Ministry of Public Health

General Directorate of Preventive Medicine

Public Nutrition Department

AUGUST 2016

ISSUE 5

Afghanistan National Nutrition

Surveillance System Bulletin

In March 2013 the Ministry of Public Health,

WHO and UNICEF began operationalizing a

sentinel site-based national nutrition surveillance

system (NNSS) in Afghanistan in coordination

and partnership with the Basic Package of Health

Services (BPHS) and the Essential Package of

Hospital Services (EPHS) implementers and other

service providers. Funded by the Global Affairs

Canada (GAC), the project seeks to establish a

sentinel site-based nutrition surveillance system

that covers all 34 provinces of the country. A well

-functioning nutrition surveillance system pro-

vides timely and reliable information which helps

the government and partners to effectively plan

and implement maternal, neonatal and child

health and nutrition programs. Ultimately, the

system seeks to increase access to equitable and

gender-sensitive health and nutrition services to

mothers and children, while ensuring that their

health needs are met and vulnerabilities reduced.

Key NNSS Objectives and Expected Outcomes:

Progress to date:

175 facility-based senti-

nel sites and 953 com-

munity-based sentinel

sites selected in all 34

provinces

34 provinces are re-

porting from health

facility sentinel sites

21 provinces are re-

porting from 102 health

facilities and 408 com-

munity sentinel sites

NNSS has been expand-

ed to all 34 provinces

Background:

Objective >>>

To establish a unified

nutrition surveillance

system composed of

sentinel sites and sur-

veys for timely action.

408 NNSS community sentinel sites are reporting

174 NNSS health facility sentinel sites are reporting

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PAGE 2 ISSUE 5 AFGHANISTAN NATIONAL NUTRITION SURVEILLANCE SYSTEM BULLETIN

1. Anthropometric Analysis Results (analyzed using ENA database and WHO-flags)

General Analysis of Key Indicators –GAM,

SAM and Underweight

All anthropometric indicators were high com-

pared to WHO thresholds.

Global Acute Malnutrition (GAM) proportion were

Q2-21%, Q3-26.9% Q4-21.1%, Q 1, 2016-20.2% and

Q2, 2016-21%

Severe Acute Malnutrition (SAM) proportion was

9.6% in Q2-2015, and 8.4% in Q2 2016.

Underweight Proportion was reported at Q2-37.6%,

Q3-45.1% and Q4-40.2%, Q1,2016-40.7% and

Q2,2016-41.9%

The Afghanistan National Sentinel based Nutrition surveillance system has con-

tinued to collect data from 174 health facilities and 408 community sites. Commu-

nity reporting have slightly improved with a total of 21 provinces reporting in

quarter 2, up from 17 provinces in quarter 2 in 2016. Efforts to improve the quali-

ty of data have continued, including joint support visits to sentinel sites and intro-

ducing data quality assurance processes for the team. The general trends from

health facility and community data show consistent malnutrition levels, implying

possible high levels of acute and malnutrition levels in the population that need

further investigation through in-depth surveys. Generally the results were show-

ing similar trends to those of quarter 2 in 2015.

Results from Health Facility-based Data:

Overview of the Health and Community-based Nutrition Surveillance System

Photo

21

26.9

21.1 20.221

9.6 12.98.8 8

8.4

37.6 45.140.2 40.7

41.9

0

5

10

15

20

25

30

35

40

45

50

Q2,2015 Q3,2015 Q4,2015 Q1,2016 Q2,2016

Malnutrition Indicators

GAM % SAM% Underweight (%)

Child receiving treatment at a therapeutic feeding unit in Bamyan Provincial Hospital. Photo: MoPH/

B. Qureshi

PAGE 3 ISSUE 5 AFGHANISTAN NATIONAL NUTRITION SURVEILLANCE SYSTEM BULLETIN

Anthropometric results - National health-facility data:

Wasting in children is an indicator of acute malnutrition.

GAM levels for 2015 and 2016 were consistently in the

“emergency levels” (above 15%) which increases the risk

of death for children. Severe acute malnutrition was con-

sistently above emergency levels (above 2%) during the

last five quarters.

SAM levels were lower in the 2nd quarter of 2016. (8.4%)

as compared to the last year same quarter (Q2,2016) .

