ICMR BULLETIN

EPIDEMIOLOGY AND SURVEILLANCE OF JAPANESE ENCEPHALITIS
IN TAMIL NADU

Japanese encephalitis (JE) is a non-contagious, mosquito-transmitted virus disease mainly affecting children below 15 years of age. Severe epidemics have occurred in the past and there is evidence to suggest that the disease is spreading to new areas. Kerala, which was so far free from JE, experienced the first outbreak in 1996, and since then sporadic cases are being reported. The epidemiology of JE is complex due to a complex transmission cycle of the virus involving a variety of vertebrate and invertebrate hosts. Although considerable information on the disease is available, there are still gaps in know-ledge about the epidemiology which need to be understood in order to develop sound surveillance systems for forecasting epidemics and control strategies. The Centre for Research in Medical Entomology (CRME), Madurai, has addressed these issues for over a decade. In this article, it is intended to provide an update of research to understand the epidemiology of the disease in Tamil Nadu, quantify transmission, and develop surveillance systems, which may serve as paradigms for other endemic areas.

Epidemiology

Human infections

In JE, there is always a preponderance of subclinical infections and therefore, reporting only overt cases underestimates the total level of virus transmission in an endemic area. Subclinical infections can be quantified by estimating seroconversion rates in susceptible age-groups of children.

South Arcot (now Cuddalore) and Thanjavur districts, present two distinct epidemiological patterns. South Arcot is relatively dry but, an extensive epidemic occurred in 1981¹ and since then the disease has remained endemic with many cases of encephalitis occurring regularly each year. Records of the past 10 years show an average annual incidence of 4.7/100,000 population. Thanjavur district is the major rice growing area in Tamil Nadu, and has provided favourable breeding conditions for JE vectors. But, paradoxically there are no outbreaks of JE and the encephalitis case incidence is very low (0.4/100,000). A study between 1989-91 in rural children of the age group 5-9 years in Nallur primary health centre (PHC) in South Arcot district showed that the seroconversion rates for flaviviruses in successive years were 43.7, 67.6 and 47.9%; the seroconversion being predominantly due to JE and minimally to West Nile virus. Relatively high dengue virus activity was seen only in 1991.The estimated ratio of overt: inapparent infections was 1: 270². A 2 year (1991 and 1992) prospective study of comparable age-groups in 3 PHCs in Thanjavur district showed that seroconversion rates for flaviviruses were 32.1 and 25.3% with dengue virus predominating (20 and 8%). JE infection rates were only 2 and 5%. The apparent: inapparent infection ratio was 1: 1774 (unpublished observations). Clearly the transmission intensity in Thanjavur district is much lower than that in South Arcot district. Reasonably assuming that the virulence of the virus is similar in both these contiguous districts, the low case incidence in Thanjavur may be due to the low intensity of JE transmission.

Complete data are not available on the dynamics of JE transmission in Thanjavur district to account for low JE transmission. However, a high cattle:pigs ratio and a high dengue infection rate observed in this district, appear to be important for a discussion on this issue. The vectors of JE are highly zoophagic mainly feeding on large domestic animals. Pigs are the amplifying hosts for JE virus while cattle act as `brakes' for JE virus transmission. In South Arcot district, children in villages with a higher ratio of cattle: pigs showed lower seroconversion rates than in villages with lower ratios². Therefore, the relative abundance of these hosts appears to be important in modulating the JE activity in an endemic area. In Thanjavur, the ratio of pigs: cattle was 1: 400, whereas in South Arcot it was 1: 4. This suggests that a lower pig and higher cattle density may be an important factor in limiting JE transmission in Thanjavur district.

In both years of study in Thanjavur district, dengue virus was predominant. In 1991, when dengue infection rate was 20%, the JE infection rate was 2% and in 1992 when dengue infection rate declined to 8%, the JE infection rate rose to 5%. A similar observation was made in South Arcot district also. In 1989 and 1990, the JE infection rate was 30 and 39% respectively and during these years there was no evidence of dengue virus activity. In 1991, there was a spurt in dengue virus activity and an infection rate of 16% was recorded with a decline in JE virus infection to 24%². These observations suggested that dengue and JE virus infections may be mutually exclusive. Earlier workers have also observed that children exposed to dengue were in someway protected against development of JE^3,4. However, more epidemiological data are needed to define the role of dengue in the context of low transmission in Thanjavur district.

JE incidence appears to be generally higher in males than in females (male: female ratio 2: 1 in Kolar⁵ and 1.0: 0.8 in Nallur²). But subclinical infections occurred equally in both sexes, since seroconversion rates for males and females were comparable in both the South Arcot and Thanjavur districts indicating that both sexes were similarly exposed to infection. Therefore, it is important to know whether gender difference in disease incidence is real or due to some other confounding factor(s).

Mosquito infection

Vector infection rate is an important parameter for quantifying transmission potential of vectors and risk of transmission to humans. From the serological study in South Arcot district it was estimated that the probability of a child receiving an infective mosquito bite during the JE virus transmission season was between 0.5 to 0.75². This implied a high transmission potential of vector population. Vector infection frequency in relation to vector abundance was studied between 1991 and 1994 in the same areas where serological study was conducted previously. Out of 5710 pools (285, 531 mosquitoes) processed, 91 virus isolations were made and 80% of them were identified as JE. Vector abundance and minimum infection rate (MIR) increased from July concurrently with the initiation of rice cultivation but MIR peaked in September followed by a decrease in October, whereas mosquitoes remained abundant until March. The decrease in MIR from October onwards coincided with the rising herd immunity in pigs. Although MIR in October (0.47) and November (0.42) were lower than in September (0.92), a comparable high risk of infection continued because of high vector abundance and human biting rates and most episodes of encephalitis occurred during these months (Fig. 1). The estimated probability of a child receiving an infective bite was 0.53 per transmission season, which reasonably agreed with the estimated probability (0.5 to 0.75) based on serological studies⁶. A similar study may help in explaining the low transmission level observed in Thanjavur district.

The JE virus is maintained in nature by a complex cycle that involves pigs as amplifying hosts, ardeid birds as reservoirs and mosquitoes as vectors. Thus, the virus is maintained mainly through biological transmission between vertebrate hosts by vector mosquitoes. Vertical transmission of JE virus in mosquitoes has been observed, but was considered of no epidemiological significance, in the belief that it occurred rarely, if at all, in nature. However, recent studies in the field by Dhanda et al⁷, showed that vertical transmission may occur quite frequently, but its real epidemiological significance is as yet unclear. In order to understand more about vertical transmission, scientists at the CRME conducted a study between 1994-97 in Cuddalore (a high JE endemicity area) and Madurai (a very low JE endemicity area) districts. There was a clear difference in vertical transmission between the two areas. In Cuddalore district 2720 pools (136,000 mosquitoes) of adults reared from wild-caught immatures were examined for virus infection and the MIR was 2.62.

Fig. 1. (A) Encephalitis patients. (B) Pig census by age with calculated number seroconverted. (C) Vector infection. Minimum infection rate (MIR)/1,000 mosquitoes tested. (D) Vector abundance. Number of female adults collected per man hour (F/MH).

The MIR showed a higher peak during the hot months (April to July) and a lower one during the cool months of September to February (Fig. 2). This correlated significantly with infection in wild-caught adults. In Madurai district 968 pools (42,418 mosquitoes) were examined, and the MIR was 0.54. There was no difinite pattern in seasonal variation in infection rates (unpublished observations). In South Arcot district in general, during hot months vector density is very low and very few non- immune pigs are available⁶. Therefore, vertical transmission may be an adaptation by the JE virus to tide over these adverse conditions.

Fig. 2. Minimum infection rate (MIR) of Cx. tritaeniorhynchus adults reared from immatures in Cuddalore and Madurai districts.

Suspected vectors

JE virus has been isolated from 10 species of genus Culex, 2 species of Anopheles and 3 species of Mansonia in India⁸. However, Culex tritaeniorhynchus and Cx. vishnui have been incriminated as the primary vectors of JE. Role of Anophelines in transmission of JE virus has not been systematically studied. A 2 year study in Cuddalore district showed that abundance of Anopheles subpictus (the dominant species among Anopheles in the rice ecosystem) was much lower than that of Cx. tritaeniorhynchus. The density of An. subpictus was higher in hot months (non-JE transmission season) than in cool months (transmission season). This species fed poorly on pigs (0.6%) and humans (0.3%) and JE virus infection was not detected. In a parallel study with Cx. tritaeniorhynchus, 2.9% fed on pigs, 2.9% on humans, the MIR was 0.57, and the density was high during JE transmission season. Therefore, it is unlikely, that An. subpictus species plays a role in JE virus transmission in Cuddalore district.

In the recent Kerala outbreak, of the 12 JE virus isolations, 4 were from Mansonia species⁹. Previously, one isolation was made from Ma. annulifera in Dibrugarh, Assam¹⁰ and one JE virus antigen positive pool was detected in Mandya district, Karnataka¹¹. Four isolations from a small number of Mansonia species in Kerala is noteworthy. Therefore, a detailed study of the vectorial potential of Mansonia species (which are vectors of brugian filariasis in Kerala) for JE transmission in Kerala has been planned.

Surveillance

Human encephalitis

Encephalitis case surveillance is based on the clinical and laboratory diagnosis¹². Encephalitis caused by other viruses does not usually occur in epidemic forms, and therefore, JE must be suspected in any large outbreaks particularly those occurring during the monsoon and post- monsoon months. When an epidemic occurs in a new area, laboratory confirmation is essential. But, when the presence of JE has been repeatedly demonstrated in an endemic area it may not be necessary to confirm every case of encephalitis. Nevertheless, for surveillance records in a new area it is essential to determine the proportion of JE among encephalitis cases. For example, in South Arcot district during the JE transmission seasons of 1993-1995, 85 patients (mostly paediatric) with acute central nervous system diseases were examined using a battery of laboratory diagnostic tests for JE. In 53 patients (62.4%) a diagnosis of JE was established. In terms of diagnostic value IgM antibody capture ELISA (MAC ELISA) on convalescent serum had the highest sensitivity (89%) and negative predictive value (NPV) (50%) followed by MAC ELISA on acute serum and CSF which had similar sensitivity (84%) and NPV (40%). The IF test to detect JE virus antigen in CSF cells was least sensitive (58%) but the distinct advantage of this test was that it could be completed in about 2-3 h¹³. The MAC ELISA can be performed using finger-prick blood specimens. Therefore, MAC ELISA and IF tests are particularly appropriate in JE surveillance programmes.

Vector surveillance

Vector abundance and vector infection are two important parameters in vector surveillance. A simple Dusk Index (DI) defined as a product of the average number of vector females per man-hour in dusk collections and proportion parous, has been developed which can be used for monitoring vector abundance. In a study in Thanjakoor, near Madurai, significant human-biting activity was not observed when the value of DI was less than 50 parous females per man hour¹⁴. However, DI needs further validation in different epidemiological situations.

An antigen capture ELISA for detection of JE virus in wild-caught mosquito has been recently validated in a large-scale field trial in South Arcot district⁶. This rapid screening system is particularly appropriate as a surveillance tool. Laboratory and field studies showed that JE virus antigen can be detected in desiccated mosquitoes by ELISA. Therefore dried specimens of vectors collected from the peripheral surveillance stations can now be sent by mail to the Central Laboratory for testing for JE virus.

A project has been initiated in order to establish a surveillance network for JE in Tamil Nadu, utilizing the 4 Zonal Entomological Teams in JE prone areas (Trichy, Cuddalore, Madurai and Virudhunagar). Peripheral health workers have been trained in JE vector taxonomy, determining vector density and submitting dried mosquito materials to CRME for detection of JE virus. From March 1996 to February 1998, of 200 pools of dried mosquito specimens submitted by these teams 3 were found positive for JE virus antigen by ELISA.

Sentinel animals

Pigs are the natural hosts of JE virus and can therefore serve as sensitive sentinel animals. But, being amplifying hosts for JE virus, introduction of non-immune pigs to endemic areas as sentinels is unethical. Further, being very sensitive to JE virus infection, the pig may serve as a sensitive indicator of JE virus activity in a given area, but it may not be a good predictor of the risk to humans of JE virus infection¹⁵. Other common domestic animals, such as cattle and goats have been found to be positive for JE antibodies after natural JE virus infections¹⁶. Moreover, JE virus does not multiply in them and therefore may be safely used as sentinels. But, cattle are large, difficult to handle, and the owners do not allow them to be bled. On the other hand, goats are small, can be easily handled and collection of blood is not a problem. Therefore, the CRME has commenced a study to examine whether goats can serve as natural sentinels for JE virus activity in Cuddalore district. After the transmission season of 1997, 35 of 100 goats examined were found to be positive for HI antibodies to JE virus. It is proposed to follow a cohort of goats to determine seroconversion rates in different seasons.

In India millions of children are exposed to JE virus infection each year in endemic areas and hundreds of them suffer from JE. JE is a vaccine preventable disease but, unfortunately there has been no national policy on vaccination against JE. This is partly because there is a lack of epidemiological data from different endemic areas which can focus on the gravity of situation. Epidemics of JE continue to occur in different parts of the country and the disease is spreading to newer areas. But, epidemic-prone states have no plans to set up effective surveillance systems which are urgently needed to monitor JE activity. It is essential that appropriate control measures are taken based on sound knowledge of epidemiology and surveillance strategies, so that the disease can be controlled.

References

1. Mohan Rao, C.V.R., Risbud, A.R., Rodrigues, F.M., Pinto, B.D. and Joshi, G.D. The 1981 epidemic of Japanese encephalitis in Tamil Nadu and Pondicherry. Indian J Med Res 87: 417, 1988.

2. Gajanana, A., Thenmozhi, V., Philip Samuel, P. and Reuben, R. A community-based study of subclinical flavivirus infections in children in an area of Tamil Nadu, India, where Japanese encephalitis is endemic. Bull WHO 73: 237, 1995.

