SUPPLEMENT ARTICLE
Bhaktapur, Nepal: The MAL-ED Birth Cohort Study in Nepal Prakash Sunder Shrestha,1 Sanjaya Kumar Shrestha,2 Ladaporn Bodhidatta,3 Tor Strand,4 Binob Shrestha,2 Rita Shrestha,1 Ram Krishna Chandyo,1 Manjeswori Ulak,1 and Carl J. Mason3 1 3
Institute of Medicine, Tribuhvan University, and 2Walter Reed/Armed Forces Research Institute of Medical Sciences, Research Unit, Kathmandu, Nepal; Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand and 4University of Bergen, Norway
Keywords. Nepal; MAL-ED; enteric infection; malnutrition; child development. The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development study (MAL-ED) network is conducting a multicountry, longitudinal prospective cohort study on the etiology, risk factors, and interactions of enteric infections and malnutrition, and the consequences of these factors on child growth, cognitive development, and vaccine response. The 8 study sites are epidemiologically and geographically diverse and comprised of low-income populations. The 8 MAL-ED cohort sites are located in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa, and Tanzania. In this article, we report on the geographic, demographic, and socioeconomic
Correspondence: Sanjaya Kumar Shrestha, MD, Director, Walter Reed/AFRIMS Research Unit Nepal, PO Box 295, Kathmandu, Nepal ([email protected]). Clinical Infectious Diseases® 2014;59(S4):S300–3 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected]. DOI: 10.1093/cid/ciu459
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features of the Bhaktapur, Nepal site and describe the data that informed our cohort recruitment strategy. Nepal is a land-locked country located in South Asia between China and India (Figure 1), with an area of 147 181 km2, ranging from sea-level plains (Tarai) to Mount Everest, the world’s highest peak. The total population in the latest census (2011) was 26.6 million with an average annual population growth rate of 1.4 [1]. Nepal is one of the world’s least developed countries, and is ranked 157 of 186 in the 2013 Human Development Report; one-third of the Nepali population lives below the poverty line [2]. Agriculture, tourism, and remittance are major contributing economic activities in Nepal, and the per capita Gross Domestic Product in 2011 was $1252. The current under-5 mortality rate is 54 per 1000 live births, the infant mortality rate is 46 per 1000 live births, and the neonatal mortality rate is 33 per 1000 live births [3]. Vaccine coverage for all Expanded Program on Immunization vaccines is >80% [3]. Among children, the most common diseases contributing to
Downloaded from http://cid.oxfordjournals.org/ at Georgetown University on July 18, 2015
The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study site in Nepal is located in the Bhaktapur municipality, 15 km east of Kathmandu, the capital city of Nepal. Bhaktapur, an ancient city famous for its traditional temples and buildings, is included on UNESCO’s World Heritage List and is a major tourist attraction in Nepal. Nepal is a land-locked country located in South Asia between China and India with an area of 147 181 km2, ranging from sea-level plains to Mount Everest, the world’s highest peak. The total population as of the 2011 census was 26.6 million, with an average annual population growth rate of 1.4. Nepal is one of the world’s least developed countries and is ranked 157 of 186 in the 2013 Human Development Report; one-third of the Nepali population lives below the poverty line. The current under-5 mortality rate is 54 per 1000 live births, the infant mortality rate is 46 per 1000 live births, and the neonatal mortality rate is 33 per 1000 live births. Vaccine coverage for all Expanded Program on Immunization vaccines is >80%. Among children, the most common diseases contributing to significant morbidity and mortality are acute respiratory infection and dehydration from severe diarrhea. In this article, we report on the geographic, demographic, and socioeconomic features of the Bhaktapur MAL-ED site and describe the data that informed our cohort recruitment strategy.
