Non-communicable diseases continue to be important public health problems in India, being responsible for sizeable mortality and morbidity. Demographic changes and changes caused in the environment and the economy are the major reasons for shift against a predominantly communicable diseases scenario. Ageing population allows manifestation of cardiovascular diseases, cancer and mental disorders which also result in high prevalence of chronic disability. The aim of research in non-communicable diseases ongoing at the ICMR is to identify risk factors, their prevention, health services requirements and control strategies.
Research in the field of oncology continued to provide data which would be helpful in the control of cancers and tobacco use. The National Cancer Registry Programme (NCRP) continued to provide information on cancer occurrence and its trends over time. The study on cost of management of tobacco related diseases has provided important insights on the burden imposed by tobacco use. Multidisciplinary study on cervical cancer continues to add useful leads in the etiology and control of this common malignancy among Indian women. Environmental carcinogen testing units aim at identifying important substances/ chemicals of special interest to India and determining their permissible limits in the environment. Dissemination of results of research and their application for control activities was also done.
National Cancer Registry Programme
Generation of authentic data, analysis and interpretation, conduct of epidemiological studies and development of human resources are the major objectives of NCRP, which is functioning since 1981-82. The current network consists of six population based (Mumbai, Bangalore, Chennai, Delhi, Bhopal & rural Barshi) and five hospital based (Thiruvananthapuram, Dibrugarh, Mumbai, Bangalore, & Chennai) cancer registries.
The data from population based cancer registries show that in 1994, the age adjusted incidence rate in urban registry areas varied between 98.7 and 138.3/100,000 among men and between 108.0 and 143.4 /100,000 among women. The age adjusted incidence rate in rural areas of Barshi (Maharashtra) was 41.1 among men and 56.3 among women. The most common site of cancer in men in all the registries (except Chennai where stomach cancer is the commonest) is lung or oesophagus. Other common sites of cancer in men include pharynx and stomach. The common sites of cancer in women include cervix, breast, oral cavity, oesophagus, stomach and ovary. The leading sites for cancer were consistent over the years in all the registries except Barshi. The incidence rate of stomach cancer is high in Chennai and Bangalore. Cancer of the gall bladder is common in Delhi, in both sexes. Over the years, Mumbai and Delhi have shown an increase in the incidence of cancer when all sites were taken into consideration. Cancer of the breast in women has also shown an increase in all urban registry areas. The data from hospital based cancer registries till 1994 showed that the histopathological verification of diagnosis varied from 69.5% (Chennai) to 94.5% (Chandigarh) among men, and from 71.5% (Chennai) to 96.1% (Chandigarh) among women. Proportion of patients with localized disease varied from 5.1% (Chennai) to 24.3% (Dibrugarh) among men, and from 5.6% (Chennai) to 22.8% (Mumbai) among women. The proportion of cases with regional spread varied from 41.6% (Mumbai) to 65.5% (Chandigarh) among men, and from 49.4% (Mumbai) to 78.0% (Chennai) among women. Radiotherapy was the commonest mode of treatment, followed by surgery or chemotherapy, depending upon the registry. The proportion of patients not receiving/accepting treatment at various centres varied from 16.1% (Dibrugarh) to 45.7% (Chennai) among men and from 15.1% (Dibrugarh) to 39.8% (Chennai) among women. Case control studies on cancers of prostate and gall bladder have been initiated under the NCRP. Two continuing education workshops on cancer registration were held. A three centre study on assessing the coverage of population based cancer registries is being carried out at Bangalore, Chennai and Mumbai.
Cost of Management of Tobacco related Diseases
The project on cost of management of tobacco related diseases [(tobacco-related cancers, coronary heart disease (CHD) and chronic obstructive pulmonary disease - (COPD)] helped in assessing the magnitude of financial burden posed by these diseases. Data on direct as well as indirect expenditure due to the disease were collected from patients and their relatives/ friends. The expenditure incurred by the treating institution for the management of these patients was also collected. The average cost due to a case of tobacco related cancer was Rs.134,449 (discounted at 1990 level). The data from patients of CHD and COPD were collected on a cross-sectional basis, in contrast to a cohort approach followed for tobacco related cancers. The per capita annual direct losses were Rs. 5,130.2 for patients of CHD and Rs. 2,670.7 for patients of COPD. The annual losses indirectly borne by the state/employer were still larger (Rs. 16,863.3 and Rs.11,454.0 per year respectively for patients with CHD and COPD).