3. Hammon, W. McD, Tigertt, W.D., Sather, G.E., Berge, T.O. and Meik Lejohn, G. Epidemiologic studies of concurrent "Virgin" epidemics of Japanese B encephalitis and mumps on Guam, 1947-1948 with subsequent observations including dengue through 1957. Am J Trop Med Hyg 7: 441, 1958.

4. Grossman, R.A., Edelman, R. and Gould, D.J. Study of Japanese encephalitis virus in Chiangmai Valley, Thailand. VI. Summary and conclusions. Am J Epidemiol 100: 69, 1974.

5. Gourie-Devi, M. Clinical aspects and experience in the management of Japanese encephalitis patients. In: Proceedings of the National Conference on Japanese Encephalitis. Indian Council of Medical Research, New Delhi, p 25, 1984.

6. Gajanana, A., Rajendran, R., Philip Samuel, P., Thenmozhi, V., Tsai, T.F., Kimura-Kuroda, J. and Reuben, R. Japanese encephalitis in South Arcot district, Tamil Nadu, India: A three-year longitudinal study of vector abundance and infection frequency. J Med Entomol 34: 651, 1997.

7. Dhanda, V., Mourya, D.T., Mishra, A.C., Ilkal, M.A., Pant, U., George, J.P. and Bhat, H.R. Japanese encephalitis virus infection in mosquitoes reared from field-collected immatures and in wild-caught males. Am J Trop Med Hyg 41: 732, 1989.

8. Reuben, R. and Gajanana, A. Japanese encephalitis in India. Indian J Pediatr 64: 243, 1997.

9. Dhanda, V., Thenmozhi, V., Kumar, N.P., Hiriyan, J., Arunachalam, N., Balasubramanian, A., Ilango, A. and Gajanana, A. Virus isolation from wild-caught mosquitoes during a Japanese encephalitis outbreak in Kerala in 1996. Indian J Med Res 106: 4, 1997.

10. Chakravarty, S.K., Chakraborty, A.K., Mukherjee, K.K., Mitra, A.C., Hati, A.K. and Chakraborty, M.S. Isolation of Japanese encephalitis (JE) virus from Mansonia annulifera species of mosquitoes in Assam. Bull Cal Sch Trop Med 129: 3, 1981.

11. Mourya, D.T., Ilkal, M.A., Mishra, A.C., George, J.P., Pant, U., Ramanujam, S., Mavale, M.S., Bhat, H.R. and Dhanda, V. Isolation of Japanese encephalitis virus from mosquitoes collected in Karnataka state, India during 1985-1987. Trans R Soc Trop Med Hyg 83: 550, 1989.

12. Japanese Encephalitis in India: Information Document. National Institute of Virology, Pune, p 6, 1980.

13. Gajanana, A., Philip Samuel, P., Thenmozhi, V. and Rajendran, R. An appraisal of some recent diagnostic assays for Japanese encephalitis. Southeast Asian J Trop Med Public Health 27: 673, 1996.

14. Mani, T.R., Mohan Rao, C.V.R., Rajendran, R., Devaputra, M., Prasanna, Y., Hanumaiah, Gajanana A. and Reuben, R. Surveillance for Japanese encephalitis in villages near Madurai, Tamil Nadu, India. Trans R Soc Trop Med Hyg 85: 287, 1991.

15. Peiris, J.S.M., Amerasinghe, F.P. Arunagiri C.K., Perera, L.D., Karunaratne, S.H.P.P., Ratnayake, C.B., Kulatilaka, T.H. and Abeysinghe, M.R.N. Japanese encephalitis in Srilanka: Comparison of vector and virus ecology in different agro-climatic areas. Trans R Soc Trop Med Hyg 87: 541, 1993.

16. Rodrigues, F.M. Epidemiology of Japanese encephalitis in India: A brief overview. In: Proceedings of the National Conference on Japanese Encephalitis. Indian Council of Medical Research, New Delhi, p 1, 1984.

Some Research Projects Completed Recently

Role of some non-steroidal anti-inflammatory drugs in carcinogenesis.

The study was carried out in male weanling inbred Swiss mice to evaluate the role of non-steroidal anti-inflammatory drugs (NSAIDs) viz. piroxican, diclofenac and naproxen in carcinogenesis. The animals were fed the NSAIDs through diet. For mechanistic studies the doses of diclofenac, naproxan and piroxican were 25, 75 and 375 ppm; 150, 500 and 1500 ppm; and 3, 10 and 30 ppm respectively for 4 weeks. For tumour studies the highest doses of the NSAIDs were used with carcinogen Nitrosodiethylamine (NDEA) in the dose of 80 mg/kg body wt. at 4 weekly intervals thrice.

Diclofenac in a dose of 375 ppm in the diet inhibited NDEA induced lung tumourigenesis by acting at the initiation and post-initiation phases of carcinogenesis, whereas naproxen in a dose of 1500 ppm stimulated the promotional phase of carcinogenesis.

Ornithine decarboxylase (ODC), which is the rate limiting enzyme in mammalian polyamine biosynthesis required for tumour promotion and cell proliferation in various organs, was inhibited by diclofenac and piroxican, but was stimulated by naproxen indicating that this enzyme is a good marker for tumourigenesis and for agents with anticarcinogenic properties.

Prostaglandin E₂ release, which is involved in inflammation and tumour promotion, was decreased to a variable degree in plasma, liver and lung by all three NSAIDs tested; diclofenac being the strongest, and naproxen the weakest inhibitor. Diclofenac and piroxican slowed down the NADPH and ascorbate dependent microsomal lipid peroxidation in vivo and in vitro, whereas naproxen at a concentration of 10 mM stimulated the process. It seems that besides being a scavenger of free radicals, enzymatic metabolism of naproxen at higher concentration formed reactive intermediates/free radicals which exceeded its scavenging capacity. The feeding of NSAIDs to mice inhibited the process of lipid peroxidation and stimulated the tissue antioxidant defense system comprising superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase and reduced glutathione. It also resulted in the decrease in cytochrome P-450 levels.

Increased activities of glutathione-s-transferase, glutathione reductase and reduced glutathione by NSAIDs may detoxify the xenobiotics more efficiently. The enhanced levels of reduced glutathione, in addition may provide protection to tissues against the damaging action of free radicals.

The enhanced tumourigenesis and ODC levels produced by naproxen requires further evaluation for its safety.

Evaluation of intra-ocular lens implantation in children.

Intra-ocular lens (IOL) implantation was evaluated in 75 eyes of 45 patients aged 14 months to 12 yr, with congenital, traumatic and developmental cataracts. Of the 75 eyes, 30 eyes were from 15 patients with congenital cataract, 15 from 15 patients with traumatic cataract and 30 from 15 patients with developmental cataract. For comparison 15 eyes (4 with congenital, 6 with traumatic and 5 with developmental cataracts) had surgery without IOL implantation (aphakic eyes). Eyes with associated systemic or ocular pathologies (other than amblyopia and strabismus) likely to affect visual prognosis later were excluded from the study.

Posterior chamber intra-ocular lenses in the range of +20 to +24 D were implanted after computerized power calculation keeping the amblyopia factor and prospective adulthood refraction in mind, and managing the school age children with low powered bifocals.

IOL implantation was found to be difficult in children compared to adults. Pseudophakes were found to have distinct advantages of better quality good binocular vision compared to aphakes who suffered from problems of magnification, disorientation, cosmetic blemish, field restrictions, anisometeropia and diplopia caused by aphakic correction. Problems of poor compliance, corneal complications and costly replacements seen with contact lens use were also eliminated with IOL implantation. Placement of the IOL in the bag is close to the physiological and anatomical positions of the natural lens and hence comparatively safe.

Intra-operative problem of scleral collapse in children was managed by application of Fleringa's ring under general anaesthesia. Post-operative severe uveitis responded to frequent administration of steroid drops for 8 to 12 weeks as well as oral steroids in the first week. Pupillary capture in 80% cases of cataract was prevented by keeping the pupil mid dilated. Over 86% of patients showed early after cataract (post capsular thickening) which responded to early YAG-laser capsulotomy in children aged above 5 yr, while this complication could be handled by secondary discission within 6 months of surgery in the age group below 5 yr. Best results were obtained in 14% of patients where primary post capsulotomy/rhexis with anterior vitrectomy was done followed by IOL implantation.

It can thus be concluded that IOL implantation is a safe and effective aphakic rehabilitation method in the management of developmental and congenital cataracts as also in the case of traumatic cataract. However, the final visual outcome in traumatic cataract depends upon the amount of damage that had occurred to various ocular structures due to the injury.

Visual recovery may be further improved and rate of complications reduced by lowering of intra-ocular pressure preoperatively, use of scleral support to prevent scleral collapse, control of iritis and maintaining pupillary mobility, promt management of posterior capsular opacification along with vigorous amblyopia therapy.

The following meetings of various technical groups/committees of the Council were held:

Meeting of the Scientific Advisory Committee (SAC):

SAC of the Centre for Advanced Research on Standardization, Quality Control and Formulation of Traditional Remedies/Natural Products, Jammu,April 2, 1998 (at Jammu)

Meetings of the Expert Group (EG)/Project Review Committee (PRC) and Annual Review Meetings held at New Delhi:

Meeting on Situation Analysis of HIV and Drug Abuse in the NE Region ,March 24, 1998

EG on Scientometric Studies, March 25, 1998

Annual Review Meetings on Traditional Remedies for (i) Bronchial asthma and (ii) Diabetes mellitus , March 25, 1998

PRC on Tuberculosis, Leprosy, Viral Diseases and other Microbial Infections, April 15, 1998

Workshop/Seminar

A workshop on Cancer Registration under the National Cancer Registry Programme was organised at the Cancer Institute, Chennai, (April 2-4, 1998).

A seminar on Situation Analysis of HIV and Drug Abuse in the NE Region was organised at the Regional Medical Research Centre, Dibrugarh, (April 6-8, 1998).

Participation of ICMR Scientists in Scientific Events:

Dr. T. Adak, Asstt. Director, Malaria Research Centre (MRC), Delhi, participated in the Workshop on Validation of the Membrane Feeding Assay as a Tool for Development of Malaria Transmission-Blocking Vaccines at Bamako, Mali, (March 21-28, 1998).

Dr. N.K. Ganguly, Director-General, ICMR, participated in the Indo-French Seminar on New Opportunities in Molecular Technologies at Bangalore, (March 26-27, 1998).

Dr. N.K. Ganguly, D.G., ICMR, Dr. V.P. Sharma, Director, MRC, Delhi and Dr. S.K. Bhattacharya, Director, National Institute of Cholera and Enteric Diseases, Calcutta, participated in the III International Conference on Emerging Infectious Diseases in the Pacific Rim at Bali (March 28-30, 1998).

Dr. Aruna Srivastava, Asstt. Director, MRC, Delhi, participated in the GIS'98/RT'98 International Conference at Toronto, (April 6-8, 1998).

** ** ** **

Dr. B.N. Saxena, Additional Director-General, ICMR and Chief, Division of Reproductive Health and Nutrition, retired on March 31, 1998.

COUNCIL'S TRAINING PROGRAMMES FOR 1998-99

Leprosy

At the Central JALMA Institute for Leprosy, Agra:

• Multidrug Therapy Orientation Course in Leprosy for Medical Officers (April 6-17, August 17-28, October 26-November 6; and December 7-18, 1998).

Virology

At the National Institute of Virology, Pune:

• Diploma in Medical Virology (July 1998-May 1999).

Reproductive Biology

At the Institute for Research in Reproduction, Mumbai:

• Workshop on Andrology for Clinicians (November 16-30, 1998)

Endocrinology

At the National Institute of Nutrition, Hyderabad:

• Annual Certificate Course on Endocrinological Techniques and their Applications (August 1-September 15, 1998).

Nutrition

At the National Institute of Nutrition, Hyderabad:

• M.Sc. in Applied Nutrition (June 1, 1998-February 28, 1999).
• Postgraduate Certificate Course in Nutrition (December 1, 1998-February 28, 1999).

Laboratory Animal Technology

At the National Centre for Laboratory Animal Science, National Institute of Nutrition, Hyderabad:

• Training Course for Laboratory Animal Technicians (June 16-July 31, 1998).

Occupational Health

At the National Institute of Occupational Health, Ahmedabad:

• Training Course on Environmental Hygiene Practice (November 16-20, 1998).

Biomedical Statistics

• Basic Course in Statistics for Postgraduate Medical Students (July 1998).
• Basic Course in Statistics for Medical Officers (November 1998).

Grant-in-aid for organising Seminars/Symposia/Workshops

The Council provides partial financial assistance for organising Seminars/Symposia/Workshops. Applications for grant of financial assistance (complete in all respects in the prescribed proforma), will be considered only if furnished at least four months before the date of commencement of the Seminar/Symposium/Workshop, etc.

EDITORIAL BOARD

Editor

Dr. N. Medappa

ICMR BULLETIN

CLINICAL FEATURES, PATHOGENESIS AND MANAGEMENT OF LYMPHATIC FILARIASIS

Lymphatic filariasis of man is due to infection by three lymphatic dwelling filarids, viz Wuchereria bancrofti, Brugia malayi and Brugia timori transmitted principally by Culex quinquefasciatus, Mansonia species and Anopheles barbirostris mosquitoes respectively. Infection by B. timori does not occur in India.

Although lymphatic filariasis has been identified as eradicable or potentially eradicable among the six infectious diseases by the International Task Force for Disease Eradication¹, it is still a major public health problem in many parts of the world including India². Recent estimates show that there are approximately 119 million persons afflicted with this disease world-wide; 106.19 and 12.91 millions with bancroftian and brugian filariasis respectively³. In India, currently 411.65 million people are exposed to the risk of infection, of which only 46 million are protected² and there are 31.26 million microfilaria carriers and 48.11 million persons with chronic disease³. The current burden of disease globally and that in India is depicted in Table I.