Underweight:

Underweight in children indicates acute weight loss, stunt-

ing, or both. The underweight levels for 2015 and 2016

were consistently in the “very high prevalence” levels

(above 30%). Children who suffer from underweight are

at greater risk of death.

Key Successes:

174 health facility sentinel sites (99.4%) from 34 provinces have reported in the 2nd

quarter of 2016

408 community sentinel sites (46%) from 21 provinces reported during the 2nd quar-

ter 2016

Four quarterly nutrition surveillance bulletins released and disseminated to date

NNSS data used in informing in-depth study of Herat province

NNSS data used as a

source in justification

of mobilizing resources for CHF funding

NNSS data analyzed on provincial level and the results

are shared with the stakeholders

Photo

21

26.9

21.120.2 21

9.612.9

8.88 8.4

0

10

20

30

Q2,2015 Q3,2015 Q4,2015 Q1,2016 Q2,2016

National GAM and SAM Trends 2015-2016

GAM % SAM%

37.6

45.1

40.2

40.741.9

32

34

36

38

40

42

44

46

Q2,2015 Q3,2015 Q4,2015 Q1,2016 Q2,2016

National Underweight trends 2015-16

Underweight (%)

A child is examined at a health facility sentinel site in Nuristan province. Photo: MOPH/Dr. Amin

MUAC measurement in Daikundi. Photo: MOPH/Dr. Noor

A child is treated for malnutrition at a therapeutic feeding unit in Parwan. Photo: WHO/S.Ramo

AFGHANISTAN NUTRITION SURVEILLANCE SYSTEM BULLETIN

PAGE 4 ISSUE 5

Regional Comparison of GAM and SAM Levels

The Southern Region reported the highest level of GAM (25.5%) during 2nd Q, 2016 as well, whilst the lowest level was reported in

the Northern Region (16.4%) this quarter as well. The Western, Northern and Southern Regions showed decline in GAM proportion

during 2nd quarter 2016 as compared to the first quarter 2016, whilst the Eastern and Central Regions showed an increased level of

GAM during 2nd quarter of 2016 as compared to the first quarter 2016.

The Southern Region reported the highest level of SAM (13..7%) during 2nd Q, 2016 as well, whilst the lowest level was reported

from the Northern Region (6.2%) this quarter . The Western Region showed a decline in SAM proportion during 2nd quarter 2016 as

compared to the first quarter 2016, whilst all other regions showed an increased level of GAM during 2nd quarter 2016 as compared

to the first quarter 2016. Efforts have been made to ensure complementarity of nutrition information systems where the health and

community-based system informs areas for in-depth surveys.

1526 STAFF FROM HEALTH FACILITIES AND 2613

STAFF FROM COMMUNITY-BASED SENTINEL

SITES, INCLUDING 2446 COMMUNITY HEALTH

WORKERS AND 167 COMMUNITY HEALTH

SUPERVISORS HAVE BEEN TRAINED ON THE

NUTRITION SURVEILLANCE SYSTEM TO DATE

Photo

Photo

Monitoring visit to sentinel site at Daikundi district hospital. Photo: MOPH/Dr. Noor

On-the-job training at a health facility sentinel site at Meramor District Hospital focusing on ante-natal and delivery data regis-

tration. Photo: MOPH/Dr. Noor

Refresher training for health facility sentinel site staff at the Nangarhar provincial hospital Photo: MOPH/Dr. Amin

Regional Analysis of NNSS

The results for provinces in the Western, Central, South-

ern, Eastern and Northern Regions have been reported by

health facility sentinel sites during the first and second

quarter of 2016. The results included GAM, SAM and un-

derweight levels. The provincial and regional analysis start-

ed last quarter and the results of the mentioned indicators

have been compared with the 1st quarter of 2016. Reports

were received from health facilities in all provinces during

this quarter.