The Institute of Cytology and Preventive Oncology (ICPO), New Delhi is conducting a multidisciplinary study on the risk factors of cervical cancer (including HPV) utilizing tools of molecular biology with emphasis on the identification of leads for its control. A multidisciplinary study on breast cancer has also been initiated. Uterine cervical dysplasia II study indicates a significant role of HPV. Other important leads include evidence of specific genetic events in cervical cancer, HPV oncogene expression, and role of some agents in viral oncogene expression. The project on reproductive tract infections (RTI) provided insight into this problem among Indian women, their clinical presentation, association with inflammatory smears and precancerous and cancerous lesions. The pioneering work of the Institute on the clinical downstaging of cervical cancer demonstrated its efficacy for early detection. This was further strengthened by the development of a simple instrument, magna visualiser, which is being patented. A national workshop on clinical downstaging as an alternative strategy for control of cervical cancer is proposed.
Studies on the genetic alteration of cervical cancerous and precancerous lesions involved 16 microsatellite markers belonging to 3p, 4q, 5p, 6q and 10p. Data obtained so far have revealed genetic deletion at 3p and 5p. In a separate analysis, 3p genetic deletions were found to be dependent on HPV whereas 5p genetic deletions at 5S406 were independent of HPV 16/18 infection.
p53 expression was studied in 101 cervical tumours and 36 healthy controls. Overexpression of p53 specific mRNA transcripts did not show any correlation with occurrence of p53 gene mutations. However, overexpression was more common in HPV positive patients. In cervical cancer p53 mutation was found to be infrequent and appears to be not mutually exclusive to HPV infection. In another study of 163 cervical cancer patients, 50 cervical dysplasia patients and 74 healthy controls, p53 gene polymorphism was studied at codon 72 proline/arginine. No strong association of HPV positivity with p53 codon 72 polymorphism was observed.
A DST sponsored workshop on molecular biology in human health and disease was conducted.
Hospital-based Study to Identify Risk Factors for Acute Myocardial Infarction
The conventional risk factors for coronary artery disease (CAD) do not appear to be solely responsible for the higher incidence of ischaemic heart disease in the Indian population. A multi-centric case-control study on acute myocardial infarction in Indians was initiated to identify and quantify the association of possible risk factors for CAD. Centres at Delhi, Lucknow, Bangalore and Hyderabad have started collecting data on standardized proformae.
Indo-US Workshop on RF/RHD and Streptococcal Infections
An Indo-US workshop on RF/RHD and Streptococcal infections was held under the US Vaccine Action Programme in April 1999. Fifteen US and 30 Indian scientists were invited for this workshop to explore the development of a joint venture for streptococcal vaccine development. These deliberations helped formulation of a research programme under the Jai Vigyan Mission mode.
Jai Vigyan Mission Mode Project on Community Control of RF/RHD in India
Streptococcal infections and rheumatic heart disease have been identified as an area under the Jai Vigyan Mission for enhancing research thrust in nationally relevant areas. The ICMR has been actively engaged in research on RF/ RHD and streptococcal infections over the past two decades. The project proposes to study the epidemiology, genetic and immunological host factors, typing of rheumatogenic strains and development of a vaccine against streptococci.
Blindness is an important national problem because it is an important cause of lost DALYs (Disability Adjusted Life Years).
Glaucoma is an important cause of preventable blindness. The Council has initiated two studies on glaucoma, one on epidemiology of glaucoma and other on its management. The project on epidemiology is still continuing while the data collection under the management of glaucoma project has been completed. The data entry and analysis are currently being done at the Council.
Epidemiological studies were undertaken in the area of child and adolescent psychiatric disorders at Bangalore and Lucknow. A Centre for Advanced Research was set up at the Maharashtra Institute of Mental Health, Pune to study the health consequences of Marathwada earthquake disaster, with special reference to mental health.
Mental Health Consequences of Earthquake Disaster
The base-line survey of psychiatric and physical disorders in the study area and comparable control area has shown excess psychiatric morbidity especially post-traumatic stress disorders, and other reactions to severe stress in the earthquake affected area. Depressive episodes were also reported more frequently in the disaster affected area. The results of nested case-control study carried out by the Centre showed that significant risk factors of excess psychiatric morbidity in earthquake affected area were disaster injury, disaster deaths, trapping experience and dissatisfaction with social support. One year follow up of cases identified in the base-line survey was carried out. This is the first large community based study in the country that has generated data on course and outcome of post-traumatic stress disorders and other reactions to severe stress. It was found that though nearly two-thirds of psychiatric patients in the disaster affected area recovered (with treatment) within an year of follow up, psychiatric morbidity there was more as compared to the control area. Significant prognostic factors included satisfaction with social support, desirable life events, absence of, or minimal injury during the disaster.
