Côte d’Ivoire faces the double burden of malnutrition characterised by both the persistence of undernutrition and the accentuation of over nutrition. It has made the fight against malnutrition a national priority. The objective of our study is to make an acute malnutrition situation analysis in the health districts of Côte d’Ivoire from 2016 to 2018 and to assess the impact of the actions carried out on the data collected in all the health structures. We collected malnutrition data by extracting them from the General Information System. Examination of the monthly distribution of Wasting; cases, shows two peaks (November 2016 and July 2017) mainly concern the north. Incidence of Wasting; among children under 5 years of age was 0.18% in 2016, 0.68% in 2017, and 0.48% in 2018. This incidence is higher in the North compared to the other zones and decreases over time. However, with regard to the incidence of Severe Wasting; with complications, it is higher at the centre (0.09% vs. 0.06% in 2017 and 0.07% vs. 0.02%). The impact of the actions carried out has been manifested by a decrease of Wasting; cases in the north. However all indications are that we are in a situation of under-reporting.

Abbreviations: AC: Arm Circumference ; CNN: National Nutrition Council (Conseil National de Nutrition) ; FETP: Field Epidemiology Training Programme; MICS: Multiple Indicator Cluster Surveys; MUAC: Mid-upper Arm Circumference Measure; SDGs: Sustainable Development Goals; W/H: Weight/Height ratio; DHIS2: District Health Information Software 2

Malnutrition, in all its forms, includes undernutrition (Wasting;, stunting, underweight), inadequate vitamins or minerals, overweight, obesity, and resulting diet-related noncommunicable diseases. In 2014, approximately 462 million adults worldwide were underweight, while 1.9 billion were either overweight or obese.

In 2016, an estimated 155 million children under the age of 5 years were suffering from stunting, while 41 million were overweight or obese. Around 45% of deaths among children under 5 years of age are linked to undernutrition. These mostly occur in low- and middle-income countries. At the same time, in these same countries, rates of childhood overweight and obesity are rising.

The developmental, economic, social, and medical impacts of the global burden of malnutrition are serious and lasting, for individuals and their families, for communities and for countries. [1] Undernourishment of women and children remains the underlying cause of 3.5 million deaths worldwide. There are 23 African countries among the 40 countries in which the prevalence of stunting is 40% or more.

There are few other challenges facing the global community today that match the magnitude of malnutrition, a health problem that directly affects one in three people. [2] There are two main forms of malnutrition resulting from nutritional deficiencies: acute malnutrition (Wasting;) and chronic malnutrition. Wasting; can be detected when assessing the weight-for-height ratio.

Côte d’ivoire faces the double burden of malnutrition characterised by both the persistence of undernutrition and the accentuation of overnutrition. In 2012, Severe Wasting; affected 7.5% of children under 5 years old [3]. However, this prevalence has been stabilized below the alert threshold (10%) in the regions concerned by nutritional emergency in the Great North region ("Grand Nord"). This situation remains fragile and requires increased monitoring. Many children continue to be born with low birth weight, particularly those in the group of teenage mothers who are themselves an at-risk population. In 2012, it was estimated that 14% of children were born weighing less than 2,500 grams. [3].

In June 2013, Côte d'Ivoire joined the global movement SUN (Scaling up Nutrition) based on the principle of the right to food and good nutrition for all. It has made the fight against malnutrition a national priority, demonstrating its commitment to the recommendations of the November 2014 ICN2 in Rome through the creation of the National Council for Nutrition ("Conseil National pour la Nutrition", CNN) in 2014 [4]. In 2015, like all member countries of the United Nations, Côte d'Ivoire adopted the sustainable development goals (SDGs), of which SDG 2 is: " End hunger, achieve food security and improved nutrition and promote sustainable agriculture". The objective of our study is to make an acute malnutrition situation analysis in the 83 health districts of Côte d’ivoire from January 2016 to November 2018 and to assess the impact of the actions carried out on the data collected in all the country's health structures.

Our study was carried out from November to December 2018 at the National Institute of Public Hygiene ("Institut National d'Hygiène Publique", INHP) with the collaboration of the National Nutrition Programme ("Programme National de Nutrition", PNN).

We collected malnutrition data on the 83 health districts, spread across the 20 health regions of Côte d’ivoire by extracting them from the General Information System ("Système d'Information General", SIG) via the DHIS2 software.

The study period covered January 2016 to November 2018. The variables studied are: low birth weight (< 2500g), Wasting;, Severe Wasting; and Severe Wasting; with complications. Diagnostic criteria for Wasting; and Severe Wasting; were either weight/height ratio (W/H) expressed in z-scores or arm circumference-for-age (AC).

 Wasting; is defined as:

• the W/H z-score (weight/height ratio expressed in z-score): between -2 and -3 units of standard deviation (
• the AC (arm circumference-for-age) :

Severe Wasting; is defined as:

• the W/H z-score (weight/height ratio expressed in z-score): less than -3 units of standard deviation (
• The AC (arm circumference-for-age) : 

The presence of bilateral oedema of the lower limbs always corresponds to Severe Wasting; regardless of the W/H index and the AC.

Data analysis was performed using the EXCELL spreadsheet. To facilitate the analysis of the data, we have subdivided Côte d'Ivoire into 3 geographical zones, according to climate, granting some similarity at the level of each zone, in terms of food availability (figure 1).

Zone 1, in the south corresponds to the forest region, the basic landscape, consisting of dense forests, globally subdivided into hygrophilic and mesophilic forests, originally occupies one third of the territory in the south and west. Small mangroves also exist on the coast [5]. It includes the economic capital of the country, Abidjan. Zone 2 in the centre consists of open forests or wooded savannah and includes the political capital. Zone 3, to the north is made up of large savannahs with thick grasses and resistant shrubs with increasingly marked Sahelian trends [6]. Each Zone contained more or less 7 health regions. The list of regions corresponding to the different zones is given in Table I.