Map of Nepal.
significant morbidity and mortality are acute respiratory infection and dehydration from severe diarrhea [3]. MAL-ED Cohort Study Site in Bhaktapur
The MAL-ED cohort study site in Nepal is located in the Bhaktapur municipality, which is 15 km east of Kathmandu, the capital city of Nepal (Figure 1). Bhaktapur, an ancient city famous for its traditional temples and buildings, is included on UNESCO’s World Heritage List and is a major tourist attraction in Nepal (Figure 2) [4]. Bhaktapur is a relatively homogenous community where most residents practice either Hindu or Buddhist religions. The status of community members is primarily distinguished by a traditional caste system. The population of Bhaktapur is comprised predominantly of the Newar ethnic group.
Figure 2.
View of neighborhood in Bhaktapur.
The most senior member of the family is usually considered to be the head of household in this community. In the Bhaktapur municipality, domestic migrant workers from diverse ethnic groups work in several carpet factories. Bhaktapur is a periurban agriculture-based community located 1400 m above sea level. The local climate is humid subtropical, with a wet and hot season (monsoon) from May to August and a dry and cool season from October to March. The annual average rainfall is 78.3 mm and the temperature ranges from −2°C to 35°C [4]. The majority of residents consume foods grown in the community. Rice is the staple food. Eating patterns vary with the season, the workload in the fields, and the availability of foods. A variety of local green leafy vegetables is widely consumed mainly in the winter and spring seasons. Collaborative Institutions The MAL-ED study in Nepal is conducted through the Department of Child Health, Institute of Medicine (IOM) with the collaboration of the Walter Reed/Armed Forces Research Institute of Medical Sciences Research Unit of Nepal and the University of Bergen, Norway. The MAL-ED study field office is located at Siddhi Memorial Children’s Hospital. The Siddhi Memorial Children’s Hospital is a nonprofit community hospital where several other observational and intervention studies on childhood nutrition and infectious disease have been successfully completed in collaboration with the University of Bergen and IOM, Nepal. In 1997, the first of these collaborative studies commenced to study the efficacy of zinc and vitamin A in the treatment of infectious diseases, and to assess the adequacy of various nutrient intakes and nutritional status in children, pregnant women, and other women of reproductive age [5–8].
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Figure 1.
Table 1. Demographic and Socioeconomic Characteristics of Nepal and the MAL-ED Bhaktapur Site Indicators
Bhaktapur
Nepal
Total population in catchment area
77 687
26 494 504
Population density per km2 Rural/urban/riverine
11 842 Periurban
181 Mixed
Total households
16 075
5 423 297
Female sex Average family size
49.8% 4.8
51.4% 4.9
Life expectancy, y
NA
64
Major employment Own home
Agriculture 82%
Agriculture 85%
Tap/piped drinking water
98%
48%
Access to toilet facility Home deliveries
99.6% 3%
62% 63%
40%
41%
Prenatal care Postnatal care
NA NA
42% 21%
EPI vaccine coverage
97%
86%
Under-5 mortality rate/1000 live births HIV infection (incidence)
NA NA
54 0.3%
Tuberculosis rate/100 000
48
64
Per capita GDP, US$ Owns a television
NA 97%
$1300 36%
Owns a computer
27%
7%
Owns a refrigerator Propane for cooking
26% 74%
7% 21%
Electricity for lighting
100%
67%
Abbreviations: EPI, Expanded Program on Immunization; GDP, Gross Domestic Product; HIV, human immunodeficiency virus; NA, not available.