Child and Adolescent Psychiatric Disorders
A task force project was carried out at Bangalore and Lucknow to find the pattern and prevalence of child and adolescent psychiatric disorders in rural and urban areas, and for studying the psychosocial correlates of these disorders. An interim analysis of data shows that following disorders are more prevalent among children in the community : non-organic enuresis, pica of infancy, stuttering, hyperkinetic disorders, conduct disorders, panic disorders, oppositional defiant disorders and specific phobias. Further data analysis is in progress on psychosocial correlates of these disorders.
Tobacco and other Substance Abuse in North-east
In an ongoing survey at the RMRC, Dibrugarh on tobacco and other substance abuse in Arunachal Pradesh, during the year, six selected villages in Khersang PHC area, two substitute villages in Khimiyong PHC area and two villages in Vijainagar PHC area of Changlang district in Arunachal Pradesh were surveyed. A total of 112 persons aged 10 years and above were interviewed during the household surveys. The prevalence of substance use in Khersang PHC area was 46.4% for tobacco (36.4% chewers and 11.1% smokers), 33.7% for alcohol and 1.0% for opium. The prevalence in the surveyed villages under Khimiyong PHC was 35.5% for tobacco (22.9% chewers and 16.7% smokers), 40.4% for alcohol and 15.5% for opium. The least substance abuse was found in Vijainagar PHC area where 5.9% persons were tobacco users (1.9% chewers and 4.6% smokers) and 6.2% alcohol users with no opium user.
Socio-demographic and Behaviour Study of Drug Addicts
Information on drug addicts along the National Highway 37 in Assam and Arunachal Pradesh was collected through Key informants like ex-drug addicts, doctors, NGOs etc., by the RMRC, Dibrugarh. Besides the Govt. hospitals, information from public sector hospitals, private nursing homes and leading private practitioners was also collected. So far 31 drug addicts have been contacted and interviewed. Most of the drug addicts were between 20-35 years of age, married and illiterate or educated up to middle standard. Majority of drug addicts were addicted to heroin and frequency of intake was several times per day according to their statements. ‘Chasing’ was the most preferred route of administration of heroin. However, many preferred the intravenous route of administration. The study is in progress.
Prevalence of Opium Use in Desert Areas of Rajasthan
A study of prevalence of opium use and socio-cultural factors associated with consumption pattern in desert areas was continued at DMRC, Jodhpur and a total of 250 households was covered. The data so far collected indicate that of the individuals examined, nearly 60 were Doda/opium consumers, 100 consumed alcohol, while 180 were smokers.
Epidemiological, Cultural and Immunological Studies on Rhinosporidium seeberi
Rhinosporidiosis is a disease of man and domestic animals. The disease has been reported to be caused by R. seeberi or by a unicellular prokaryotic cyanobacterium. In man, it is primarily a disease of the nose, nasopharynx, eye and skin and occasionally affects the viscera and external genitalia.
A study was initiated with the overall objective to identify the specific antigens of R. seeberi that cause rhinosporidiosis in humans so as to be able to clone the gene for the above antigen to develop specific diagnostic probes.
During the year under report, work mainly centered around identification of the pathogen. In order to resolve the issue of the pathogenesis, biopsy material from rhinosporidiosis patients and samples of Microcystis aeruginosa were independently evaluated by experts from AIIMS, New Delhi; PGIMER, Chandigarh as well as V.P. Chest Institute, Delhi. Work on DNA sequencing of the short fragment of R. seeberi genome was also undertaken and compared with the sequence available with the data bank. A genomic library was constructed in ngt11 vector. Immunological studies of the pathogen were also attempted . The pathogen was isolated from pond water and attempts were made to grow the organism in axenic culture.
The Institute of Immunohaematology (IIH), Mumbai continued basic, clinical and epidemiological research in haematological disorders which included haemoglobinopathies, bleeding and thrombotic disorders, generation of monoclonal antibodies, transfusion medicine etc.
Prenatal Diagnosis of Thalassaemia Syndromes
Oligo probes were designed for inclusion of one more mutation in the reverse dot blot hybridization ship making it possible to screen for 6- b-thalassaemia mutations (IVS 1-5(G-C), IVS 1-1(G-T), Codon 8/9 +G, Codon 41/42 -CTTT, Codon 15G-A and Codon 30G-C along with HbS and HbE in a single step (Fig.15). Evaluation was done to check the stability of a PCR premix prepared containing the primers, dNTPs, buffer etc as well as the oligoprobe blotted ships. Both these were stable for up to 6 months and could be provided in a kit for detection of common Indian mutations for b-thalassaemia and abnormal haemoglobins.
