West (51)52. 0% (12)52. 2% >0. 05 Non-significant difference (16)54. 8% (47)48. 0% (11)47. 8% 24 -59 m Chi-square analysis indicates that there is no significant difference (p<0. 05) between the younger (6 -23 m) and whole (6 -59) sample. Exception: Turkana North (Younger age group affected more by SAM)

Nutrition Status of caregivers of < 5 year old children: Turkana Central N=509 % Caretakers (41) 8. 2% with MUAC < 21 cm Turkana South N=541 (59) 10. 9% Turkana North N=440 (39) 8. 9% Turkana West N=439 (26) 5. 9% % women (395) 77. 6% pregnant and lactating (447) 82. 0% (377) 84. 3% (367) 83. 4 %

Maternal Nutritional Status - Turkana County Maternal Malnutrition Pregnant and Lactating mothers of U 6 by MUAC: Wasted <21 cm % of female caretakers at risk of malnutrition (MUAC<23. 0) TURKANA CENTRAL TURKANA SOUTH TURKANA NORTH TURKANA WEST N=147 N=157 N=126 N=173 11(7. 5%) 16(10. 2%) 12(9. 5%) 12(6. 9%) 38(25. 9%) 56(35. 7%) 35(27. 8%) 51(29. 5%) Iron Supplementation N=495 N=512 N=445 Iron supplementation among pregnant women 274 (55. 4%) 407(79. 5%) 380(85. 4%) Vast improvement compared to 2011 N=418 289(69. 4%)

Morbidity, immunization and deworming results Child morbidity (6 -59 months old) Prevalence of reported illness Fever /Malaria(alone or in combination with other symptoms) ARIs (cough and cough with difficult breathing) Watery Diarrhoea Bloody Diarrhoea Others (skin/fungal/eye/ear infection; vomiting; boils scabies; bites) Zinc supplementation(Diarrho ea cases) Immunization 6 -59 months old OPV 1 (card and recall) OPV 3 (card and recall) Measles (children ≥ 9 -59 months TURKANA CENTRAL N= 720 (391)54. 3% TURKANA SOUTH N= 704 (321)45. 6% TURKANA NORTH N= 669 (427)63. 8% TURKANA WEST N= 632 (437) 69. 1% 44. 6% 40. 8% 40. 9% 41. 5% 31. 9% 34. 3% 19. 6% 1. 7% 20. 9% 1 unconfirmed 1. 6% case of TB 1. 1% 1. 3% Included 8 suspected cases from one cluster 28. 8% in Kibish. 30. 3% Reporting 16. 2% protocol was 25. 3% followed 2. 2% 2. 5% 13. 0% 4. 4% 66(19%) 78(16. 6%) (109)25. 2% (57) 9. 1% N=752 (688)97. 2% (654)92. 4% (585)91. 2% N= 704 (663)94. 7% (591)91. 2% (553)85. 4% N= 669 N= 632 (596)94. 6% (550)87. 2% (494)85. 5% (650)97. 8% (636)95. 8% (569)89. 5%

Vitamin A Supplementation and deworming results TURKANA CENTRAL TURKANA SOUTH TURKANA NORTH TURKANA WEST Deworming once in the last 6 months(12 -59 months) (180)30. 1% (296)51. 9% (315)54. 0% (316)59. 9% Turkana Central N=719 Vitamin A n=716 supplementation (424) 59. 2% 6 -59 months Once Vitamin A n=109 supplementation (69) 77. 6% 6 -11 months Once Vitamin A n=607 supplement (357) 58. 5% 12 -59 months Turkana South N=704 n=694 (517) 73. 4% Turkana North N=669 n=669 (600) 89. 7% Turkana West N=632 n=632 (529) 83. 7% n=111 (71) 64. 0% n=90 (73) 81. 1% n=103 (72) 69. 9 % n=580 (330) 56. 9% n=578 (224) 38. 8% n=529 (376) 28. 9%

Health and Sanitation Turkana Central N=560 Caretakers n=552 25. 9% washing (143) hands appropriat ely Access to 334 59. 6% safe water sources Access to 55 9. 8% safe (treated) drinking water Access to 106 18. 9% toilet or latrine Turkana South N=538 n=535 35. 1% (188) Turkana North N=489 n=480 60. 6% (291) Turkana West N=478 n=470 56. 0% 263 275 51. 1% 347 71. 0% 263 55. 0% 141 26. 2% 34 7. 0% 46 9. 6% 64 11. 9% 124 25. 5% 72 15. 1%