All states and union territories except those of Jammu & Kashmir, Himachal Pradesh, Punjab, Haryana, Chandigarh, Delhi, Rajasthan, Arunachal Pradesh, Meghalaya, Mizoram, Nagaland, Manipur, Tripura and Sikkim are endemic for bancroftian filariasis². About 95% of the total infection is due to W. bancrofti³. Brugian filariasis is mainly found in Kerala, but scattered foci of low prevalence are reported in Orissa, Assam, Madhya Pradesh, Andhra Pradesh and Tamilnadu. A focus of sub-periodic bancroftian filariasis has been described in the Nicobar Islands⁴.

Table I. Disease burden of lymphatic filariasis in the world and in India.

Categories of cases	Number of cases in millions
	W. bancrofti		B. malayi		Total
	World	India	World	India	World	India
Microfilaria carriers	73.27	29.46	10.36	1.80	83.63	31.26
						(37.00)
Lymphoedema	13.21	6.58	2.81	0.86	16.02	7.44
						(46.40)
Hydrocele	26.79	12.88	_	_	26.79	12.88
						(48.00)
Total cases#	106.19	45.53	12.91	2.58	119.10	48.11
		(42.88)				(40.30)

Figures in parentheses show contribution of India to the world burden of disease in percentage.
# Excludes cases which have both infection and disease
Source:- Reference 3

This disease due to its prolonged course and non fatal nature has attracted little attention of the health planners, thus a low priority has been accorded by the States to the National Filaria Control Programme⁵. The disease, however, has serious socio-economic impact on the society by the significantly lowered productivity and economic loss resulting from its chronicity^6-11. In addition, there are stigmatizing effects due to the grotesque disfigurements as sequelae of the disease. The number of individuals world-wide with overt physical disabilities resulting from the infection is approximately 43 million, with bancroftian filariasis accounting for about 40 million of these cases¹². Lymphatic filariasis is the second leading cause of permanent physical disability in humans next to mood disorders¹³.

The public health impact of different diseases is compared by using Disability Adjusted Life Years (DALYs) as a standardized metric by the World Bank Development Report (WDR)¹⁴. By using current estimates of the disease incidence with focus on chronic manifestations only, the global burden of lymphatic filariasis by this measure has been estimated by WDR to be 850,000 DALYs lost representing a mere 0.23% of the total global burden of parasitic and infectious disease. This is seen as a gross underestimate of the disease incidence which ignores the influence of acute disease on DALYs^4,6. It has been estimated that on an average 23.4 and 26.5 man-days are lost per individual per year due to bancroftian and brugian filariasis respectively and an overall 162.12 million man-days are lost per year in India due to acute filarial attacks¹⁵. If the cost of treatment including hospitalization and surgical procedures were also to be included, the actual loss would have been manifold. Acute disease is likely to be many times more prevalent than the chronic¹⁶. In a recent study in an endemic rural area of Tamil Nadu in south India, it was shown that the mean cost incurred on treatment of each episode of the acute disease ie. adenolymphangitis (ADL) amounted to Rs. 2.35. It was further estimated, that the cost of treatment of the acute disease (per attack of ADL) was equal to the wages for 2 days for men and for 4 days for women¹⁷. Presently, filariasis control does not only imply interruption of disease transmission, but also morbidity control by appropriate medical or surgical procedures. In addition, there has of late been a sea change in our understanding of the pathogenesis and progression of the disease process by hitherto unavailable diagnostic tools like ultrasound¹⁸ and lymphangioscintigraphy^19-21. The definition of the infected person itself has taken a U-turn, since the individual without symptoms or microfilaria in a filaria endemic zone can no longer be considered normal following direct visualization of the parasite by the use of these new diagnostic technologies and by the detection of renal and lymphatic abnormalities in apparently normal individuals. The principles of mass as well as individual chemotherapy have also witnessed a dramatic change. The current review encompasses these recent advances in the understanding of lymphatic filariasis.

Clinical Features

The clinical manifestations of lymphatic filariasis tend to vary in different geographical locations^22,23. The disease spectrum of bancroftian and brugian filariasis varies widely from an asymptomatic state to a severely debilitating chronic condition. Depending upon the infection status of the individuals in endemic areas and the resulting clinical consequences thereof, five main categories of the filarial clinical spectrum have been recognized⁴. These are: (i) asymptomatic amicrofilaraemia; (ii) asymptomatic microfilaraemia; (iii) acute manifestations; (iv) chronic manifestations; and (v) allergic manifestations.

Besides, there are reports of manifestations like glo-merulonephritis and monoarthritis in patients with bancroftian filariasis^24-27.

Asymptomatic Amicrofilaraemia

A proportion of individuals in endemic areas neither show any microfilaria (mf) in the blood nor exhibit any symptoms. This may comprise persons who have not been exposed enough to become infected or persons though sufficiently exposed, do not show any detectable infection by current diagnostic techniques⁴. It may be that they have successfully cleared the infection (immune individuals) or are harbouring developing worms of one sex or unfertilized female adult worms. This group may have subclinical infection as evidenced by detectable antigenaemia^28-34.

Asymptomatic Microfilaraemia

Some individuals who develop microfilaraemia do not manifest any clinical disease. Among these, some may remain asymptomatic for years even for life, while others manifest clinical disease with or without losing the microfilaraemic status⁴. Besides, this group of individuals shows lowered parasite specific IgE response but generate large amounts of specific antibody of the IgG₄ class which is considered as a blocking antibody^33,35.

Acute Manifestations

The acute manifestations are characterized by episodic attacks of ADL with constitutional symptoms like fever, chills, malaise, headache, nausea and vomiting^4,36,37. The ADL attacks usually involve the limbs and the groins and also the male genitals (acute funiculitis or epididymitis or orchitis, most commonly involving all three simultaneously), the female breast and rarely other sites. Acute attacks never occur at more than one site at the same time³⁶. In case of the limb, groin or breast, there are local signs of lymphangitis and lymphadenitis (redness, swelling, raised local temperature, pain and tenderness at the local site). These attacks have been described as adenolymphangitis, since the patients usually complain of lymph node involvement followed by retrograde lymphangitis^36,38. Sometimes infection of deep lymphatics may mimic an acute abdominal emergency as if to require surgical intervention immediately^39,40.

The ADL attacks commonly occur in patients with established chronic filarial disease, more frequently with lymphoedema than with hydrocele³⁴. The attacks can also occur in asymptomatic persons, many of whom present with lymphoedema with the first attack itself. Most often, repeated attacks of ADL precede the development of chronic lymphatic pathology of filariasis and these often continue for many years^34,41. The ADL attacks usually last for about 3 to 5 days, but rarely may be prolonged upto a fortnight^10,16,37,41. The frequency of these attacks is usually 1 to 3 in a year. However, it can also be more than twice a month in some patients¹⁶. Each attack of fever and lymphadenitis subsides spontaneously with a crisis. Lymphoedema is frequently present during these episodes, but usually subsides after the acute stage. With time, resolution of the lymphoedema after each attack becomes less complete and the characteristic chronic changes develop⁴².

Chronic Manifestations

The common chronic manifestations of lymphatic filariasis affect the male genitals and limbs of both sexes. Most of these patients are amicrofilaraemic^39,43-46. The incidence and severity of these chronic clinical manifestations tend to increase with age^4,47,48. These manifestations are the result of structural damage following lymphatic obstruction and fibrosis. In brugian filariasis, genitals are rarely involved.

Hydrocele

Hydrocele is the commonest manifestation of chronic bancroftian filariasis. It has only been very rarely recorded in brugian filariasis. It presents as a swelling of the peritoneal lining that surrounds each of the testicles. A clear straw coloured fluid accumulates in the closed sac (hydrocele) as a result of the blockage in the lymphatics draining the retro-peritoneal and sub-diaphragmatic areas. Rarely the fluid has a milky appearance caused by the presence of chyle, a condition known as chylocele. Sometimes mf can be detected in the hydrocele fluid^4,49. Besides hydrocele, chronic epididymitis, funiculitis, lymph scrotum (vide infra) are other genital manifestations of chronic bancroftian filariasis in males⁴. Though in an endemic region hydrocele is assumed to be of filarial origin and conventionally used as an absolute indicator of filarial disease in clinical surveys, even in known endemic areas of India, eg., Pondicherry and Orissa, only 69 and 43% of cases of hydrocele respectively could be demonstrated to be of definite filarial etiology^49,50. Similar findings have been reported from Puerto Rico⁵¹.

Lymphoedema

For both sexes, and independent of age, it has been observed that approximately 11% of the population at risk eventually develop lymphoedema. Lymphoedema commonly affects the lower limbs, rarely upper limbs and genitals in both sexes and female breast. In both forms of lymphatic filariasis, the legs are most commonly involved^52-54. Lymphoedema can be graded as follows⁵⁵:

Grade I : Oedema spontaneously reversible on elevation.

Grade II : Oedema not spontaneously reversible on elevation, skin normal.

Grade III : Oedema not spontaneously reversible on elevation, skin thickened.

Grade IV : Oedema not spontaneously reversible on elevation, skin thickened with warty/papillomatous growth.

Elephantiasis supervenes following persistent fibrotic changes in the skin and subcutaneous tissue. Elephantiasis can also affect the genitals as stated above (lymph scrotum or penis in males and vulva in females) and the female breast^4,39.

Chyluria

Chyluria is the excretion of milky urine due to admixture of chyle with urine. A minority of the affected subjects complain of gross haematuria. The condition is due to the blockage of the retro-peritoneal lymph nodes below the cisterna chyli, with consequent reflux and flow of the intestinal lymph directly into the renal lymphatics which may rupture and permit flow of chyle into the urinary tract. Microfilaraemia may or may not be present in these patients. The urinary sediment may contain microfilaria and red cells but seldom leucocytes. Chyluria is often symptomless, but some patients complain of fatigue and weight loss due to loss of fat and protein^4,39,56.

Allergic Manifestations

Tropical pulmonary eosinophilia (TPE) is a form of occult filariasis developing in a small proportion of individuals in areas endemic for filariasis. It is considered as an allergic manifestation of the disease with extremely high titres of anti-filarial antibodies⁴. A majority of these antibodies is of IgE class and is directed against microfilaria⁵⁷. Hypereosinophilia is the most common feature with absolute eosinophil counts ranging from 3,000-50,000 cells/mm³ of blood. Here the classical clinical manifestations are not present, with absence of circulating mf in the blood, but probably present in the tissues particularly the lung. The commonest presentation is nocturnal paroxysmal cough with radiological evidence of diffuse miliary lesions or increased broncho-vascular markings and elevated erythrocyte sedimentation rate⁴. There is impaired lung function in most cases with a reduction in the vital capacity, total lung capacity and residual volume⁵⁸. Males are affected twice as often as females and the disease is rarely reported in children⁴. The therapeutic response to diethylcarbamazine (DEC) is generally good. If untreated (even in some treated cases) TPE may progress to chronic pulmonary fibrosis⁵⁸.

Differences between Bancroftian and Brugian Filariasis

In India, bancroftian and brugian filariasis are characterized by a wide range of clinical manifestations presented by only a small proportion of infected individuals.

Although, it has been reported that in bancroftian filariasis genital involvement is more in the north Indian states when compared to states in south India²², subsequent studies have shown that the disease distribution is more or less uniform^44,59. The reported discrepancy was attributable to the difference in methods of clinical examination and improper survey design⁴⁸. In periodic brugian filariasis in Kerala, the clinical spectrum of the disease though found to be generally similar to that reported elsewhere in the world,^6,36,60 the progress of oedema to elephantiasis was observed to be a slow process extending even upto a period of 20 years probably related to the frequency of ADL attacks⁵³, and abscess formation in the inguinal lymph nodes and along the main lymphatic channel was found to be rare⁵³ though reported to be common in similar infection in Indonesia⁵² and Sri Lanka⁶. This is in contrast to bancroftian infection in south India where elephantoid changes and dermatosclerosis appear more rapidly⁵³. In brugian filariasis, involvement of the male genitals was found to be much less common as compared to bancroftian filariasis in Kerala⁵³ as found elsewhere^6,36. A comparison between the clinical aspects of the two forms of lymphatic filariasis is shown in Table II.

Table II. Comparison of clinical aspects of bancroftian and brugian filariasis.

Parameter	Bancroftian filariasis	Brugian filariasis
Progression of the disease53	Fast	Relatively slow
Relation with gender39,48,53	Occurrence in males more than in females	No difference between genders
Frequency of acute attacks per year in patients with lymphoedema34 Grade I Grade II Grade III	4.9±1.70 5.5±1.01 10.4±3.20	0.9±0.22 2.5±0.29 5.1±1.08
Mean duration (yr) of lymphoedema34 Grade I Grade II Grade III	0.1±0.02 5.8±0.56 8.6±0.92	0.1±0.01 13.6±1.17 28.7±2.66
Involvement of male genitals39,53	Common	Rare
Extent of elephantiasis39	Above kneee	Below kneee

Superscript numbers refer to sl.nos. in the reference list.

Filarial arthritis which may manifest in endemic regions is monoarthritic usually affecting the knee joint. Other conditions suggested to be associated with lymphatic filariasis include endomyocardial fibrosis, glomerulonephritis, thrombophlebitis, tenosynovitis, nerve palsies, dermatoses, etc. Lymphoedema has also been considered to predispose to lymphosarcoma⁶¹.

Pathogenesis

Observations on studies undertaken in Pondicherry and Calcutta suggest that filariasis endemic populations consist of individuals who remain amicrofilaraemic and asymptomatic and those who progress through the sequence: uninfected, microfilaraemic and amicrofilaraemic to develop irreversible lymphatic pathology⁶².