MAL-ED Census of Bhaktapur A census of the study area was carried out in March 2010 to obtain demographic information on the population and focused on the identification of pregnant women and women of reproductive age. A total population of 77 687 individuals in 16 075 households was identified in the Bhaktapur municipality and its surrounding neighborhoods (Table 1). In the study catchment area, 487 pregnant women were identified with an estimated 35 births per month. In addition, anthropometric, socioeconomic, and food security information were obtained via a pilot of the MAL-ED socioeconomic status (SES) survey from 100 households in Bhaktapur where children aged 24–36 months resided. Although 73% of households in this survey did not consider any food insecurity to be a problem, 42% of children were suffering from low height for age (ie, stunting) [9]. Socioeconomic Features of the MAL-ED Nepal Study Cohort
A comparison of the MAL-ED SES results for the Bhaktapur municipality and similar national-level data for Nepal are listed
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MAL-ED Study Recruitment
We recorded 668 deliveries in Bhaktapur during the enrollment period of the study (June 2010 to February 2012). Most of these deliveries (97%) occurred at the hospital. Study field-workers used and maintained a list of deliveries by surveying households. Randomization of households with recent deliveries was done on a weekly basis using simple random technique in Microsoft Excel (Microsoft Corporation, Redmond, Washington). Those households that were randomly selected were visited and briefed about the MAL-ED study and its protocol. Only consenting participants were screened for enrollment. Cohort selection was based on criteria described in the introductory article of this supplement [10]. CONCLUSIONS The MAL-ED network’s Bhaktapur, Nepal, cohort represents a periurban community in one of South Asia’s least developed countries. Socioeconomic indicators within this cohort are higher than many national averages, including access to
Downloaded from http://cid.oxfordjournals.org/ at Georgetown University on July 18, 2015
Stunting (10 years of school. Municipal piped drinking water ( private or public) is accessible in almost all households (98%); however, the supply is limited to only a few hours per day. Nearly half of the households (47%) treat water before drinking, of which two-thirds use conventional porous water filters. Similarly, electricity was available in the all households but interruption for several hours a day is common, particularly during the dry winter season. Among the 46% of families who ever heated a room, electricity and wood were used by 71% and 22%, respectively. Toilet facilities were available in almost all cohort households (99%), and most (93%) of these toilets flush to the central municipal drainage system, which exits without treatment into a nearby river. Only 5% of the toilets flush to septic tank. Propane gas stoves are the most common type of cooking stove used in this community (74%), followed by electric stoves (9%) and traditional mud stoves (7%) in which residual crops such as straw or wood are used as fuel. Mobile phones (99%) and television (93%) are present in most of the study cohort households, but only one-fourth of the families possess a computer (27%) and/or refrigerator (26%). Although Bhaktapur is an agrarian community, only two-thirds of families own agricultural land, with a median area of 1018 m2 (SD, 1235 m2). Seventy percent of households have a separate kitchen, and 21% of households live and cook in only 1 room. The majority of homes are made with mud-bonded bricks and with roofs of galvanized sheet metal used on about half (47%) of these homes.
electricity, tap/piped drinking water, and toilet facilities. Nonetheless, stunting rates are comparable to nationwide data. It is anticipated that a better understanding of the risk factors contributing to child health and development in Nepal will result from the findings of the MAL-ED study.
2.
3.
Notes 4.
5.
6.
7.
8.
9.
10.