Antenatal Screening for Thalassaemia
Antenatal screening for thalassaemia was done in 12098 pregnant women. Among these 196 had b–thalassaemia trait and 37 had other abnormal haemoglobins. A total of 126 women were counselled and their husbands checked subsequently and 9 couples at risk were identified prospectively, 8 of whom underwent antenatal diagnosis. One woman was already in the 7th month of gestation and was advised to check the baby’s cord blood.
Isolation of Foetal Cells from Maternal Blood
Further work on isolation of foetal cells from 7 ml sample of maternal blood for non invasive prenatal diagnosis was done. By percol density gradient centrifugation carried out in 30 pregnant women at 10 to 23 weeks of gestation, nucleated erythroblast (NRBCs) counts at the interface were found to be 0.6 to 5. Immunogenetic sorting using CD71 resulted in isolation of 5 to 16 cells, while flow cytometry using a monoclonal anti-HbF as a foetal marker gave about 200 cells (Fig.16).
Generation of Monoclonal Antibody by Hybridoma Technology
A monoclonal anti HbF was generated and its specificity was tested by flow cytometry to obtain accurate estimation of haemoglobin F in various conditions.
Molecular Studies in G6PD Deficiency
Seventy five subjects screened for mutations underlying G6PD deficiency showed G6PD Kerala Kalyan in 20, G6PD Mediterranean in 18 and G6PD Orissa in 6. Twenty five uncharacterised samples were negative for G6PD Seattle. SSCP of all exons was standardised and uncharacterised samples screened but no altered mobility was found. The 1311 polymorphism was also studied in all samples and both the C and T polymorphisms were seen. Correlating the degree of haemolysis and type of mutation it was observed that all the cases with severe haemolysis did not have Mediterranean type of mutation only as reported earlier.
Carrier detection and antenatal diagnosis in families of haemophilia was continued. In the year under report, 28 families of haemophilia A and 8 families of haemophilia B were referred for carrier diagnosis. Out of 43 females examined, 20 were diagnosed as carriers, 22 as non carriers and status of one could not be ascertained. Antenatal diagnosis in haemophilia by chorionic villus sampling was performed in 15 haemophilia A families and 3 haemophilia B families. One family was referred at 18 weeks and the results were given following cordocentesis.
The etiology of thrombophilia was studied in 248 patients (aged below 40 years) with deep vein thrombosis (DVT). Factor V Leiden mutation which is a major risk factor for thrombophilia in Western countries (i.e. 20 – 30%), was found to have minimal role in its etiology in these patients i.e. 3% prevalence in DVT patients against a control prevalence of 2.7%. However, patients with Budd- Chiari syndrome still showed a very high prevalence of factor V Leiden mutation i.e. 20%. The prothrombin gene polymorphism G 20210 A was found to be rare in the studied population. The MTHFR gene polymorphism showed similar prevalence in control population as well as in the DVT patients.
Carrier detection in von Willebrand (VW) disease which is an autosomal disorder of factor VIII deficiency is another major achievement during the year. Earlier an extensive study of the allele frequency and heterozygosity frequency of the two polymorphic markers of the intron 40 of VW factor gene in 250 unrelated subjects was carried out (Fig.17). The carrier detection was performed in 3 severe von Willebrand families and they were counselled.
Platelet Alloantigen in Indian Population and Detection of Neonatal Alloimmune Thrombocytopenic Purpura (NAITP) by Allele Specific Amplification
As information on the distribution of platelet specific alloantigen in the Indian population is not available, this study was undertaken. The population screening so far included 300 subjects who were selected randomly from among voluntary blood donors and attendees of antenatal clinics at Mumbai. The results revealed PLA1 homozygosity of 84% and PLA2 homozygosity of 1% and the rest 15% were found to be heterozygous. One per cent of this female population having PLA2 are at risk of having neonatal alloimmunisation and alloimmune thrombocytopaenia in the newborn.