Conventionally, it had been the view that the pathogenesis of the lymphatic abnormalities in this disease is essentially mediated by the immune system of the host³³ but the advent of recent techniques such as ultrasound¹⁸ and lymphangioscintigraphy^19-21 has shown that factors other than immunological, such as the parasite itself may play a role in the pathogenesis. The presence of the adult worms in the lymphatics causes early lymphatic dysfunction and dilatation etc due to factors released by the parasite as described in other systems⁶³ or elaborated directly by the host. The primary role of the immune system in this early lympathic dysfunction appears to be the production of down-regulatory molecules which contain or inhibit inflammatory responses⁶⁴; this hypothesis being supported by recent findings that cytokine responsiveness in microfilaraemics is of the Th-2 type ie. heightened production of interleukins-4, -5 and -10 which are contra-inflammatory ^65,66. Th-2 type down regulating suppressive cytokines in asymptomatic microfilaraemics facilitate persistence of the parasite in the host while inducing little or no inflammatory clinical disease. IL-4 stimulates B cells proliferation resulting in IgG₄ and IgE production where IgG₄ acts as blocking antibody with consequent reduction of the inflammatory activity of IgE²⁹. This contrasts with the relatively pro-inflammatory Th-1 response seen in amicrofilaraemic patients with chronic lymphatic pathology following breakdown of this tolerance. This is associated with a high level of IgE, IgG₁ and IgG₂ and low level of IgG₄. Elephantiasis may result by IgE mediated mechanisms or a passive reaction to naturally dying adult worm evoking IgG₁ and IgG₂ antibody response mediating inflammatory reactions. This immunological hyper-responsiveness may remove the parasite from circulation as in developing lymphoedema⁶⁷.

Though microfilaraemics remain asymptomatic for long periods, they cannot be considered to be truly free from any abnormalities. The asymptomatic state earlier thought to be benign is no longer so; it has been demonstrated that most of the so called asymptomatic microfilaraemics have lymphatic abnormalities as detected by lymphangioscintigraphy and also renal abnormalities as evidenced by microscopic haematuria and/or proteinuria. Renal abnormalities are generally reversible after treatment²⁷. Prenatal tolerance to filarial antigens has been shown to determine immune responsiveness to the parasite and thereby the development of lymphatic pathology ie. children born of microfilaraemic mothers are much less capable of responding to filarial antigens than those born of non-infected mothers^68,69. However, recent studies on bancroftian microfilaraemia in children in relation to parental infection have shown that there

is hardly any role of intrauterine sensitization, since the microfilaraemic status of the father has also been seen to influence microfilaraemia in bancroftian infection of the children⁷⁰. This only highlights the influence of household exposure on all family members.

The findings in animal models parallel those in the affected humans, ie. lymphatic proliferation, dilatation and oedema formation due to the presence of living adults and obstructive, obliterative reactions in the lymphatics around dead parasites. The earliest changes occur four weeks after infection and involve the regional lymph nodes. Within four days of the infecting larvae reaching the lymphatics, there is a marked cell mediated response in the regional lymph nodes followed by an antibody mediated response in the afferent lymphatics. The local lymph node is enlarged followed by an increase in diameter and formation of tortuosities of the lymphatics through which the infective larvae migrate. These changes may revert if the worms are killed by microfilaricidal drugs⁷¹. Following appearance of antimicrofilarial antibodies, resistance to reinfection develops causing obstruction to the lymph flow resulting in lymphoedema. Initially there is an acute inflammatory response characterized by infiltration of polymorphs, histiocytes, eosinophils and lymphocytes around the lymphatics. This is followed by formation of epitheloid granuloma and foreign body giant cells after the death of the adult worms, which may calcify, become lysed and surrounded by fibrosis. Lymphatic abscesses may form at the site of dead and degenerating worms. Finally, the lymphatics are obliterated by fibrosis with the disappearance of microfilariae from the blood⁷¹. Lymph stasis results in increased susceptibility to secondary bacterial infection particularly with group A streptococci resulting in episodic attacks of ADL. Each attack of ADL results in the progression of chronicity of disease and increased lymph stasis, thereby, again increasing susceptibility to ADL attacks¹⁶. This culminates in fibrosis with the formation of solid oedema and probable decline in ADL attacks.

The pathogenesis of late stage abnormalities (lymphoedema and elephantiasis) includes an inflammatory component comprising significant cellular infiltration in the epidermis and hypodermis as revealed by examination of biopsy specimens of skin from patients of filarial lymphoedema. In comparison, similar examinations in individuals with non-filarial lymphoedema showed far fewer changes⁷². Alternatively, in a compromised state of lymphatic function, superinfection of tissue with micro-organisms may be largely responsible for local inflammation⁶⁷ and eventual elephantiasis as the clinical outcome of this disease⁷³.

Management

The management of lymphatic filariasis varies according to the stage of infection, disease manifestations and its complications. The overall management comprises mainly medical measures and surgical intervention is only called for if indicated. Medical measures include physiotherapy and chemotherapy for the acute and chronic forms of the disease. The principles of management accordingly are enunciated below:

Asymptomatic Infected

Chemotherapy is the mainstay of treatment of mf carriers and antigen positive individuals. The following drug or combination of drugs are in use currently: diethylcarbamazine citrate (DEC) is the drug of choice. It is used singly or in combination with other anthelmintics eg. ivermectin or albendazole. One of the following schedules is advocated. (i) DEC: 6mg/kg body weight (b w) in three divided doses per day after meals for 12 days [W.bancrofti] or for 6 days [B. malayi]- standard regimen¹², or (ii) DEC: 6 mg/kg bw in single dose at monthly intervals for 12 months, or (iii) Ivermectin: 400 mg/kg bw repeated at three monthly intervals for 12 months (not marketed currently in India for human use), or (iv) DEC and ivermectin: a single dose of DEC 6 mg/kg b w and ivermectin 200 mg/kg bw repeated after 6 months, or (v) DEC and albendazole: DEC 6mg/kg bw and albendazole 600 mg for adults to be repeated after one year if required⁷⁴.

Acute Manifestations

Antibiotic therapy has recently gained importance following recent studies that have demonstrated the role of bacteria especially beta haemolytic streptococci in the causation of ADL episodes⁶⁷. Penicillin, the drug of choice, is given as Benzathine penicillin G1,200,000 units by injection every 4 weeks or penicillin G potassium salt 250,000 units or 250 mg penicillin V orally 3 to 4 times a day till the symptoms subside⁷⁵. Synthetic penicillin analogues like amoxycillin can also be given. If allergic to penicillin, erythromycin or other macrolides may be used. Antipyretics eg. paracetamol; non-steroidal anti-inflammatory drugs (NSAID) eg. diclofenac sodium and antihistaminics may be used if indicated. Symptomatic treatment for nausea and vomiting if necessary can be given. Immobilization and elevation of the affected limb should be carried out to ameliorate suffering during the acute attack. In case of abscess formation, surgical drainage is to be done with necessary follow up.

Standard regimen of DEC is to be administered after the acute attack of ADL has subsided to avoid severe allergic reactions during the acute attack.

Chronic Manifestations

Hydrocele

Most hydroceles of small size may not require any treatment. For moderate to large hydroceles, the treatment of choice is surgical. Monthly courses of DEC (10mg/kg b w per day for three weeks) for a period of 6 months have been reported to be beneficial⁷⁶. However, further evaluation in this regard is required.

Lymphoedema

Management of lymphoedema calls for both prophylactic and therapeutic measures. Therapeutic measures comprise the following:

1. Medical

1. Physiotherapy: It is useful in the early stages of lymphoedema and includes the use of pressure bandage, manual massage, thermotherapy, pneumatic compression and interferential current therapy.
   
   Pressure bandage: Crepe bandages and elasto-crepe stockings are commonly used and the latter are preferred for simplicity, but they have to be tailor made for individual patients. Care has to be taken to educate the patients in the proper use of these, since these are often used inadequately and improperly.
   
   Manual massage: The principle is to mobilize the oedema fluid away from the affected part milking it upwards along the cutaneous and subcutaneous networks to the abdomen. Though the experience in filarial lymphoedema is limited, it has the potential for domiciliary management since the patients and relatives could be educated and trained in this therapy for daily application. It is a technique where gentle pressure is applied on the skin to reduce the pain and oedema of the affected region by promoting lymph circulation from the periphery to the centre. The massage needs to be done daily and requires a lot of patience and motivation on the part of the patient as well as total involvement of the therapist. The massage needs to be done daily and evaluated regularly at monthly intervals. The details of the procedure are given elsewhere⁷⁴.
   
   Thermotherapy: It is useful both for the reduction of oedema and the associated pain. Wet heat therapy by immersing the affected limb in a bucket of warm water for about 10 to 15 min daily in the evenings when the size of the swelling is increased due to the day's activities, is recommended to facilitate circulation. After this, the patient could massage the limb and lie flat with the foot being kept elevated. In addition, hot ovens (modified Chinese therapy) have also been found to be useful.
   
   Pneumatic compression: Single and multi-cell jackets are used for pneumatic compression of affected parts either by intermittent low pressure or continuous high pressure generated by electrically operated machines. Reduction occurs immediately after therapy, but the results are not sustained in course of time particularly in ambulatory patients. Hence, elastic bandaging as an adjunct after compression is essential.
   
   Interferential current therapy: Low frequency interferential current stimulation is given to the affected part using two electrodes placed diametrically opposite on the skin, with one having a fixed stimulation (4000 Hz) and the other variable (3850 to 4000 Hz). This creates an interferential beat frequency equivalent to the difference between the two through the tissue. This therapy though tried on a limited scale has been found to be useful in the reduction of pain and oedema particularly in patients with grades II and III lymphoedema (VCRC data).
   
   
2. Chemotherapy: Standard regimen of DEC as for mf carriers can be given every month for 12months. Apart from this coumarin 200 mg twice a day has been reported to be helpful in the reduction of filarial oedema in the long run. However, the role of coumarin needs further evaluation.

(ii) Surgical interventions

In lymphoedema, surgery is resorted to only in cases who do not respond to aggressive medical management or have impaired functions particularly in cases with physical and occupational disabilities or for social reasons. The surgical procedures include lymphatic drainage and/or excisional surgery.

1. Drainage procedures: These include lymphangioplasty, omentoplasty, flaps, lymph-vein anastomosis, lymph-lymph anastomosis, lympho-nodo-venous (LNV) shunt, etc. LNV shunt shows immediate good response epecially in patients with moderate to high oedema ie. grade III with oedema volume more than 2 litres and duration of about 5 years. There is a rapid reduction in oedema volume (about 40%). The gains are not sustained and in most of the patients the oedema volume gets gradually increased. Post-surgery ADL attacks are the most important cause for the failure of the viability of the shunt. However, LNV shunt may have a role as a pre-excisional surgical procedure in filarial lymphoedema
   
   
2. Excisional procedures: These procedures are resorted to only in patients with gross physical deformities or occupational disabilities. Reliable objective assessment of excisional procedures are not available for long-term results.

Allergic Manifestations

Tropical pulmonary eosinophilia, a form of occult filariasis considered as the most important allergic manifestation of this disease, responds fairly well to standard regimen of DEC. If neglected, it may lead to an irreversible condition of chronic pulmonary fibrosis. However, relapses may occur in 20% of patients who may require higher doses of the drug ie. 6-12 mg/kg b w daily for 21-30 days. Beneficial effects of DEC have also been observed in other forms of occult filariasis.

Management of Adverse Reactions to Antifilarial Drugs

The adverse reactions to antifilarial drugs may result in two ways. The first is a pharmacological dose dependent response to the chemical properties of the drug itself. This may occur in infected as well as in uninfected recipients of the drug with equal frequency. The second is due to the response of the infected host to the destruction and death of the parasite and is independent of the dose but is related to the pre-therapy parasite load^77-79. Usually, there is hardly any adverse effect due to pharmacological toxicity of the standard dose of DEC in the uninfected person. At higher dosage only, there may be anorexia, nausea, abdominal pain, weakness, dizziness or lethargy which may begin 1-2 hours after ingestion of the drug on an empty stomach and persist for a few hours. There is no accumulation of the drug following prolonged administration and chronic toxicity does not occur. The second type of reactions is attributed to the filaricidal action of DEC. These reactions are the result of immunological response to the disintegrating microfilariae and dead adult parasites. They are usually less severe in bancroftian than in brugian filariasis. These reactions may be systemic or local, both with and without fever.

Systemic reactions include malaise, headache, body ache, joint pain, dizziness, anorexia, vomiting, transient haematuria, allergic reactions and rarely bronchial asthma. They usually occur a few hours after the first dose of DEC and last for about 3 days. Fever may be present. The systemic reactions cease spontaneously and symptomatic treatment with antipyretics and analgesics is given.

Local reactions usually comprise lymphadenitis, abscess, ulceration, transient lymphoedema and hydrocele occurring in decreasing frequency. In bancroftian filariasis, there may be funiculitis and epididymitis. Though they appear later in the course of the disease and last longer, they also disappear spontaneously and interruption of treatment may not be necessary. In cases where lymphoedema and hydrocele have persisted for several months after DEC therapy, elephantiasis has not been observed. Local reactions tend to occur more often in patients with history of ADL being probably related to the presence of adult or immature worms or fourth stage larvae in the tissues.

Prophylaxis of Filariasis

For prevention and management of the acute disease, foot hygiene is of prime importance⁷⁴. This consists of the following: (i) cleaning feet with soap containing 2% glycerine, (ii) regular application of Whitfield ointment on the webs of toes to prevent fungi infection and to smoothen the skin, (iii) regular clipping of toe and finger nails. Clipping of finger nails is important to prevent injuring the skin of the affected limb by scratching on itching, and (iv) prompt and appropriate attention to all injuries in the body specially the feet.

Other measures of prevention include (i) treatment of any other focus of infection eg. caries tooth, CSOM etc.; and (ii) for patients who get frequent attacks of ADL, long acting penicillin (benzathine penicillin 12 lakhs units) intra-muscular once every 3 weeks after carrying out mandatory sensitivity skin test or oral penicillin V 100 00 IU, 65 mg tablet can be given daily (VCRC unpubished data).

As stated above, in endemic areas, individuals termed endemic normals may not be so, since the absence of symptoms or microfilaraemia does not necessarily mean that they are uninfected. In a proportion of this population, infection may be evidenced only by the demonstration of antigenaemia, whereas in the rest, the presence of infection or otherwise cannot be ascertained by the currently available means. This justifies the institution of mass chemotherapy for the infected and individual prophylaxis for the supposedly uninfected by antifilarial drugs.