The prevalence of low birth weight (calculated as the ratio of the number of births below 2500g to the number of live births) has declined over the years; from 7.65% in 2016 to 5.96% in 2018 in the country as a whole. This trend was observed in each of the zones, but the northern zone has consistently shown the highest prevalence (Table II).

Examination of the monthly distribution of moderate and Severe Wasting; cases, all zones combined, shows two peaks, the largest of which, in July 2017, is of more than 5,500 cases (Figure 2). The distribution of Wasting; and Severe Wasting; data cases are parallel with each other; Wasting; cases being about twice as numerous as Severe Wasting; cases.

The analysis of malnutrition data by geographical zone reveals that the malnutrition peaks mainly concern zone 3 (figures 3 and 4), i.e. the north. We also note a peak in Severe Wasting; cases in July 2017 in the centre of the country (Figure 4).

During 2018, no peak in Wasting; cases was observed in zone 3, with a lower trend than in zones 1 and 2. An examination of Zone 1 data shows a late start of notification activities, starting only in December 2016 (Figure 3). A peak of Severe Wasting; cases was observed in April 2018. (Figure 4).

Incidence of Wasting; among children under 5 years of age in Côte d'Ivoire was 0.18% in 2016, 0.68% in 2017, and 0.48% in 2018 This incidence is higher in the North (Zone 3) compared to the other zones and decreases over time. However, with regard to the incidence of Severe Wasting; with complications, it is higher at the centre (0.09 vs. 0.06 in 2017 and 0.07 vs. 0.02).

The National Multisectoral Nutrition Plan (PNMN) 2016-2020 was developed and adopted in 2016.  Global targets include reducing the low birth weight rate to 12% (14.8% of births in 2012) and reducing Wasting; to 5%. [7]

 However, we have noted that the prevalence of low birth weight observed from the general information system data in 2016 (7.65%) is much lower than the rate obtained in the last MICS 2016 survey (17%). [8]. This discrepancy could be explained more by poor sampling in the MICS 2016 survey than by a reporting problem. Indeed, after extracting the data, we were able to observe that low birth weight was the only data variable that was systematically and regularly reported in all the health districts, without exception. However, under-notification cannot be ruled out.

It is from June 2016 that Wasting; and Severe Wasting; data start to appear in the general information system. This corresponds to the end of the training of the first cohort of health professionals in field epidemiology, FETP-frontline [9]. We attribute the impetus of the reporting activities to this training.  This is confirmed by the late appearance of malnutrition data in zone 1; from December 2016 (figure 3) which corresponds to the end of the training in epidemiology for health actors in this zone.  

The malnutrition peaks observed in zone 3 correspond to the lean season (generally between July and September). Indeed, the nutritional situation in the north has always been critical due to the Sahelian (desert) climate. In July 2016, the alert threshold was reached in the north [8] leading to emergency interventions. In 2018, no peak in malnutrition was observed in the north. This is due to the many nutrition interventions that have been made in this area.

It should be noted that, in addition to this, the national nutrition program organises training courses for the diagnosis of Wasting;, during which equipment is made available to the health districts (MUAC, scales, Z score tables, etc.). These interventions are relaunching reporting activities and are at the origin of data malnutrition peaks. For example, a peak of Severe Wasting; cases was observed in April 2018, following training in the Abidjan region (Figure 4). All indications are that we are in a situation of under-reporting, judging by the increase in malnutrition cases as a result of reporting activities. This situation is often due to the lack of equipment to carry out nutrition diagnosis.  In this context, the data obtained are difficult to interpret.

The upward trend in the malnutrition curves for zones 1 and 2 reflects both a problem in reporting cases of malnutrition and a problem of food availability. Indeed, the Ivorian forest is said to have shrunk from 16 million hectares to less than 2 million in about 50 years [10]. Forest destruction for cash crops has been to the detriment of subsistence crops [11]. This also raises the problem of the survival of wild food plants, which are a real source of nutritional supplements and currency in rural areas [12].  Many of them have played an important role in the survival of populations in the past, especially in times of war, drought and crop invasion by locusts. Many wild food species are now extinct or in short supply [12; 13]. The fact is that the nutritional situation remains a cause for concern despite the measures taken. The question is whether these are suitable? Nutritional epidemiological surveillance is more than indispensable in order to assess not only the nutritional situation in Côte d'Ivoire but also the impact and relevance of the actions carried out.

Côte d'Ivoire has made the fight against malnutrition a national priority. Several actions have been carried out. The impact of the actions carried out has been manifested by a decrease of Wasting; cases in the north. However, Wasting; remains high in the South and the Center. All indications are that we are in a situation of under-reporting. The nutritional situation in Côte d'Ivoire remains fragile, which is why routine surveillance needs to be the object of priority actions. Child malnutrition has lifelong consequences for health, human potential, economic development, prosperity and equity. Little information is available on the impact of food security and nutrition interventions due to the inefficiency of the monitoring and evaluation mechanism. Appropriate measures are needed for the management of malnutrition. For this, precise data is required. Evaluation of actions is necessary, hence the importance of prioritising epidemiological surveillance activities in general, in particular the implementation of a nutritional Early Warning System (EWS) in accordance with WHO recommendations.

Acknowledgments
We thank Dr Fall who provided us with the FETP training opportunity and Mr Wally Emmanuel Gauze for the translation of the manuscript.