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
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.
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
Figure 1.
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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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%
Stunting (<5 y)
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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in Table 1. In Bhaktapur municipality, 67% of heads of household in our cohort families are literate, with an average of 5.8
years of schooling (range, 1–18 years). Most of the mothers
(94%) are literate, but only one-fourth attended >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.
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
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
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.
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10.
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