References 1. Central Bureau of Statistics, National Planning Commission Secretariat. Gender equity and socially exclusive population and housing census. Kathmandu, Nepal: National Planning Commission Secretariat, Central
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Acknowledgments. We thank the entire network of MAL-ED Network study investigators. We also acknowledge and thank the participating children and their families in the MAL-ED cohort study. Financial support. The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED) is carried out as a collaborative project supported by the Bill & Melinda Gates Foundation, the Foundation for the NIH, and the National Institutes of Health, Fogarty International Center. Supplement sponsorship. This article appeared as part of the supplement “The Malnutrition and Enteric Disease Study (MAL-ED): Understanding the Consequences for Child Health and Development,” which is sponsored by the National Institutes of Health and the Foundation for the National Institutes of Health. Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Bureau of Statistics, 2011. Available at: http://cbs.gov.np/. Accessed 7 December 2013. United Nations Development Programme. Human development report 2013. New York: United Nations, 2013. Available at: http://hdr.undp. org/en/media/HDR_2013_EN_complete.pdf. Accessed 7 December 2013. Ministry of Health and Population, New ERA, ICF International. 2011 Nepal Demographic and Health Survey (NDHS), 2012. Available at: http://www.measuredhs.com/pubs/pdf/GF25/GF25.pdf. Accessed 7 December 2013. Central Bureau of Statistics, National Planning Commission Secretariat. District profile: Bhaktapur. Available at: http://cbs.gov.np/?page_id= 1573. Accessed 7 December 2013. Valentiner-Branth P, Shrestha PS, Chandyo RK, et al. A randomized controlled trial of the effect of zinc as adjuvant therapy in children 2–35 mo of age with severe or nonsevere pneumonia in Bhaktapur, Nepal. Am J Clin Nutr 2010; 91:1667–74. Chandyo RK, Strand TA, Mathisen M, et al. Zinc deficiency is common among healthy women of reproductive age in Bhaktapur, Nepal. J Nutr 2009; 139:594–7. Chandyo RK, Strand TA, Ulvik RJ, et al. Prevalence of iron deficiency and anemia among healthy women of reproductive age in Bhaktapur, Nepal. Eur J Clin Nutr 2007; 61:262–9. Strand TA, Chandyo RK, Bahl R, et al. Effectiveness and efficacy of zinc for the treatment of acute diarrhea in young children. Pediatrics 2002; 109:898–903. Psaki S, Bhutta ZA, Ahmed T, et al. Household food access and child malnutrition: results from the eight-country MAL-ED study. Popul Health Metr 2012; 10:24. The MAL-ED Network Investigators. The MAL-ED study: a multinational and multidisciplinary approach to understand the relationship between enteric pathogens, malnutrition, gut physiology, physical growth, cognitive development, and immune responses in infants and children up to 2 years of age in resource-poor environments. Clin Infect Dis 2014; 59(suppl 4):S193–206.
Bhaktapur, Nepal: The MAL-ED Birth Cohort Study in Nepal Prakash Sunder Shrestha,1 Sanjaya Kumar Shrestha,2 Ladaporn Bodhidatta,3 Tor Strand,4 Binob Shrestha,2 Rita Shrestha,1 Ram Krishna Chandyo,1 Manjeswori Ulak,1 and Carl J. Mason3 1 3
Institute of Medicine, Tribuhvan University, and 2Walter Reed/Armed Forces Research Institute of Medical Sciences, Research Unit, Kathmandu, Nepal; Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand and 4University of Bergen, Norway
Keywords. Nepal; MAL-ED; enteric infection; malnutrition; child development. The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development study (MAL-ED) network is conducting a multicountry, longitudinal prospective cohort study on the etiology, risk factors, and interactions of enteric infections and malnutrition, and the consequences of these factors on child growth, cognitive development, and vaccine response. The 8 study sites are epidemiologically and geographically diverse and comprised of low-income populations. The 8 MAL-ED cohort sites are located in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa, and Tanzania. In this article, we report on the geographic, demographic, and socioeconomic
Correspondence: Sanjaya Kumar Shrestha, MD, Director, Walter Reed/AFRIMS Research Unit Nepal, PO Box 295, Kathmandu, Nepal ([email protected]). Clinical Infectious Diseases® 2014;59(S4):S300–3 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected]. DOI: 10.1093/cid/ciu459