AFGHANISTAN NUTRITION SURVEILLANCE SYSTEM BULLETIN PAGE 5 ISSUE 5

27 26.9

11

32

22.729.3

11.5

28.3

Hirat Badghis Farah Ghor

GAM % West Region

Q1,2016 Q2,2016

14.2

8.9

5

16.5

12.610.9

5.1

11.4

Hirat Badghis Farah Ghor

SAM % West Region

Q1,2016 Q2,2016

35.5 37.4

22

59.1

41.848.4 44.4

57.4

Hirat Badghis Farah Ghor

Underweight % West Region

Q1,2016 Q2,2016

16.411.9

20.4 20.2

33.6

14.3 15.419.4

Nangarhar Kunar Laghman Nuristan

GAM % East Region

Q1,2016 Q2,2016

4.93.1 3.5

7.8

14.6

4.4 4.77.3

Nangarhar Kunar Laghman Nuristan

SAM% East Region

Q1,2016 Q2,2016

36.1 37.1 32.9

51.157.5

40.1

23.5

40.5

Nangarhar Kunar Laghman Nuristan

Underweight % E.Region

Q1,2016 Q2,2016

Photo

Anthropometric measurement at a health facility sentinel site in Nuristan. Photo: MOPH/Dr. Amin

PAGE 6 ISSUE 5 AFGHANISTAN NUTRITION SURVEILLANCE SYSTEM BULLETIN

8.6 8.1

11.414

23

10.9

24.4

0

31.5

12.4

20.2

16.113.3

8.5

12.7 13.4

16.9

34.1

GAM % North Region

Q1,2016 Q2,2016

3.9

1.7

7.7

3.5

6.14.8

3.7

13

4.3

7.2 7.6

4.5 4.73.8 3.6

8.1

12.2

SAM % N-Region

Q1,2016 Q2,2016

12.6

3.5

13

30.936

20.524.1

0

27.8

19.5

31.138.8

24.6

16

2719.3 20.5

49.3

Underweight % N-Region

Q1,2016 Q2,2016

17.9 18.9

30.1 3234.1

21.618.2

22.626.9

38.3

Kandahar Urozgan Nimroz Helmand Zabul

GAM % South Region

Q1,2016 Q2,2016

7.6 8

18.316.2

14.711.3

9.58

12

27.5

Kandahar Urozgan Nimroz Helmand Zabul

SAM% S-Region

Q1,2016 Q2,2016

54 56.1

39

73.281.1

53.8 60

31.5

71.9 66.9

Kandahar Urozgan Nimroz Helmand Zabul

Underweight % S-Region

Q1,2016 Q2,2016

Photo

Photo

MUAC measurement at a community site in Bamyan. Surveillance recording tools at a health facility sentinel site in Bamyan. Photos: MOPH/Dr. Noor

Acute Malnutrition (Community-based data):

The results below were from community-based sentinel sites (HPs) which were reported from 21 provinces. During the first and second quarters of 2016, GAM was reported at 29.7%, 31.1% and SAM at 8.4% and 10%, respectively. Both GAM % and SAM% have increased compared to the first quarter of 2016.

PAGE 7 ISSUE 5 AFGHANISTAN NUTRITION SURVEILLANCE SYSTEM BULLETIN

11.3

17.919.4 19

23.519.7

29.8

3.1

18.120.9 22

37.5

28.5

16.2

20.117.2

24.5

20.9

31.4

21.7

16.6

23.320.2

37.8

GAM % Central-RegionQ1,2016 Q2,2016

6.3 5.9 6.55.1

7.7 7.8

13.8

0.8

5.5 6.1

9.2

18.8

12.9

4.22.3

6.3

8.2

8.2

11 10.5

7 7.96.6

18.2

SAM % C-Region

Q1,2016 Q2,2016

43.1

27.2

54.738.7

38.344.1

52.6

3.5

43.7

34

48.9

29.437.6 37.1

65.4

40.141.6

30.4

49

28.2 32.8

38.3

64.9

47.7

Underweight % C-Region

Q1,2016 Q2,2016

29.7

8.4

31.1

10

GAM % SAM%

GAM & SAM Levels (MUAC)

Q1,2016 Q2,2016

Photo

Visit of community surveillance site in Samangan

AFGHANISTAN NUTRITION SURVEILLANCE SYSTEM BULLETIN PAGE 8 ISSUE 5

Infant and Young Child Feeding (IYCF) Good IYCF practices play an important role in preventing

acute malnutrition

Early initiation of breastfeeding decreases neonatal mortal-ity

55% of infants received breast milk within one hour of birth

89% of infants were exclusively breastfed during their first six months of life

Proper complementary feeding (introduction of complementary foods at 6 months, minimum meal frequency and minimum dietary diversity) is still at a low level at 20%.