Population Screening for Detection and Molecular Characterisation of Partial 'D' Antigen and Rh Variant
Recent studies have suggested that Rh antigen has more than 30 well defined epitopes. A panel of epitope specific monoclonal anti- D culture supernatant was obtained from USA and UK and 983 blood samples of various caste groups and communities were screened. Interestingly, 20 to 49% samples showed reactivity with all monoclonal antibodies indicating the presence of majority of D antigenic epitopes. However, 4.5% of the population showed absence of more than 5 epitopes. The same panel of monoclonal antibodies when used to investigate 16 known cases of weak D antigen showed absence of 25 to 70% epitopes. Rh genotyping was performed in all the 16 cases and the results matched with the overall incidence of these genotypes.
Bone Marrow Transplantation
The Council’s Centre for Advanced Research for Bone Marrow Transplantation at Christian Medical College, Vellore completed five years of sanctioned duration. The Centre aims to develop bone marrow transplantation technology for thalassaemia in India with appropriate modification of specific transplant techniques to suit Indian conditions. Attempts were made to reduce the incidence of graft rejection by increasing the dose of busulphan and estimating the blood levels of busulphan achieved in individual patients and to evaluate the place of additional immunosuppression with antilymphocyte globulin (ALG). A total of 51 patients with thalassaemia major have been given bone marrow transplantation, 26 in Group I receiving Regimen A comprising busulphan 600mg/m2+cyclophosphamide 200mg/kg and 25 in Group II receiving Regimen B (busulphan 16mg/kg+cyclophosphamide 200mg/kg+ALG). The overall survival was 72.5% with both groups having similar results. However, the overall survival was found to be 93.3% amongst 15 cases in class II and 65.7% in class III patients which is comparable to best results in the world. Only 40 cases were evaluable for rejection of which 4 from class III had rejection, (10%) with no rejection in class II. Overall mortality was 27.5% with 13 in class III and one in class II, of these 11 were not related to rejection. The hospital stay varied from 28-84 days depending on post-transplant complications. The study has shown that 600mg/m2 busulphan dose is not more toxic than the standard dose of 16mg/kg. Further addition of ALG to the conditioning regimen had no additional benefit thereby suggesting that omitting ALG can reduce the cost without compromising with the outcome.
Major achievements of the Centre include development of a HPLC based method for assaying busulphan levels in plasma. The assays can be done in a hospital setting and results made available quickly for clinical decisions in individual patients. Documentation of busulphan levels in thalassaemia patients undergoing bone marrow transplantation using 16mg/kg and 600 mg/m2 showed 2-12 fold variation in levels between individuals irrespective of the dosing strategy. The results have shown for the first time that plasma busulphan levels correlate with hepatic glutathione S transferase levels. An increased incidence of gastrointestinal bleeding in patients whose busulphan mean residual value(MRV) is>500ng/ml and area under concentration curve(AUC) >5000ng/ml has been documented.
An increased risk of rejection was observed in patients whose systemic exposure to busulphan is sub-optimal. No patient in whom the MRV was greater than 300 ng/ml rejected while all patients whose MRV was below 150ng/ml rejected the transplant. There was also a correlation with the first dose minimum concentration (C min) and the mean of the first, second and thirteenth dose C min with the probability of rejection being increased if levels were below 200 ng/ml. The data suggest that individualized busulphan dosing based on first dose pharmacokinetics would be the best way to reduce toxicity and rejection.
The Centre has facilities of antenatal diagnosis of thalassaemia for clinical documentation of the molecular defects. DNA fingerprinting for documenting mixed chimerism post -bone marrow transplantation and for maternal contamination in chorionic villus sampling has been standardized. The Centre is now comprehensive and is able to offer all services from antenatal diagnosis to bone marrow transplantation for patients with thalassaemia major.
Intervention Programme for Nutritional Anaemia and Haemoglobinopathies amongst Primitive Tribal Population of India
In view of the prevalence of blood disorders in various primitive tribal populations this multicentric study was initiated in October 1999 at 5 centres in four states namely Maharashtra, Gujarat, Orissa and Tamil Nadu to assess nutritional and sickle cell anaemia in the study population, introduce appropriate intervention and follow up for a period of 3 years. Initial training of the staff appointed at various centres was conducted to obtain uniformity of procedures to be adopted by all the centres. The pilot testing is in progress.
Community Control of Thalassaemia Syndromes - Awareness, Screening, Genetic Counselling and Prevention
The project has been chosen as one of the mission mode projects under the Jai Vigyan Science and Technology Mission. The project aims at educating, screening, counselling and identifying couples at risk of having thalassaemic children and developing regional and national referral centres for control of thalassaemia major in the country. The study on college students and pregnant women has been launched in 6 states viz. Maharashtra, Gujarat, Assam, West Bengal, Punjab and Karnataka.