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features of the Bhaktapur, Nepal site and describe the data that informed our cohort recruitment strategy. Nepal is a land-locked country located in South Asia between China and India (Figure 1), with an area of 147 181 km2, ranging from sea-level plains (Tarai) to Mount Everest, the world’s highest peak. The total population in the latest census (2011) was 26.6 million with an average annual population growth rate of 1.4 [1]. Nepal is one of the world’s least developed countries, and is ranked 157 of 186 in the 2013 Human Development Report; one-third of the Nepali population lives below the poverty line [2]. Agriculture, tourism, and remittance are major contributing economic activities in Nepal, and the per capita Gross Domestic Product in 2011 was $1252. The current under-5 mortality rate is 54 per 1000 live births, the infant mortality rate is 46 per 1000 live births, and the neonatal mortality rate is 33 per 1000 live births [3]. Vaccine coverage for all Expanded Program on Immunization vaccines is >80% [3]. Among children, the most common diseases contributing to
Downloaded from http://cid.oxfordjournals.org/ at Georgetown University on July 18, 2015
The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study site in Nepal is located in the Bhaktapur municipality, 15 km east of Kathmandu, the capital city of Nepal. Bhaktapur, an ancient city famous for its traditional temples and buildings, is included on UNESCO’s World Heritage List and is a major tourist attraction in Nepal. Nepal is a land-locked country located in South Asia between China and India with an area of 147 181 km2, ranging from sea-level plains to Mount Everest, the world’s highest peak. The total population as of the 2011 census was 26.6 million, with an average annual population growth rate of 1.4. Nepal is one of the world’s least developed countries and is ranked 157 of 186 in the 2013 Human Development Report; one-third of the Nepali population lives below the poverty line. The current under-5 mortality rate is 54 per 1000 live births, the infant mortality rate is 46 per 1000 live births, and the neonatal mortality rate is 33 per 1000 live births. Vaccine coverage for all Expanded Program on Immunization vaccines is >80%. Among children, the most common diseases contributing to significant morbidity and mortality are acute respiratory infection and dehydration from severe diarrhea. In this article, we report on the geographic, demographic, and socioeconomic features of the Bhaktapur MAL-ED site and describe the data that informed our cohort recruitment strategy.
Map of Nepal.
significant morbidity and mortality are acute respiratory infection and dehydration from severe diarrhea [3]. MAL-ED Cohort Study Site in Bhaktapur
The MAL-ED cohort study site in Nepal is located in the Bhaktapur municipality, which is 15 km east of Kathmandu, the capital city of Nepal (Figure 1). Bhaktapur, an ancient city famous for its traditional temples and buildings, is included on UNESCO’s World Heritage List and is a major tourist attraction in Nepal (Figure 2) [4]. Bhaktapur is a relatively homogenous community where most residents practice either Hindu or Buddhist religions. The status of community members is primarily distinguished by a traditional caste system. The population of Bhaktapur is comprised predominantly of the Newar ethnic group.
Figure 2.
View of neighborhood in Bhaktapur.
The most senior member of the family is usually considered to be the head of household in this community. In the Bhaktapur municipality, domestic migrant workers from diverse ethnic groups work in several carpet factories. Bhaktapur is a periurban agriculture-based community located 1400 m above sea level. The local climate is humid subtropical, with a wet and hot season (monsoon) from May to August and a dry and cool season from October to March. The annual average rainfall is 78.3 mm and the temperature ranges from −2°C to 35°C [4]. The majority of residents consume foods grown in the community. Rice is the staple food. Eating patterns vary with the season, the workload in the fields, and the availability of foods. A variety of local green leafy vegetables is widely consumed mainly in the winter and spring seasons. Collaborative Institutions The MAL-ED study in Nepal is conducted through the Department of Child Health, Institute of Medicine (IOM) with the collaboration of the Walter Reed/Armed Forces Research Institute of Medical Sciences Research Unit of Nepal and the University of Bergen, Norway. The MAL-ED study field office is located at Siddhi Memorial Children’s Hospital. The Siddhi Memorial Children’s Hospital is a nonprofit community hospital where several other observational and intervention studies on childhood nutrition and infectious disease have been successfully completed in collaboration with the University of Bergen and IOM, Nepal. In 1997, the first of these collaborative studies commenced to study the efficacy of zinc and vitamin A in the treatment of infectious diseases, and to assess the adequacy of various nutrient intakes and nutritional status in children, pregnant women, and other women of reproductive age [5–8].
The MAL-ED Birth Cohort Study in Nepal
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Downloaded from http://cid.oxfordjournals.org/ at Georgetown University on July 18, 2015
Figure 1.