In endemic areas, preventive measures against mosquito bites eg. bednet and mosquito proofing of the house should be taken. In addition, DEC 300 mg as a single dose after dinner per day for 2 days every month acts as prophylaxis against filariasis for people from non-endemic regions visiting endemic regions immediately on arrival. In an area with cofirmed active transmission of filariasis, DEC at a dosage of 500 mg on each of two consecutive days each month for 18 months has been shown to be prophylactic throughout and also for further 12 months after the cessation of DEC administration⁸⁰.

Conclusions

Although lymphatic filariasis continues to be a major public health problem in many parts of the world particularly India, it has of late been identified as a potentially eradicable disease. The clinical features of lymphatic filariasis present a highly variable spectrum and recent advances in diagnostic techniques have led to questioning of the earlier concept of endemic normals, since lymphatic and renal abnormalities have been directly visualized in otherwise apparently normal individuals in endemic regions. In such cases as also in arthritis associated with this disease, the exact etiopathogenesis is not fully understood. Control of acute attacks of ADL by antibiotics and simple measures like foot hygiene etc. have been shown to prevent the progression of the disease to its chronic from with the resultant disability. Though DEC continues to be the mainstay of individual as well as mass chemotherapy, newer antifilarials like ivermectin and anthelmintics like albendazole are being added to the arsenal of antifilarial treatment. The earlier sense of hopelessness in morbidity management has also given way to a new sense of optimism and hope both to the clinician and the patient who can be given simple training of self support.

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18. Amaral, F., Dreyer, G., Figueredo-Silva, J., Noroes, J., Cavalcanti, A., Samico, S.C., Santos, A. and Coutinho, A. Live adult worm detected by ultrasonography in human bancroftian filariasis. Am J Trop Med Hyg 50: 753, 1994.

19. Witte, M.H., Jamal, S., Williams, W.H., Wittee, C.L., Kumaraswami, V., McNeil, G.C., Case, T.C. and Panicker, T.M.R. Lymphatic abnormalities in human filariasis as depicted by lymphangioscintigraphy. Arch Int Med 153: 753, 1993.

20. Freedman, D.O., Filho, P.J., Besh, S., Silva, M., Braga, C. and Maciel, A. Lymphangioscintigraphic analysis of lymphatic abnormalities in symptomatic and asymptomatic human filariasis. J Infect Dis 170: 927, 1994.

21. Dreyer, G., Figueredo-Silva, J., Andrade, L.D., Marchetti, F. and Coutinho, A. Diagnosis, treatment and control of filariasis. Parasite 1 (Suppl 1): 22, 1994.

22. Hawking, F. The distribution of human filariasis throughout the world. Part II. Asia. Trop Dis Bull 73: 967, 1977.

23. Rao, C.K. Current knowledge on selected aspects of the epidemiology of bancroftian filariasis. J Commun Dis 9: 185, 1977.

24. Chaturvedi, P, Gawdi, A. and Dey, S. Occult filarial infections. Natl Med J India 3: 7, 1990.

25. Jamal, S. and Pani, S.P. The clinical perspectives and research needs in lymphatic filariasis. (Proceedings of a Seminar on Future Research Needs in Lymphatic Filariasis). VCRC Pondichery, Misc Publ No.16: 29, 1990.

26. Rath, R.N., Mishra, N., Sahu, R.N., Mohanty, G. and Das, B.K. Renal involvement in bancroftian filariasis. Natl Med J India 4: 65, 1991.

27. Dreyer, G., Ottesen, .A., Galdino, E., Andrade, L., Rocha, A., Medeiros, Z., Moura, I., Casimiro, I., Beliz, F. and Coutinho, A. Renal abnormalities in microfilaraemic patients with bancroftian filariasis. Am J Trop Med Hyg 46: 754, 1992.

28. Bundy, D.A.P., Grenfell, B.T. and Rajagopalan, P.K. Immunoepidemiology of lymphatic filariasis: The relationship between infection and disease. Immunol Today 12(3): A71, 1991.

29. Maizels, R.M. and Lawrence, R.A. Immunological tolerance: The key feature in human filariasis. Parasitol Today 7: 21, 1991.

30. Day, K.P. The endemic normal in lymphatic filariasis: A static concept. Parasitol Today 7: 341, 1991.

31. Grenfell, B.T., Michael, E. and Denham, D.A. A model for the dynamics of human lymphatic filariasis. Parasitol Today 7: 318, 1991.

32. Grenfell, B.T. and Michael, E. Infection and disease in lymphatic filariasis-an epidemiological approach. Parasitology 104 (Suppl): S81, 1992.

33. Ottesen, E.A. Infection and disease in lymphatic filariasis. An immunological perspective. Parasitology 104 (Suppl): S71, 1992.

34. Pani, S.P. and Dhanda, V. Natural history and dynamics of progression of filariasis. In: Proceedings of the CSIR Golden Jubilee Symposium on Tropical Diseases, Molecular Biology and Control Strategies. Eds. S. Kumar., A.K. Sen., G.P. Dutta, and R.N. Sharma, Publication and Information Directorate, New Delhi, p.1, 1994.

35. Ottesen, E.A. Filariasis now. Am J Trop Med Hyg 41 (Suppl 3): 9, 1989.

36. Turner, L.H. Studies on filariasis in Malaya: The clinical features of filariasis due to Wuchereria malayi. Trans R Soc Trop Med Hyg 53: 154, 1959.

37. Weller, P.F. Paroxysmal inflammatory filariasis: filarial fevers. Arch Int Med 143: 1523, 1983.

38. Kumaraswami, V. Clinical aspects of filariasis. In: Proceedings of the First International Conference on the Control of Lymphatic Filariasis. Ann Austral College Trop Med Inc. 2: 39, 1997.

39. Partono, F. The spectrum of disease in lymphatic filariasis. In: Filariasis. CIBA Foundation Symposium, No. 127. John Wiley & Sons, Chichester, U.K. p 15, 1987.

40. Wartman, W.B. Filariasis in American armed forces in World War II. Medicine 26: 333, 1947.

41. Ramaiah, K.D., Ramu, K., Vijaykumar, K.N. and Guyatt, H. Epidemiology of acute filarial episodes caused by Wuchereria bancrofti infection in two rural villages in Tamil Nadu, south India. Trans R Soc Trop Med Hyg 90: 639, 1996.

42. Dissanaike, A.S. Filarial infections. In: Recent Advances in Tropical Medicine. Ed. H.M. Gillies. Churchill Livingstone, Edinburg p.115, 1984.

43. Weller, P.F., Ottesen, E.A., Heck L., Tere, T. and Neva, F.A. Endemic filariasis on a Pacific island. I. Clinical, epidemiologic and parasitologic aspects. Am J Trop Med Hyg 31: 942, 1982.

44. Pani, S.P., Das, L.K., Balakrishnan, N., Sadanandane, C., Rajavel, A.R., Subramanian, S. and Vanamail, P. A study on the clinical manifestations of bancroftian filariasis in Pondicherry, south India. Indian Med Gaz 123: 111, 1989.

45. Pani, S.P., Srividya, A. and Rajagopalan, P.K. Clinical manifestations of bancroftian filariasis in relation to microfilaraemia and diethylcarbamazine therapy. Natl Med J India 4: 9, 1991.

46. Michael, E., Grenfell, B.T. and Bundy, D.A.P. The association between microfilaraemia and disease in lymphatic filariasis. Proc R Soc London B256: 33, 1994.

47. Brabin, L. Sex differentials in susceptibility to lymphatic filariasis and implications for maternal child immunity. Epidemiol Infect 105: 335, 1990.

48. Pani, S.P., Balakrishnan, N., Srividya, A., Bundy, D.A.P. and Grenfell, B.T. Clinical epidemiology of bancroftian filariasis: Effect of age and gender. Trans R Soc Trop Med Hyg 85: 260, 1991.

49. Sivam, N.S., Jayanthi, S., Ananthakrishnan, N., Elango, A., Yuvaraj, J., Hoti, S.L. and Pani, S.P. Tropical vaginal hydroceles. Are they all filarial in origin? Southeast Asian J Trop Med Public Health 26: 739, 1995.

50. Dandapat, M.C., Mohapatra, S.K. and Mohanty, S.S. The incidence of filaria as an etiological factor for testicular hydrocele. Br J Surg 73: 77, 1986.

51. Jachowski, L.A., Gonzalez-Flores, B. and Lichtenberg, F.V. Filarial etiology of tropical hydroceles in Puerto Rico. Am J Trop Med Hyg 11: 220, 1962.

52. Partono, F. Filariasis in Indonesia. Clinical manifestations and basic concepts of treatment and control. Trans R Soc Trop Med Hyg 75: 9, 1984.

53. Pani, S.P., Krishnamoorthy, K., Rao, A.S. and Pratibha, J. Clinical manifestations in malayan filariasis infection with special reference to lymphoedema grading. Indian J Med Res 91: 200, 1990.

54. Pani, S.P. and Srividya, A. Clinical manifestations of bancroftian filariasis with special reference to lymphoedema grading. Indian J Med J Res 102: 114, 1995.

55. World Health Organization. Informal consultation on evaluation of morbidity in lymphatic filariasis. WHO/TDR/FIL Mimeographed Document: 92.3, 1992.

56. Das, S. and Dandapat, M.C. Management of acute manifestations of filariasis. J Indian Med Assoc 73: 215, 1979.

57. Ottesen, E.A. Immunological aspects of lymphatic filariasis and onchocerciasis in man. Trans R Soc Trop Med Hyg 78: 9, 1984.

58. Vijayan, V.K., Kuppu Rao, K.V., Sankaran, K., Venkatesan, P. and Prabhakar, R. Tropical eosinophilia: Clinical and physiological response to diethylcarbamazine. Respir Med 85: 17, 1991.

59. Sarma, R.V.S.N., Vallishayee, R.S., Mayurnath, S., Narayanan, P.R., Radhamani, M.P. and Tripathy, S.P. Prevalence survey of filariasis in two villages in Chingleput district of Tamil Nadu. Indian J Med Res 85: 522, 1987.

60. Wilson, T. Filariasis in Malaya _ A general review. Trans R Soc Trop Med Hyg 55: 107, 1961.

61. Muller, R., Hajdu, S.I. and Brennan, M.F. Lymphangiosarcoma associated with chronic filarial lymphoedema. Cancer 59: 179, 1987.

62. Srividya, A., Pani, S.P., Rajagopalan, P.K., Bundy, D.A.P. and Grenfell, B.T. The dynamics of infection and disease in bancroftian filariasis. Trans R Soc Trop Med Hyg 85: 255, 1991.

63. Lamb, V.L., William, J.F. and Kaiser, L. Effect of serum from dogs infected with Dirofilarie immitis on endothelium dependent relaxation of rat aorta in vitro. Am J Vet Res 54: 2056, 1993.

64. Ottesen, E.A. The human filariases: New understanding, new therapeutic strategies. Current opinion. Infect Dis 7: 550, 1994.

65. King, C.L., Mohanty, S. Kumaraswami, V., Abrams, J.S., Ragunathan, J., Jayaraman, K., Ottesan, E.A. and Nutman, T.B. Cytokine control of parasite specific anergy in human lymphatic filariasis: Preferential induction of a regulatory T helper type 2 lymphocyte subset. Clin Invest 92: 1667, 1993.

66. Maizels, R.M., Bundy, D.A., Selkirk, M.E., Smith D.F. and Anderson, R.M. Immunological modulations and evasion by helminth parasites in human populations. Nature 365: 797, 1993.

67. Olszewski, W.L., Jamal, S., Manokaran, G., Pani, S.P., Kumaraswami, V., Kubicka, U., Lukomska, B., Dworczynski, A., Swoboda, E. and Meisel-Mikolajczyk, F. Bacteriological studies of skin tissue fluid, lymph and lymph nodes in patients with filarial lymphoedema. Am J Trop Med Hyg 57: 7, 1997.

68. Steel, C., Guinea, A., Mc Carthy, J. and Ottesen, E.A. Long-term effect of prenatal exposure to maternal microfilaraemia on immune responsiveness to filarial parasite antigen. Lancet 343: 890, 1994.

69. Lammie, P.J., Hitch, W.L., Walker Allen, E.M., Hightower, W. and Eberhard, M.L. Maternal filarial infection as risk factor for infection in children. Lancet 337: 1005, 1991.

70. Das, P.K., Srividya, A., Vanamail, P., Ramaiah, K.D., Pani, S.P., Michael, E. and Bundy, D.A.P. Wuchereria bancrofti microfilaraemia in children in relation to parental infection status. Trans R Soc Trop Med Hyg 91: 667, 1997.

71. Manson's Tropical Diseases. 19th Edition. Bailliere Tindal. p 356, 1987.

72. Olszewski, W.L., Jamal, S., Manokaran, G., Lukomska, B., and Kubicka, U. Skin changes in filarial and non-filarial lymphoedema of the lower extremitis. Trop Med Parasitol 44: 40, 1993.

73. World Health Organization. Lymphatic filariasis: Reason for hope. WHO/CTD/FIL/97.4, p 12, 1997.

74. Vector Control Research Centre. Management of lymphatic filariasis: A manual for clinicians. Misc Publ No.21: 1997.

75. Cecil: Textbook of Medicine. Eds. J.B. Wyngaarden, L.H. Smith and J.C. Bennett. 19th Edition (Vol.2), p 1629, 1992.

76. Kar, S.K. and Mania, J. Filarial hydrocele and its treatment with DEC. Progress in Lymphology. XIV. In: Proceedings of the XIV International Congress of Lymphology. Washington, D.C. p.364, 1993.

77. Glaziou, P., Moulia-Pelat, J.P., Nguyen, L.N., Chanteau,S., Martin, P.M.V. and Cartel, J.L. Double-blind controlled trial of a single dose of the combination ivermectin 400 mg/kg plus diethylcarbamazine 6 mg/kg for the treatment of bancroftian filariasis: Results at six months. Tans R Soc Trop Med Hyg 88: 707, 1994.