92% of assessed children under the age of 2 years were breastfed

Results related to IYCF INDICATORS (National Level) Q2,2015 Q2,2016

Total number of assessed children 8,958 24,533

Currently Breastfed

% of <2 children with continued breast feeding 89% 92%

Early initiation

of BF

Early. BF at <=1 hour (%) 54% 55%

Early. BF at 1 to < 24 hour (%) 44% 45%

Early. BF at >24 hour (%) 2% 0%

Exclusive BF Exclusive BF 0-5 m (%) 83% 89%

Complementary feeding

Proper Comp. Feeding (%) 16% 20%

Photo

Anthropometric measurement at a Daikundi district hospital. Photo: MOPH/Dr. Noor

AFGHANISTAN NUTRITION SURVEILLANCE SYSTEM BULLETIN ISSUE 5

Birth Outcomes

Low Birth Weight:

The proportion of babies born with low birth weight was at 6% during the 2nd quarter of 2016. Low birth weight (< 2500 gr) is an important factor affecting neonatal mortality and a significant determinant of post neonatal mortality. Low birth weight infants who survive are at an increased risk of health problems ranging from neuro-developmental disabilities to respiratory disorders.

Neural Tube Defects (NTD):

The NTD rate per 10,000 births was 10 during the 2nd quarter of 2016 . NTDs (Anencephaly, Spina Bifida and encepha-

locel) have a strong association with folic acid deficiency.

PAGE 9

Result of indicators related to birth Outcome Q2, 2015 Q2, 2016

Number of assessed children 20,115 53,980

Sex

Total Male 10,785 28,636

Total Female 9,330 25,344

Male/Female Ratio 1.15 1.12

Birth weight

Stillbirths per 1,000 births (Birth Status) 9 14

Mean weight (gr) 3,239 3,244

Percentage of birth weight less than 2500 gr 4% 6%

Percentage of birth weight between 2500 - 4000 gr 92% 89%

Percentage of birth weight more than 4000 gr 4% 5%

Neural Tube Defect (NTD)

Prevalence of NTD per 10,000 births 12 10

Photo

Photo

Weighing scale at a delivery room in Samangan A child is brought in for growth monitoring at a health facility in Daikundi Photo: MoPH/Noor

Results of Hemoglobin Levels in Pregnant Women

The proportion of pregnant women with hemoglobin level < 11 gr/dl was 26% in the 2nd quarter 2016.

The proportion of women with Hb<11 gdl (have pregnancy age =< 12 weeks) was reported 26% in the 2nd

quarter

The proportion of women with Hb<11 gdl in the second and third trimesters was 26% and 28%, respectively

CONTACT:

Dr. M. Homayoun Ludin Acting Director of Public Nutrition Department, MoPH Email: nutrition.moph@gmail.com Mobile: 0093 700 604 649

Dr. Abdul Baseer Qureshi National Nutrition Surveillance Consultant, PND, MoPH Email: abaseerq@yahoo.com Mobile: 0093 786 56 1156

Web:

http://nutritionmoph.gov.af

Facebook:

Ministry of Public Health

Afghanistan

PAGE 10 AFGHANISTAN NUTRITION SURVEILLANCE SYSTEM BULLETIN ISSUE 5

Anaemia:

A low hemoglobin (Hb) level is an indication of anaemia. The anaemia levels of 26% for 2nd quarter of 2016 were con-

sistently in the “moderate” levels (≥20% - <40%),. Anaemia is associated with increased risks of maternal and child mor-

tality.

Results of hemoglobin levels in pregnant women during first antenatal care (ANC) visit

Q2-2015 Q2-2016

Total assessment 7,747 32,499

Hb level

Percentage of pregnant women with Hb level < 11 gr/dl 40% 26%

Percentage of pregnant women (have pregnancy age =< 12 weeks) with Hb level < 11 gr/dl

41% 22%

Percentage of pregnant women (have pregnancy age 12 to < 24 weeks) with Hb level < 11 gr/dl

41% 26%

Percentage of pregnant women (have pregnancy age >24 weeks) with Hb level < 11 gr/dl

40% 28%