Table 1. Demographic and Socioeconomic Characteristics of Nepal and the MAL-ED Bhaktapur Site Indicators
Bhaktapur
Nepal
Total population in catchment area
77 687
26 494 504
Population density per km2 Rural/urban/riverine
11 842 Periurban
181 Mixed
Total households
16 075
5 423 297
Female sex Average family size
49.8% 4.8
51.4% 4.9
Life expectancy, y
NA
64
Major employment Own home
Agriculture 82%
Agriculture 85%
Tap/piped drinking water
98%
48%
Access to toilet facility Home deliveries
99.6% 3%
62% 63%
40%
41%
Prenatal care Postnatal care
NA NA
42% 21%
EPI vaccine coverage
97%
86%
Under-5 mortality rate/1000 live births HIV infection (incidence)
NA NA
54 0.3%
Tuberculosis rate/100 000
48
64
Per capita GDP, US$ Owns a television
NA 97%
$1300 36%
Owns a computer
27%
7%
Owns a refrigerator Propane for cooking
26% 74%
7% 21%
Electricity for lighting
100%
67%
Abbreviations: EPI, Expanded Program on Immunization; GDP, Gross Domestic Product; HIV, human immunodeficiency virus; NA, not available.
MAL-ED Census of Bhaktapur A census of the study area was carried out in March 2010 to obtain demographic information on the population and focused on the identification of pregnant women and women of reproductive age. A total population of 77 687 individuals in 16 075 households was identified in the Bhaktapur municipality and its surrounding neighborhoods (Table 1). In the study catchment area, 487 pregnant women were identified with an estimated 35 births per month. In addition, anthropometric, socioeconomic, and food security information were obtained via a pilot of the MAL-ED socioeconomic status (SES) survey from 100 households in Bhaktapur where children aged 24–36 months resided. Although 73% of households in this survey did not consider any food insecurity to be a problem, 42% of children were suffering from low height for age (ie, stunting) [9]. Socioeconomic Features of the MAL-ED Nepal Study Cohort
A comparison of the MAL-ED SES results for the Bhaktapur municipality and similar national-level data for Nepal are listed
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MAL-ED Study Recruitment
We recorded 668 deliveries in Bhaktapur during the enrollment period of the study (June 2010 to February 2012). Most of these deliveries (97%) occurred at the hospital. Study field-workers used and maintained a list of deliveries by surveying households. Randomization of households with recent deliveries was done on a weekly basis using simple random technique in Microsoft Excel (Microsoft Corporation, Redmond, Washington). Those households that were randomly selected were visited and briefed about the MAL-ED study and its protocol. Only consenting participants were screened for enrollment. Cohort selection was based on criteria described in the introductory article of this supplement [10]. CONCLUSIONS The MAL-ED network’s Bhaktapur, Nepal, cohort represents a periurban community in one of South Asia’s least developed countries. Socioeconomic indicators within this cohort are higher than many national averages, including access to
Downloaded from http://cid.oxfordjournals.org/ at Georgetown University on July 18, 2015
Stunting (10 years of school. Municipal piped drinking water ( private or public) is accessible in almost all households (98%); however, the supply is limited to only a few hours per day. Nearly half of the households (47%) treat water before drinking, of which two-thirds use conventional porous water filters. Similarly, electricity was available in the all households but interruption for several hours a day is common, particularly during the dry winter season. Among the 46% of families who ever heated a room, electricity and wood were used by 71% and 22%, respectively. Toilet facilities were available in almost all cohort households (99%), and most (93%) of these toilets flush to the central municipal drainage system, which exits without treatment into a nearby river. Only 5% of the toilets flush to septic tank. Propane gas stoves are the most common type of cooking stove used in this community (74%), followed by electric stoves (9%) and traditional mud stoves (7%) in which residual crops such as straw or wood are used as fuel. Mobile phones (99%) and television (93%) are present in most of the study cohort households, but only one-fourth of the families possess a computer (27%) and/or refrigerator (26%). Although Bhaktapur is an agrarian community, only two-thirds of families own agricultural land, with a median area of 1018 m2 (SD, 1235 m2). Seventy percent of households have a separate kitchen, and 21% of households live and cook in only 1 room. The majority of homes are made with mud-bonded bricks and with roofs of galvanized sheet metal used on about half (47%) of these homes.