78. Cartel, J.L., Sechan, Y., Boutin, P., Celerier, R., Plichart, R. and Roux, J.F. Ivermectin for treatment of bancroftian filariasis in French Polynesia: Efficacy in man, effect on transmission by vector Aedes polynesiensis. Trop Med Parasitol 44: 241, 1990.

79. Sabry, M., Gamal, H., El-Masry, N. and Kilptrick, M.E. A placebo-controlled double-blind trial for the treatment of bancroftian filariasis with ivermectin or diethylcarbamazine. Trans R Soc Trop Med Hyg 85: 640, 1991.

80. Chakravertty, R.K., Srivastav, V.K., Srivastav, S.P., C, Phool Chand and Rao, C.K. Prophylactic effect of diethylcarbamazine on Wuchereria bancrofti filariasis. J Common Dis 19: 128, 1987.

Over expression of p53 and cell proliferation indices in non-Hodgkin's lymphoma.

The study was carried out to assess the morphological classification of non-Hodgkin's lymphoma (NHL) on H&E stained sections and the over expression of p53, argyrophilic nucleolar organiser regions (AgNORs) and proliferating cell nuclear antigen (PCNA) in immunohistochemistry of formalin-fixed, paraffin embedded sections.

According to the NCI Working Formulations for Clinical Usage, 1982 the 50 NHLs were classified as small lymphocytic lymphoma-17; follicular, small cleaved lymphoma-6; follicular, mixed small and large lymphoma-2; diffuse small cleaved lymphoma-11; diffuse, mixed small and large lymphoma-7; diffuse, small non-cleaved lymphoma-4; immunoblastic lymphoma-2; and lymphoblastic lymphoma-1. Out of 50, 25 were low grade lymphomas, 18 intermediate

Six (12%) NHLs (1/25 low grade, 2/18 intermediate and 3/7 high grade lymphomas) were positive for p53 (>10% of tumour cells showing positivity).

PCNA labelling index was >1% in 4(16%) of the low grade lymphomas, 6 (33%) of the intermediate and 5 (71.5%) of the high grade lymphomas. It was found that all the p53 positive lymphomas had a PCNA labelling index of >30%. The range of AGNORs was 2.0 to 7.0 in all but one low grade lymphomas, whereas the intermediate grade lymphomas showed a range of 7.0 to 9.2 and high grade lymphomas a range of 8.0 to 14.4.

It was found that PCNA showed a higher labelling index in high grade cases, indicating the presence of higher proportion of proliferating cells. AGNOR scores showed a direct relationship to PCNA lebelling index in that both were increased in high grade lymphomas.p53 and PCNA immunoreactivity showed a relationship in that PCNA labelling index was high in tumours with p53 positivity.

Findings of this study indicate that p53 expression in malignant lymphomas is related to the grade of lymphomas and that p53 positivity may also be a marker for cell proliferation.

Usha K. Burra
P. Shanthi
Department of Pathology,
Dr. ALM Postgraduate Institute of
Basic Medical Sciences, Chennai

Role of peptide M, uveitopathogenic fragment of 45 kDa retinal S-antigen in human uveitis.

The study was carried out in patients of uveitis (38), diabetic retinopathy (27) and systemic connective tissue disease (CTD, 30) and 30 healthy volunteers to investigate the role of retinal S-antigen and its uveitopathogenic peptides (M and G) and uveitopathogenic fragment of interphotoreceptor retinoid binding protein (IRBP) in idiopathic human uveitis. Lymphoproliferative responses were tested in vitro against native S-antigen, peptides M and G, yeast histone H3 peptide and IRBP:R 16 to establish their role in pathogenesis of human uveitis.

Seven of 38 (18.4%) patients with uveitis, and none among the diabetic retinopathy and CTD patients and healthy volunteers responded (stimulation index >3) to at least one antigen used. One uveitis patient showed response to native S-antigen, peptide M and yeast histone H3. One responded to both S-antigen and peptide M and another to both peptide G and R-16 peptide. Two responded to S-antigen only, one to peptide M and one to peptide G. In addition, one uveitis patient and two patients of diabetic retinopathy responded to histone H3 only.

These findings thus suggest that retinal antigens may play a role in the etiopathogenesis of a subset of idiopathic human uveitis.

V.K. Singh
Department of Immunology,
Sanjay Gandhi Postgraduate Institute of
Medical Sciences, Lucknow

Publications:

1. Nityanand, S., Singh, V.K., Shinohara, T., Paul, A.K., Singh, V., Agarwal, P.K. and Agarwal, S.S. Cellular immune response of patients with uveitis to peptide M, a retinal S-antigen. J Clin Immunol 13: 352, 1993.
   
   
2. Rajasingh, J., Singh, V.K., Singh, V., Sharma, K. and Agarwal, S.S. Cellular immune response to retinal S-antigen and interphotoreceptor retinoid binding protein fragments in idiopathic human uveitis. Indian J Med Res 103: 222, 1996.
   
   
3. Singh, V.K. and Nagaraju, K. Experimental antiimmune uveitis. Molecular mimicry and oral tolerance. Immunol Res 15: 323, 1996.
   

ICMR NEWS

The X meeting of the Directors of the ICMR Institutes/Centres located in different parts of India was held at New Delhi on May 6 and 7, 1998.

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PRC for Projects in Non-Communicable Diseases                             April 16, 1998

TF on Management of Glaucoma under Indian Conditions                  May 8, 1998

Participation of ICMR Scientists in Scientific Events:

Dr. N.K. Ganguly, Director-General, ICMR, participated in the I Joint Session of the South-East Asia Advisory Committee on Health Research and Directors of Medical Research Councils at Colombo (April 22-24, 1998).

Dr. Manjula Datta, Dy. Director, Tuberculosis Research Centre (TRC), Chennai, participated in the meeting of the WHO Steering Committee on the Immunology of Mycobacteria at Geneva (April 22-24, 1998).

Dr. Soumya Swaminathan, Asstt. Director, TRC, Chennai, participated in the International Conference of the American Thoracic Society at Chicago (April 24-29, 1998).

Dr. Sajid Hussain, Senior Research Officer, Central JALMA Institute for Leprosy, Agra, participated in the Conference of Orthopaedic Surgeons from SAARC Countries at Kathmandu (April 28-May 1, 1998).

Dr. L. Singotam, Dy. Director, National Institute of Nutrition (NIN), Hyderabad, participated in the X Annual International Scientific Meeting on Scanning Microscopies "Scanning 98" at Baltimore, Maryland (May 9-12, 1998).

Dr. D.K. Das, Officer-in-Charge, Institute of Cytology and Preventive Oncology, New Delhi, participated in the XIII International Congress of Cytology at Tokyo (May 10-14, 1998).

Dr. Ganguly participated in the VIII meeting of the Indo-Russian Joint Council for Integrated Long-term Programme (ILTP) of Cooperation in Science and Technology at Moscow (May 14-15, 1998).

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Dr. V.P. Sharma, Addl. Director-General, ICMR and Director, Malaria Research Centre, Delhi, retired on April 30, 1998.

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Dr. Padam Singh, Director, Institute for Research in Medical Statistics, New Delhi, took over as Additional Director-General of ICMR w.e.f. May 1, 1998.

• Multidrug Therapy Orientation Course in Leprosy for Medical Officers (August 17-28, October 26-November 6; and December 7-18, 1998).

• Diploma in Medical Virology (July 1998-May 1999).

• Workshop on Andrology for Clinicians (November 16-30, 1998)

• Annual Certificate Course on Endocrinological Techniques and their Applications (August 1-September 15, 1998).

• M.Sc. in Applied Nutrition (June 1, 1998-February 28, 1999).

• Postgraduate Certificate Course in Nutrition (December 1, 1998-February 28, 1999).

• Training Course for Laboratory Animal Technicians (June 16-July 31, 1998).

• Training Course on Environmental Hygiene Practice (November 16-20, 1998).

• Basic Course in Statistics for Postgraduate Medical Students (July 1998).

• Basic Course in Statistics for Medical Officers (November 1998).

  Haematology

• Training Course in Transfusion Medicine for Blood Bank Medical Officers (August 11-October 9, 1998).

• Training Course in Blood Group Serology and Blood Bank Methodology for Blood Bank Technicians (August 11-September 10, 1998).

• Training Course in Advanced Haematology and Immunohaematology (September 21-October 9, 1998).

Grant-in-aid for organising Seminars/Symposia/Workshops

The Council provides partial financial assistance for organising Seminars/Symposia/Workshops. Applications for grant of financial assistance (complete in all respects in the prescribed proforma), will be considered only if furnished at least four months before the date of commencement of the Seminar/Symposium/Workshop, etc.

EDITORIAL BOARD

Editor

Dr. N. Medappa

ICMR BULLETIN

ISSN 0377-4910

Vol. 28, No.6

June, 1998

Safe, adequate and nutritious food intake is an essential pre-requisite for maintaining good health. A variety of naturally occurring food contaminants like mycotoxins constantly pose a threat to human health. Mycotoxins, the secondary metabolites produced by fungi have gained considerable health and economic significance during the last four decades. Application of the risk analysis approach to food safety issues revealed the need for assessing the occurrence of mycotoxins in various food items, particularly in staple cereals. The National Institute of Nutrition (NIN), Hyderabad, has been investigating outbreaks of food-borne disease due to the consumption of mycotoxin-contaminated food commodities. These include aflatoxic hepatitis in parts of Gujarat and Rajasthan, enteroergotism in Rajasthan and acute deoxynivalenol mycotoxicosis in the Kashmir Valley due to the consumption of mouldy maize, ergoty bajra and rain damaged wheat respectively^1-3.

Fumonisin Mycotoxins

Fumonisins are a group of mycotoxins produced by species of Fusarium, mainly F. moniliforme⁴. The discovery of fumonisins in 1988 by researchers from the South African Medical Research Council received world-wide attention⁵. Chemically, fumonisins are diesters of propane 1,2,3 tricarboxylic acid and are structurally similar to sphingosine produced by F. moniliforme and related species in agricultural commodities, in the field as well as during storage. Although different fumonisins viz fumonisin A₁, A₂, B₁, B₂, B₃, B₄ and C₁ have been reported, only fumonisin B₁, B₂ and B₃ were found to occur naturally in foods⁶. Among the different varieties, fumonisin B₁ is the major metabolite occurring naturally, mostly in maize. Fumonisins have been shown to be hepatotoxic, hepatocarcinogenic and nephrotoxic to rats, atherogenic to monkeys and also lead to poor weight gain, diarrhoea and rickets in broiler poultry⁷. Fumonisins are shown to cause developmental toxicity in rats, mice and hamsters, and are toxic to chick embryos⁸. Studies have shown that fumonisins are cytotoxic to different mammalian cell lines in vitro, although the sensitivity differs between different cell lines⁹. Fumonisin B₁ has been found to inhibit the de novo sphingolipid synthesis both in vitro and in vivo^10,11. The International Agency for Research on Cancer (IARC) has classified fumonisin B₁ under the 2B group of carcinogens, ie, "possibly carcinogenic". In view of its potential toxic effects¹², a study has been initiated to find out the relevance of fumonisins in the Indian context.

Natural Occurrence

Fumonisins have been shown to occur naturally in maize and maize-based animal feeds throughout the world in levels ranging from a few nanograms to a few hundred micrograms⁷. In general, maize and its products meant for animal consumption, contain higher levels of fumonisin B₁. Maize has been shown to be a good substrate for many of the mycotoxins. Maize is not only consumed as a staple by certain segments of the Indian population, but also used as an important ingredient in animal feed.

A total of 157 samples consisting of maize, sorghum, poultry feeds and horse feeds collected from northern and southern parts of India, were analysed using high performance liquid chromatography (HPLC) for the possible presence of mycotoxins like fumonisin B₁ and aflatoxin B₁. Detection limits were 20 ng/g for fumonisin B₁ and 1.5 ng/g for aflatoxin B₁. Their levels in maize, sorghum and poultry feeds are given in the Table. Maize showed higher fumonisin B₁ contamination than sorghum¹³. All the rain affected maize and sorghum samples showed fumonisin B₁ contamination, whereas 74% of the normal maize and 4.5% of the normal sorghum samples contained fumonisin B₁. Highest fumonisin B₁ level was seen in a rain-affected maize sample (64.7µg/g). Though aflatoxins were found to co-occur, no correlation was observed between fumonisin B₁ and aflatoxin B₁ indicating that both the toxins exist independently in the samples.

In comparison with sorghum, maize samples showed higher contamination with Fusarium sp. In addition, highest number (16/26) of Fusarium species belonging to the section Liseola were isolated from the maize samples. Majority of the isolates (19/26) belonged to F. moniliforme. Most of the isolates from maize (15/16) produced fumonisin B₁. Highest fumonisin B₁ production was seen with F. moniliforme isolate from feed (234µg/g). In general, Fusarium isolates from maize produced higher fumonisin B₁ than the isolates from sorghum.

Substrate Specificity

Studies carried out on the production of fumonisin B₁ in maize¹⁴ in the laboratory by different workers¹⁵ revealed that maximum fumonisin B₁ production occurs when inoculated maize is incubated at 25⁰C for 7 to 9 weeks. However, they varied greatly in their capacity to support fumonisin B₁ production. The Figure shows the production of fumonisin B₁ on different substrates at the end of 60 days of incubation. Highest fumonisin B₁ production (2101 µg/g) was seen in maize followed by rice (1448 µg/g), sorghum (125 µg/g) and least in wheat (31 µg/g). Rapid production of fumonisin B₁ was seen from 10 days onwards in maize, 20 days onwards in rice and was tardy throughout in wheat and sorghum. Although production of fumonisin B₁ in rice was seen to be tardy during the first 10 days of incubation, its production increased rapidly by the end of 60 days of incubation. The reported variation in the production of fumonisin may be due to the differential availability of various intermediates required in the biosynthetic pathway or the presence of inhibiting compounds in wheat and sorghum¹⁴.