Meal Frequencies for household members Children 6 -23 months mean number of times/day (Mean SD) Children 24 -59 months mean number of times/day (Mean SD) Other members (> 5 years) mean number of times/day (Mean SD) Number of meals usually consumed (Mean SD) Turkana Central Turkana South Turkana North Turkana West 2. 76 ± 1. 32 2. 48 ± 0. 65 2. 65 ± 0. 80 2. 56 ± 0. 58 1. 58 ± 0. 75 1. 64 ± 0. 74 1. 81 ± 0. 68 1. 58 ± 0. 69 1. 88 ± 0. 74 1. 94 ± 0. 73 1. 72 ± 0. 70

IYCF: Summary of Breastfeeding Practices Initiation of breast feeding: Age Group Turkana Central N=224 Turkana South N=248 Turkana North N=233 Turkana West N=220 Target Comment Currently breastfeeding 0 -5 m (223)99. 6 % (243)98. 0 % (214)91. 8 % (206)93. 7 % >80% Ever breastfed 0 -5 m >80% Given pre-lacteals 0 -5 m within 3 days of birth (220)100 % (212)96. 4 % (40)18. 2 % 0 -5 m (232)99. 6 % (220)94. 4 % (47)20. 2 % Given colostrum (248)100 % (247)99. 6 % (31)12. 5 % >80% (224)100 % (211)94. 2 % (54)24. 1 % n/a Unsatisfactory Early introduction to 0 -5 m complementary foods (12)05. 4 % (11)04. 7 % (32)14. 6 % n/a Unsatisfactory Key Indicator 1 Timely Initiation of Breastfeeding (within 1 hr. ) 0 -5 m (122)54. 5 % (191)77. 0 % (146)62. 7 % (112)50. 9 % >80% Unsatisfactory Key Indicator 2 Exclusive Breastfeeding 0 -5 m (141)62. 9 % 196(79. 0 %) (164)70. 4 % (152)69. 1 % >50% Indicators comparable, but EBF rate improved(2011); Some BF practices poor; Community Strategy(CS) to be launched; Mt. MSG existing- to be up-scaled in community units

IYCF: Summary of Complementary Feeding Practices Age Group Complementary Feeding Practices Key Indicator 5 6 -8 m Introduction to solid and semisolid food Key Indicator 6 6 -59 m Minimum Dietary Diversity Key Indicator 7 6 -59 m Minimum Meal Frequency Children <6 months mean 0 -59 m number of times/day (Mean SD) Children 6 -8. 9 months 6 -9 m mean number of times/day(Mean SD) Children 9 -23. 9 months 9 -23 m mean number of times/day (Mean SD) Turkana Central Turkana South Turkana North Turkana West Target Comment (25)71. 4% (28)75. 6 % (22)64. 0% (21)65. 6% n/a (104)57. 6 (83)42. 8 % % (56)20. 0% (62)28. 2 % 1. 92( 1. 55( SD± 1. 9) (91)53. 9% (95)52. 8% >80% Unsatisfactory (58)19. 1% (63)26. 7% >80% Unsatisfactory 2. 03( SD± 1. 7) 1. 27( SD± 1. 8) 0 Unsatisfactory 3. 02( SD± 1. 6) 3. 46( SD± 1. 7) 3. 18( SD± 1. 9) 2. 98( SD± 1. 8) 3 -5 Unsatisfactory 2. 64( SD± 1. 7) 1. 96( SD± 1. 4) 2. 59( SD± 1. 7) 2. 30( SD± 1. 5) 4 -5 Unsatisfactory DD and frequency static from 2011; DD impacts on nutrition status of U 24 months particularly. Agropastoral zone has introduced new species(traditional vegs; legumes; fruits- but utilization is not known (Mo. A). Mt. MSG scale-up may have an impact.

Programme type Coverage of feeding programs Turkana Central Turkana South Turkana North Turkana West Comments Supplementa Registered = 5 ry feeding Referred =70 programme 6. 7% coverage (SFP) coverage Registered = 35 Registered = 87 Registered = 49 Low except T. North Referred = 78 Referred = 85 Referred = 56 Use of MUAC for 31. 0% 50. 6% 46. 7% Therapeutic Registered = 13 feeding Referred = 10 programme 56. 5% coverage (OTP) coverage Registered = 11 Registered = 14 Registered = 17 Low Referred = 19 Referred = 17 Referred = 18 except T. Central Use of MUAC for 36. 7% 45. 2% 48. 6% field case-finding Use of WHO-GS and MUAC as admission criteria at HCs field case-finding Use of WHO-GS and MUAC as admission criteria Calculated using direct method (SPHERE) to estimate PERIOD PREVALENCE Lower coverage than Sphere recommendations for rural area coverage (>50%)