electricity, tap/piped drinking water, and toilet facilities. Nonetheless, stunting rates are comparable to nationwide data. It is anticipated that a better understanding of the risk factors contributing to child health and development in Nepal will result from the findings of the MAL-ED study.
2.
3.
Notes 4.
5.
6.
7.
8.
9.
10.
References 1. Central Bureau of Statistics, National Planning Commission Secretariat. Gender equity and socially exclusive population and housing census. Kathmandu, Nepal: National Planning Commission Secretariat, Central
The MAL-ED Birth Cohort Study in Nepal
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CID 2014:59 (Suppl 4)
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Downloaded from http://cid.oxfordjournals.org/ at Georgetown University on July 18, 2015
Acknowledgments. We thank the entire network of MAL-ED Network study investigators. We also acknowledge and thank the participating children and their families in the MAL-ED cohort study. Financial support. The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED) is carried out as a collaborative project supported by the Bill & Melinda Gates Foundation, the Foundation for the NIH, and the National Institutes of Health, Fogarty International Center. Supplement sponsorship. This article appeared as part of the supplement “The Malnutrition and Enteric Disease Study (MAL-ED): Understanding the Consequences for Child Health and Development,” which is sponsored by the National Institutes of Health and the Foundation for the National Institutes of Health. Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Bureau of Statistics, 2011. Available at: http://cbs.gov.np/. Accessed 7 December 2013. United Nations Development Programme. Human development report 2013. New York: United Nations, 2013. Available at: http://hdr.undp. org/en/media/HDR_2013_EN_complete.pdf. Accessed 7 December 2013. Ministry of Health and Population, New ERA, ICF International. 2011 Nepal Demographic and Health Survey (NDHS), 2012. Available at: http://www.measuredhs.com/pubs/pdf/GF25/GF25.pdf. Accessed 7 December 2013. Central Bureau of Statistics, National Planning Commission Secretariat. District profile: Bhaktapur. Available at: http://cbs.gov.np/?page_id= 1573. Accessed 7 December 2013. Valentiner-Branth P, Shrestha PS, Chandyo RK, et al. A randomized controlled trial of the effect of zinc as adjuvant therapy in children 2–35 mo of age with severe or nonsevere pneumonia in Bhaktapur, Nepal. Am J Clin Nutr 2010; 91:1667–74. Chandyo RK, Strand TA, Mathisen M, et al. Zinc deficiency is common among healthy women of reproductive age in Bhaktapur, Nepal. J Nutr 2009; 139:594–7. Chandyo RK, Strand TA, Ulvik RJ, et al. Prevalence of iron deficiency and anemia among healthy women of reproductive age in Bhaktapur, Nepal. Eur J Clin Nutr 2007; 61:262–9. Strand TA, Chandyo RK, Bahl R, et al. Effectiveness and efficacy of zinc for the treatment of acute diarrhea in young children. Pediatrics 2002; 109:898–903. Psaki S, Bhutta ZA, Ahmed T, et al. Household food access and child malnutrition: results from the eight-country MAL-ED study. Popul Health Metr 2012; 10:24. The MAL-ED Network Investigators. The MAL-ED study: a multinational and multidisciplinary approach to understand the relationship between enteric pathogens, malnutrition, gut physiology, physical growth, cognitive development, and immune responses in infants and children up to 2 years of age in resource-poor environments. Clin Infect Dis 2014; 59(suppl 4):S193–206.