Health Implications

Though consumption of maize contaminated with fungus F. moniliforme has been traditionally associated with human and animal health hazards, the toxin responsible for these effects was not identified till the discovery of fumonisins. The two major diseases associated with fumonisins are leukoencephalomalacia in horses and pulmonary oedema in pigs. Leukoencephalomalacia is characterized by degeneration of white matter of the brain. Horses are the most sensitive animals for the fumonisin toxicity and levels as low as 8 µg/g in the feed may be fatal. Pulmonary oedema and hydrothorax, a fatal syndrome in pigs has been reported from different parts of the world¹⁶. Of late, field outbreaks of leukoencephalomalacia and pulmonary oedema have also been reported from USA¹⁶. However, so far such incidences have not been reported from India.

Disease Outbreak in Humans

During October 1995, there were unseasonal rains in certain parts of the Deccan Plateau at the time of harvesting the Kharif crops of maize and sorghum. Heaps of harvested maize and sorghum were left in the field for about 10 days. Due to improper storage, these crops got affected by moulds and when food items prepared from these mouldy grains were consumed by animals as well as humans, disease outbreaks were reported. There were reports of deaths of domestic animals and of an acute disease outbreak in humans living in the affected region. A rapid epidemiological survey was conducted in 50 villages belonging to 6 districts of Andhra Pradesh and Karnataka states of southern India. The disease was characterized by borborygmy, abdominal pain and diarrhoea. The problem has been traced to the consumption of food prepared from mouldy sorghum and maize. The disease persisted as long as mouldy grains were consumed. However, those who had access to alternative foods, did not show the symptoms of disease. Fortunately the disease was self-limiting, non-contagious and not fatal. Though people were aware of the cause of the disease, they continued to consume mould affected grains as its consumption was not considered by them to be life endangering. Besides, they did not have any alternative food source. The disease occurred in the poorest segments of the population such as marginal farmers and agricultural labourers. High levels of fumonisin B₁ was found in the maize (upto 65 µg/g) and sorghum (8 µg/g) collected from the affected households, whereas these levels were comparatively lower in the unaffected households. Samples did not contain any other fusarium mycotoxins and had low levels of aflatoxin B₁¹⁷.

Disease Outbreak in Poultry

During the study period, it was observed that rain affected mouldy maize was purchased by middlemen to be used as poultry feed ingredient after mixing with normal grains. Hence, a few farms in the region were visited to find out the possibility of disease outbreak which occurred only in two layer poultry farms. The disease was characterized by black sticky diarrhoea, reduced weight gain, drastic drop in egg production, lameness and mortality. Antibiotic and vitamin supplementation had no effect. Feed withdrawal showed improvement. The cause for the disease outbreak was traced to a fresh batch of feed containing high levels of fumonisin B₁ (8.5 µg/g). Some of the symptoms were reproduced by giving the incriminated feed to cockerels and fumonisin B₁ containing culture material to layer hens in the laboratory¹⁸.

Oesophageal Cancer and Fumonisins

Fumonisins have been epidemiologically correlated with the high incidence of human oesophageal cancer in certain parts of the world such as South Africa¹⁹ and China²⁰. The highest incidence of human oesophageal cancer has been reported from the lower Assam region of India. This region comes under the Dibrugarh Hospital Cancer Registry²¹. To find out whether fumonisin has any role in the etiology of oesophageal cancer in the region, a survey was conducted with the cooperation of the Regional Medical Research Centre, Dibrugarh. However, none of the food samples tested contained detectable fumonisin B₁ indicating that fumonisin may not have any role in the etiology. Other possible etiological factors investigated include a special food ingredient called Kalakhar, a highly alkaline coffee-decoction like liquid made from the charred banana false stem. This product is frequently used in the lower Assam region. Being highly alkaline and a charred product, it may play a role in the etiology of the oesophageal cancer. This problem required further study. During the study, the role of food and domestic environment in the etiology was studied by investigating the incidence of oesophageal tumours in the domestic poultry population in the region. Interestingly, 9 of 680 oesophagi collected from the region showed visible tumours. Histopathological study of the samples revealed that they were pseudo tumours. While samples collected from the Hyderabad region did not show any visible tumours, the oesophagi from the lower Assam region showed histopathological changes such as basal cell hyperplasia, glandular hypertrophy, acanthosis and reactive changes. Hence, these results suggest that food and domestic environment might play a major role in the etiology of human oesophageal cancer in the region (unpublished observation).

Detection Methods

There are a number of methods available for the detection and quantitation of fumonisins in food samples. Methods include TLC, HPLC, GC and ELISA^22,23. The HPLC procedure with the ophthaladehyde derivatization is widely used. During the epidemiological survey of human disease outbreak, the need of a method for the detection and quantitation of fumonisin B₁ in human urine was recognised as there is no sensitive method available. A two-step HPLC clean up method was developed with an additional non-ionic polymeric absorbant resin Amberlite XAD-2 clean up before the strong anion exchange (SAX) cartridge clean up. The presently available method involved a single step SAX cartridge clean up and was not found to be suitable for human urine with large volume at low toxin levels due to salt interference. The newly developed method had detection limit of less than 8 ng/ml with a high recovery and reproducibility²⁴.

Prevention and Control Strategies

Effect of cooking

Effect of household cooking processes such as preparation of unleavened Indian bread (roti) and porridge made out of naturally contaminated maize and sorghum on fumonisin levels was studied by simulating household cooking conditions in the laboratory. During preparation of unleavened Indian bread upto 29% reduction in toxin was seen in maize and no reduction was observed in sorghum based preparation. No reduction in fumonisin B₁ was noticed in porridge prepared from maize although a little (12%) reduction was observed during sorghum porridge preparation²⁵.

Decontamination

Density seggregation of fumonisin-contaminated maize kernels in water and with different concentrations of sodium chloride was studied. Results showed that the buoyant kernels separated in water alone contained upto 74% of the total fumonisin B₁. With the increasing concentration of sodium chloride in water, more fumonisin B₁ was removed. The maximum effective removal was upto 86% with saturated NaCL solution. Removal of fumonisin B₁ in 30% NaCL was optimal, as it was not significantly different from the saturated NaCL solution²⁶.

Varietal differences

To assess the susceptibility to fumonisin B₁, 10 genotypes of maize consisting of 5 inbred and 5 hybrid varieties were screened. A large variation was seen among different varieties with respect to fungal growth and fumonisin B₁ production in the laboratory. Two inbreds viz Trishula and Harsha and one hybrid, 5015x5016 supported very low production of fumonisin B₁ (<200 µg/g) and all the remaining genotypes supported production of high level of fumonisin B₁ (>1200 µg/g)²⁷.

Conclusions

Maize is the high risk commodity for fumonisin B₁ contamination. Although low levels of fumonisin B₁ were found in sorghum, high levels may accumulate under conditions favourable for mould growth. Fumonisin producing capacity of the Indian isolates indicates the need for control of fungal contamination in the field and at the post-harvest level. Naturally occurring fumonisin B₁ levels in maize and sorghum also can cause health disorders in humans and poultry. Cooking does not result in considerable loss of fumonisin B₁. However, fumonisin levels can be effectively controlled by the available procedures of decontamination.

References

1. Krishnamachari, K.A.V.R., Bhat, R.V., Nagarajan, V. and Tilak, T.B. Hepatitis due to aflatoxicosis. An outbreak in western India. Lancet i: 1061, 1975.

2. Bhat, R.V., Roy, D.N. and Tulpule. Ergot contamination of Bajra. In: Proceedings of Nutrition Society of India. National Institute of Nutrition, Hyderabad. 19: 7, 1975.

3. Bhat, R.V., Beedu, S.R., Ramakrishna, Y. and Munshi, K.L. Outbreak of trichothecene mycotoxicosis associated with consumption of mould damaged wheat produced in Kashmir Valley, India. Lancet i: 35, 1989.

4. Gelderblom, W.C.A., Jaskiewicz, K., Marasas, W.F.O., Thiel, P.G., Horak, R.M., Vleggaar, R. and Kriek, N.P. Fumonisins-novel mycotoxins with cancer-promoting activity produced by Fusarium moniliforme. Appl Environ Microbiol 54: 1806, 1988.

5. Bezuidenhout, S.C., Gelderblom, W.C.A., Gorst-Allman, C.P., Horak, R.M., Marasas, W.F.O., Spiteller, G. and Vleggaar, R. structure elucidation of the fumonisins, mycotoxins from Fusarium moniliforme. J Chem Soc Chem Commun 743, 1988.

6. Thiel, P.G., Marasas, W.F.O., Sydenham, E.W., Shephard, G.S. and Gelderblom, W.C.A. The implications of naturally occurring levels of fumonisins in corn for human and animal health. Mycopathologia 117: 3, 1992.

7. Marasas, W.F.O. Fumonisins: History, world-wide occurence and impact. In: Fumonisins in food; Advances in Experimental Medicine and Biology. Eds. L.S. Jackson, J.W. De Vries and L.B. Bullerman, Plenum Press, New York. p 1, 1996.

8. Zacharias, C., Van Echten-Deckert, G., Wang, E., Merrill, A.H. Jr. and Sandhoff, K. The effect of fumonisin B₁ on developing chick embryos: Correlation between denovo sphingolipid biosynthesis and gross morphological changes. Glycoconjugate J 13: 167, 1996.

9. Wang, E., Norred, W.P., Bacon, C.W., Riley, R.T. and Merrill A.H. Jr. Inhibition of sphingolipid biosynthesis by fumonisins. Implications for diseases associated with Fusarium moniliforme. J Biol Chem 266: 14486, 1991.

10. Norred, W.P., Wang, E., Yoo, H., Riley, R.T. and Merrill, A.H. Jr. In vitro toxicology of fumonisins and the mechanistic implications. Mycopathologia 117: 73, 1992.

11. Stevene, V.G. and Tang, J. Fumonisin B₁_induced sphingolipid depletion inhibits vitamin uptake via the glycosyl phosphotidyl inositor-anchored folate receptor. J Biol Chem 272: 18020, 1997.

12. IARC. Toxins derived from Fusarium moniliforme: fumonisins B₁ and B₂ and fusarin C. In: IARC Monogr Eval Carcinog. Risks. Hum., International Agency for Research on Cancer, Lyon, France. 56: p 445, 1993.

13. Shetty, P.H. and Bhat, R.V. Natural occurrence of fumonisin B₁ and its co-occurrence with aflatoxin B₁ in Indian sorghum, maize and feeds. J Agric Food Chem 45: 2170, 1997.

14. Shetty, P.H. and Bhat, R.V. Effect of different substrates on production of fumonisin B₁ by Fusarium moniliforme MRC-826. Appl Environ Microbiol (In Press), 1998.

15. Christley, R.M., Begg, A.P., Hutchine, D.R., Hodgson, D.R. and Bryden, W.L. Leukoencephalomalacia in horses. Aust Vet J 70: 225, 1993.

16. Ross, P.F., Rice, L.G., Osweiler, G.D., Nelson, P.E., Richard, J.L. and Wilson, T.M. A review and update of animal toxicoses associated with fumonisin-contaminated feeds and production of fumonisins by Fusarium isolates. Mycopathologia 117: 109, 1992.

17. Bhat, R.V., Shetty, P.H., Amruth, R.P. and Sudarshan, R.V. A food-borne disease outbreak due to the consumption of mouldy sorghum and maize containing fumonisin mycotoxin. J Toxicol Clin Toxicol 35: 249, 1997.

18. Shetty, P.H., Sudarshan, R.V., Rao, J.P.K. and Bhat, R.V. Disease outbreak in layer hens due to consumption of fumonisin contaminated feed. Br Poult Sci 38: 475, 1997.

19. Rheeder, J.P., Marasas, W.F.O., Thiel, P.G., Sydenham, E.W., Shephard, G.S. and Van Schalkwyk, D.J. Fusarium moniliforme and fumonisins in corn in relation to human oesophageal cancer in Transkei. Phytopathology 82: 353, 1992.

20. Chu, F.S. and Li, G.Y. Simultaneous occurrence of fumonisin B₁ and other mycotoxins in mouldy corn collected from the People's Republic of China in regions with high incidence of oesophageal cancer. Appl Environ Microbiol 60: 847, 1994.

21. National Cancer Registry Programme. Indian Council of Medical Research, New Delhi, p 84, 1989.

22. Sydenham, E.W., Gelderblom, W.C.A., Thiel, P.G. and Marasas, W.F.O. Evidence for the natural occurrence of fumonisin B₁, a mycotoxin produced by Fusarium moniliforme in corn. J Agric Food Chem 38: 285, 1990.

23. Chu, F.S., Huang, X. and Maragos, C.M. Production and characterization of anti-idiotype and anti- anti-idiotype antibodies against fumonisin B₁. J Agric Food Chem 43: 261, 1995.

24. Shetty, P.H. and Bhat, R.V. Sensitive method for detection and quantitation of fumonisin B₁ in human urine. J Chromatogr B: Biomed Appl 705: 171, 1998.

25. Shetty, P.H. Relevance of fumonisin mycotoxins in Indian context. Ph.D. Thesis, National Institute of Nutrition, Hyderabad, 1997.

26. Shetty, P.H. and Bhat R.V. Effect of density seggregation on fumonisin B₁ content in naturally contaminated maize. Food Chem, (In Press), 1998.

27. Shetty, P.H. and Bhat R.V. Differential production of fumonisin B₁ in maize inbreds and hybrids in laboratory. Cereal Res Commun 25: 1011, 1997.

This write-up has been adapted from the article entitled "Health hazards of fumonisin mycotoxins and its prevention" by Sh. P.H. Shetty, Senior Research Fellow and Dr. Ramesh V. Bhat, Dy. Director (Sr.Grade), published in the Nutrition News 18(3), 1997.