Prevalence of Malnutrition Contextual Factors: Trend analysis shows that there has been no significant difference in GAM/SAM reported for Turkana County since December 2011, taking into consideration seasonality: Four surveys were carried out in 2011, in Turkana The Dec 2011 and July 2012 surveys show no significant difference (overlapping confidence intervals and 2011 comparison with two survey calculator (CDC) also indicates a non-significant difference (p=0. 362), with current survey. However, there is a significant difference, in all zones, with May 2011 survey Sharp increase of malaria incidence Children who have recently recovered (MAM and SAM) are likely to relapse when the water and food security situation deteriorates because the effect of the ongoing hazards is likely to further lower the resilience of vulnerable groups. Age-verification; over-reporting of illness is major challenge in the survey, despite specifying illness over the preceding 15 -day period.

Prevalence of Malnutrition Contextual Factors: Nutrition surveillance data in Turkana since 2011 indicate CRM has consistently exceeded emergency levels (1. 0 CMR). This has been exacerbated by increasing insecurity. Poisson distribution WHZ -2, showed a slight significant difference (p=0. 000) in cluster heterogeneity which matched the clusters/villages in North zone that have never previously been surveyed, and had high rate of malnutrition. The statistical analysis of surveyed children (plausibility test) and graphical data below shows that there was a significant difference in age distribution (p=0. 000), which suggests that there are currently less children in some age groups than expected. This may be indicative of: 1. incorrect age given and/or the impact of migration of younger children 0 -24 months, due to insecurity. 2. Older children not being present during the survey day because of pre-school attendance

Factors linked to Malnutrition in the Survey Area Indicators used Interpretation Malnutrition Children WHZ <-2 SD Critical Caretakers MUAC <23. 0 cm High Meal/day Low Food diversity Low Child milk consumption Lower Crude mortality rate Emergency Under five mortality rate Emergency Morbidity-High prevalence of Malaria, ARIs and Diarrhoea High Relief food distribution i-June 2012 BSFP Cycle 5 - ended in April 2012 None Milk availability Lower than past months Pastoralist Purchasing power Agropastoral- Reduced harvests Fisheries- Markets migrated from Todonyang Casual Labour- Higher food prices Income source Decreased Livestock asset base Fair/Good Coping strategies Poor Sanitation Poor Immediate causes Food intake Diseases Underlying causes Current Household Food Security Health/Water/Sanitation Inadequate Vit. supplementation/Deworming Access to safe water Health services/personnel/drugs A Shifted to temporary sources Poor Medium/Low Inadequate

Factors linked to Malnutrition in the Survey Area Indicators used Interpretation Malnutrition Children WHZ <-2 SD Critical Caretakers MUAC <23. 0 cm High Iron Supplementation for pregnant women Zinc Supplementation for diarrhoea Poor Appropriate Handwashing practice Poor Deworming for 12 -59 m Poor Prelacteals Poor Early introduction of complementary foods Timely initiation of breastfeeding Poor HINI Implementation Poor Underlying causes Social Care Practices Poor Health/Water/Sanitation Poor Vaccination coverage Satisfactory Utilization of safe (treated) water Medium/Low Water quantities/person Inadequate

Conclusion • With deteriorating NS indicators and estimated programme coverage(SFP and OTP) seemingly inadequate, further investigation is warranted through a coverage survey to determine specific causal factors and areas for IMAM programme implementation improvement • Coverage for Vitamin A supplementation was relatively low with most of the children having received vitamin A only once. • Under five illnesses are high, and fever rate indicative of malarial outbreak. Morbidity and malnutrition rates likely to increase with depletion of water levels from safe sources • Sub-optimal hand-washing practices, poor sanitation practices and minimal treatment of unsafe drinking water at the household level • Household food DD & security low due to increasing food prices and drought. • A prevailing food deficit situation that is set to deteriorate further, pending the performance of the short rains

Recommendations (draft) Summary of the analysis/conclusion Recommendations Short term 1 GAM: Serious (critical in T. South) ; SAM: High(emergency in T. South) and programme coverage suboptimal, in all zones • • • 2 Low micronutrient and deworming coverage • • • 3 IYCF practices sub-optimal- Good EBF but early weaning, • By Long term strengthen outreach health facilities and community and satellite services, and maintain IMAM-trained CHW and community volunteers, with priority in locations with low HC coverage. Establishment of C. Us to cover all zones of the county Pa ag W UN an M M strengthen outreach health facilities and community and satellite services, and maintain IMAM-trained CHW and community volunteers Strengthen the mobile clinics and community strategy components Pa ag U an M M Continuous MUAC screening for active case-finding Strengthen therapeutic targeted interventions SFP and OTP Establish regular nutrition surveillance through nutrition surveys- at both seasonal periods (April & Dec) Supporting and Strengthening community strategy OTP (U 5 and PLW) should be linked to GFD to reduce the likelihood of relapse Coverage surveys to verify coverage of IMAM services as well as barriers/boosters • Ensure distribution during vaccination and outreach campaigns and concurrent recording in EPI cards Additional distribution through ECD and during school feeding programs Strengthen HINI interventions including maternal micronutrient supplementation during pregnancy (iron and folate), ensuring ORS/zinc support • Strengthening facility and community level care for pregnant women and lactating mothers for delivery of key • Mt. MSG, BFHIa nd CS and Malezi Bora as well as outreach efforts should • • Pa ag

Recommendations (Draft) Summary of the analysis/conclusion Recommendations Short term Long term 4 Child Morbidity(45 -69%) found to significantly affect nutritional status • Strengthen integrated outreach component- primarily focusing on regular medical outreach camps/mobile clinic to improve access by the nomadic and remote populations. • Advocacy for use and treatment of ITNs by all family members • Prescription of zinc sulphate, with ORS for all diarrhoeal episodes, with concurrent recording, for monitoring purposes • 5 Sub-optimal hand-washing practices and minimal treatment of unsafe drinking water at the household level • 6 Household food DD & security low due to • • • strengthen outreach health facilities and community and satellite services Supporting and Strengthening C. S. with establishment of C. U. Standardization of zinc reporting By who? Mo. PHS HINI interventions-critical hygiene messages Advocacy/public health campaigns on domestic water treatment such as boiling of drinking water and use of purification chemical to minimise risks of water-borne diseases, should be carried out. • Provision of water purification chemicals for water treatment at Household level Partner agencies, UNICE F and MOPHS /MOMS all HH with recently-discharged SFP children should be targeted for GFD, to buffer household food • Focus on programmes by relevant actors that improve and sustain ARLMP/ DSG/G

Recommendations (Draft) Summary of the analysis/conclusion Recommendations Short term 7 An anticipated food deficit situation that is set to deteriorate further before the onset of long rains • 8 Poor Sanitation practices • • • By who? Long term upscale the food aid targets as recommended by DSG assessment use of CSB Plus to ensure optimal micronutrient fortified foods for young children. Livelihoods programmes like FFA and HSNP should continue to strengthen sustainable coping • Implementation of drought preparedness strategies • Building of alternative and sustainable livelihoods to enhance resilience to drought, with a focus on gender empowerment should be encouraged. • Improve road infrastructure WFP; Partner agencies; ARLMP/D SG/GOK Increase support for WASH programs in the rural and semi- urban centers e. g Use of toilet facilities, personal and environmental sanitation. • Focus on KAP studies around WASH issues Partner agencies, UNICEF and MOPHS/M OMS

Lessons Learnt: Training: Coordinated; Joint practical exercises; assessment of use of calendar of events; modified standardization Questionnaires: Use of HH and summary mortality; Addition of ‘reason for leaving column(triangulation of causal factors); Cluster sheets; Data Collection: Migrated clusters surveyed in current location; Enhanced and cumulative calendar of events (multi-sectoral-initiate at KNBS office) Data Entry: Individual mortality (advantages) Capacity-building: ENA Clinic for Supervisors Overall(Turkana Surveys): Strong survey planning committee; Supervision of surveys (Min. 2 supervisors daily- each survey)

Acknowledgments The Turkana District Health Management Team for taking the lead in implementation of the nutrition survey, UNICEF KCO for technical and financial support The District Nutritionists for Turkana Central, South, North East and North West for taking an active role in planning the survey, training enumerators, supervising data collection and entry and lastly reporting and dissemination of results. Partner Support: MERLIN; IRC; WORLD VISION; APHIA PLUS IMARISHA The MOPHS(Survey Planning Committee) and DNTF for their invaluable support during survey preparations as well as the actual surveillance implementation The team members (Enumerators, team leaders and Coordinators) involved in ensuring the survey obtained good quality data; not forgetting the drivers who efficiently facilitated teams’ movement to the various locations The parents and caretakers for providing valuable information by patiently providing their time to be interviewed and allowing their children to be measured.