ABSTRACTS

The study was carried out on inbred Swiss albino mice to evaluate the effect of gamma irradiation at selected critical developmental stages during gestation on the adult neurophysiology and to see, if the neurophysiological effects of prenatal irradiation persist to later part of life. Efforts were also made to find out if prenatal irradiation would impair the reproductive performance of mouse.

Pregnant mice were whole body irradiated with 0.25, 0.35 or 0.5 Gy of gamma radiation on days 11.5, 12.5 (late organogenesis days), 14.5 or 17.5 (foetal days) post coitus (pc) and allowed to complete gestation and parturate. Behavioural and haematological changes were studied in the adults at 6,12 and 18 months of age. Reproductive performance was tested at 6-8 months of age after mating the irradiated F₁ males with normal females of the same age. For neonatal exposure, pups were whole body exposed to 0.5 Gy of gamma radiation on days 4,5 or 6 post-partum.

Adult behaviour was not affected by prenatal irradiation with 0.25 Gy. Exposure to 0.5 Gy on days 11.5, 12.5 or 14.5 pc produced significant changes in the exploratory, locomotor and learning and memory performances at 6 months of age. The changes were more pronounced after irradiation on the late organogenesis days (11.5 and 12.5 pc) than on the foetal day (14.5 pc). Normal brain function was restored by 12 months in all animals, except those exposed on 11.5 day pc in which the impaired locomotor activity and learning deficiency persisted even at 12 months of age. Even 0.35 Gy on day 11.5 pc produced a significant change in the locomotor and learning performance of the young adult mice. Animals born to mice irradiated on day 17.5 pc were more resistant to these effects. The peripheral RBC counts and haemoglobin showed significant decrease at 6 months of age when the pregnant mouse was exposed to 0.5 Gy on the foetal gestation (14.5 or 17.5 pc) days, but not during the organogenesis period. Post-partum exposure did not have any significant effect on the adult behaviour or haematological parameters. None of the hippocampal biogenic amines (noradrenaline, dopamine, 5-hydroxytryptomine and its metabolite _ 5-hydroxyindolacetic acid) studied showed any significant change after any level of exposure on any of the gestation days.

The reproductive performance of the F₁ males exposed to different doses of irradiation did not show any significant change from normal.

It is clear from the study that the late organogenesis period, especially day 11.5 pc is a particularly sensitive phase in brain development and long lasting behavioural changes can be produced in the adult by exposure at this stage to doses below 1Gy.

R. Bhaskar
P. Uma Devi
Department of Radiobiology
Kasturba Medical College
Manipal.

Publications:

1. Bhaskar, R., Uma Devi, P., Nalini, N. and Shivananda, B. Age dependent changes in body weight, brain weight, behaviour and biogenic amines in the hippocampus of mouse. Indian J Gerontol 9(3&4): 51, 1955.
2. Bhaskar, R., and Uma Devi, P. Long-term effect of prenatal exposure to low level of gamma radiation on neurophysiology of mouse. Indian J Expt Biol 34: 887, 1996.

Lung specific liposomes as drug delivery vehicles.

The study was carried out to formulate liposomes with increased affinity for lung tissues and decreased uptake by liver and spleen and to evaluate the chemotherapeutic efficacy of antitubercular drugs encapsulated in these liposomes, against experimental tuberculosis in mice.

Surface modification of stealth liposomes by tagging O-stearyl amylopectin (O-SAP) resulted in increased affinity towards lung tissue of mice. Liposomes containing egg phosphatidyl-choline (ePC) and cholesterol (CH) in a molar ratio of 2:1.5 were found to be stable in serum. Inclusion of dicetylphosphate (DCP), O-SAP and monosialoganglioside (GM₁)/distearyl phosphatidylethanolamine-poly (ethylene glycol) 2000 (DSPE-PEG 2000) in PC: CH liposomes further increased the stability in serum.

Tissue distribution of different formulations of liposomes revealed that lung specific stealth liposomes (PC:CH:O-SAP:DCP:GM₁/DSPE-PEG2000) accumulated more in the lungs than the reticuloendothelial system of mice. The preadministration of PC and CH (2:1.5) liposomes or injections of dextran sulphate (DS) before the administration of lung specific stealth liposomes further enhanced their uptake in the lungs. The behaviour of these liposomes in mice infected with Mycobacterium tuberculosis H₃₇ Rv was similar to that in normal mice. In vivo stability of these liposomes demonstrated slow and controlled release of their encapsulated contents.

Isoniazid and rifampicin encapsulated in liposomes were less toxic to peritoneal and alveolar macrophages compared to free drugs in spite of their uptake being equal in both the macrophages. Further, the encapsulated drugs, were less hepatotoxic as compared to free drugs.

The chemotherapeutic efficacy of isoniazid and rifampicin entrapped in lung specific stealth liposomes was evaluated by injecting the liposomal and free drugs intravenously twice a week, for six weeks to tuberculous mice. Liposome encapsulated drugs at and below therapeutic concentrations were more effective than free drugs on the basis of colony forming units (CFUs). The organomegaly and histopathological studies also demonstrated that liposomal drugs cleared the mycobacteria more efficiently compared to free drugs. Liposomal drugs had marginal hepatotoxicity as seen by the levels of total bilirubin and serum glutamate pyruvate transaminase and alkaline phosphatase.

The study thus demonstrated that lung specific stealth liposome encapsulated antitubercular drugs are more effective against tuberculous infection in mice and seems to be a promising therapeutic approach for the chemotherapy of tuberculosis.

G.K. Khuller
Department of Biochemistry
Postgraduate Institute of
Medical Education and Research
Chandigarh.

Publications:

1. Parampal Deol, I., Khuller, G.K., and Joshi, K. Therapeutic efficacies of isoniazid and refampicin encapsulated in lung-specific stealth liposomes against Mycobacterium tuberculosis infection induced in mice. Antimicrob Agents Chemother 41: 1211, 1997.
2. Parampal Deol, I. and Khuller, G.K. Lung specific stealth liposomes: Stability, biodistribution and toxicity of liposomal antitubercular drugs in mice. Bicohim Biophys Acta 1334: 161, 1997.

ICMR NEWS

Meetings

Meeting of the Project Advisory Committee on ICRC Leprosy Vaccine Trial was held at New Delhi (May 25, 1998):

Participation of ICMR Scientists in Scientific Events:

Dr. G.P. Chhotray, Asstt. Director, Regional Medical Research Centre, Bhubaneswar, participated in the VIII International Congress on Infectious Diseases at Boston (May 15-18, 1998).

Dr. Dipika Mohanty, Director, Institute of Immunohaematology, Mumbai, participated in the XXIII International Congress of the World Federation of Haemophilia at The Hague (May 17-22, 1998).

Dr. Y. Venkataramana, Research Officer, National Institute of Nutrition, (NIN), Hyderabad, participated in the XXVI FIMS World Congress of Sports Medicine at Orlando (May 30-June 3, 1998).

Dr. K. Vijayaraghavan, Dy. Director (Sr. Grade), NIN, Hyderabad, undertook a Short-term WHO Consultancy on Nutritional Emergencies in Papua New Guinea (May 15-June15, 1998).

Symposium/Seminar /Workshop/ Course/Conference	Date & Place	Contact Address
National Workshop of Medical Editors and Reviewers in Medical Communication: Peer Review, Ethics and internet	June 16-18,1998; (at Pondicherry)	Dr. C. Adithan, Organising Secretary of the Workshop, Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry-605006.
National Conference on Molecular Diagnostics	June 27-29,1998; (at Thiruvananthapuram)	Dr. P.R. Sudhakaran, Organising Secretary of the Conference, Department of Biochemistry, University of Kerala, Thiruvananthapuram-695581.
International Symposium on Frontiers of Genetics and Development	July 7-8,1998; (at Bangalore)	Dr. U. Vijayaraghavan, Convenor of the Symposium, Department of Microbiology and CellBiology, Indian Institute of Science, Bangalore-560012.
International Symposium on Temporomandibular Joint Disorders and Chronic Orofacial Pain	October 30-31,1998; (at Mangalore)	Prof. P.K. Dayal, Organising Secretary of the Symposium, KMC College of Dental Surgery, Mangalore-575001.

 

 

COUNCIL'S TRAINING PROGRAMMES FOR 1998-99

Leprosy

At the Central JALMA Institute for Leprosy, Agra:

• Multidrug Therapy Orientation Course in Leprosy for Medical Officers (August 17-28, October 26-November 6; and December 7-18, 1998).

Virology

At the National Institute of Virology, Pune:

• Diploma in Medical Virology (July 1998-May 1999).

Reproductive Biology

At the Institute for Research in Reproduction, Mumbai:

• Workshop on Andrology for Clinicians (November 16-30, 1998)

Endocrinology

At the National Institute of Nutrition, Hyderabad:

• Annual Certificate Course on Endocrinological Techniques and their Applications (August 1-September 15, 1998).

Nutrition

At the National Institute of Nutrition, Hyderabad:

• M.Sc. in Applied Nutrition (June 1, 1998-February 28, 1999).

• Postgraduate Certificate Course in Nutrition (December 1, 1998-February 28, 1999).

Laboratory Animal Technology

At the National Centre for Laboratory Animal Science, National Institute of Nutrition, Hyderabad:

• Training Course for Laboratory Animal Technicians (June 16-July 31, 1998).

Occupational Health

At the National Institute of Occupational Health, Ahmedabad:

• Training Course on Environmental Hygiene Practice (November 16-20, 1998).

Medical Entomology

At the Vector Control Research Centre, Pondicherry:

• Postgraduate Diploma Course in Medical Entomology (from August 10,1998).

Biomedical Statistics

At the Institute for Research in Medical Statistics, Chennai:

• Basic Course in Statistics for Postgraduate Medical Students (July 1998).

• Basic Course in Statistics for Medical Officers (November 1998).

  Haematology

At the Institute of Immunohaematology, Mumbai:

• Training Course in Transfusion Medicine for Blood Bank Medical Officers (August 11-October 9, 1998).

• Training Course in Blood Group Serology and Blood Bank Methodology for Blood Bank Technicians (August 11-September 10, 1998).

• Training Course in Advanced Haematology and Immunohaematology (September 21-October 9, 1998).

 

---

Indian Council of Medical Research Grant-in-aid for organising Seminars/Symposia/Workshops The Council provides partial financial assistance for organising Seminars/Symposia/Workshops. Applications for grant of financial assistance (complete in all respects in the prescribed proforma), will be considered only if furnished at least four months before the date of commencement of the Seminar/Symposium/Workshop, etc.)

 

 

	EDITORIAL BOARD
	Chairman	Members
	Dr.N.K. Ganguly	Dr.Padam Singh
	Director-General	Dr.Bela Shah
		Dr.Lalit Kant
		Dr.R.Ravi
		Dr.V.Muthuswamy

 

Editor

Dr. N. Medappa

 

In modern clinical practice and medical research, exposures to ionizing radiation are inescapable as they help to provide new insights into the functions of body fabric both in health and disease. Radiation exposures in medicine are predominantly to the individual undergoing diagnosis, screening or therapy. Except in radiotherapy, it is not the aim to deliver a dose of radiation to the patient, but rather to use ionizing radiation to provide diagnostic information. Nevertheless, the radiation dose is given deliberately and it cannot be reduced indefinitely without prejudicising the intended outcome. The detrimental effects of such radiation are well documented^1-4. Although the exposures in diagnostic radiology are far greater due to rapid growth in recent times, the practice of nuclear medicine also contributes significant doses to the patient population^5,6. Information on many aspects of nuclear medicine practice for a large number of countries (mainly countries of higher health care_category I) is available. For India, despite the fact that nearly all types of in vitro and in vivo programmes including basic research and patient service are being carried out in major metropolises, and excellent nuclear medicine facilities exist that are at par with the rest of the world, yet authentic data on the type and frequency of nuclear medicine investigations and on the resultant radiation dose, are very sparse. Further, the frequency and total medical irradiation is expected to increase over the next decades due to the growth of population and urbanization particularly in countries like India. Such a deficiency or lack of data was also pointed out in the earlier report of the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR 1988)⁵. To supplement the available data on medical radiation exposure statistics, UNSCEAR undertook a survey in 1990-91 of medical radiation usage and exposures world-wide. Due to the efforts initiated by the Division of Radiological Protection, Department of Atomic Energy, Government of India, some useful and much needed information was provided for the Indian scenario (UNSCEAR 1993)⁶; however, it was far from adequate⁷. Keeping in view the deficiency of the data and its necessity in health planning in the country, the Indian Council of Medical Research sponsored a project on Nuclear Medicine Practice and Radiation Doses to Patients in India with the objectives to (i) compile data on various aspects of nuclear medicine practice in the country with the help of a broad based questionnaire; (ii) estimate effective dose (that reasonably reflects the health risk associated with radiation exposures) due to some selected and widely used nuclear medicine investigations carried out in the country; and (iii) transform these estimated radiation effective doses (that are true for an ICRP reference man that is a Caucasian and a Western European or North American in habitat and customs) to an average Indian.

The findings of this study will be presented in a series of articles. This write-up provides information collected with reference to the first objecting of the study.

Nuclear medicine is that field of medical practice in which unsealed radioactive substances are used for diagnosis, therapy and clinical research. Diagnosis that is the major part of this discipline involves two approaches viz (i) in vivo studies in which radioactive substances are administered to the patient either to evaluate the functioning of an organ or to provide an image of it and employs, as a rule, radionuclides with short half lives. Information on the amount of radioactivity employed in various diagnostic nuclear medicine procedures carried out at different centres in the country, and the resultant radiation doses to patients was collected; (ii) in vitro methods, in which body fluids or tissues are analysed by radioimmunoassay or allied techniques. In these methods, radioactive substances are not administered to the patient and therefore do not contribute to his/her radiation dose. However, being important constituent of nuclear medicine procedures, information on this aspect of nuclear medicine was also collected.

Data Collection

Basic information on the nuclear medicine centres of the country was collected using a broad based, closed ended and exhaustive questionnaire. It was designed to elicit information on the nature and structure of the nuclear medicine centres, their staffing pattern, types of available instrumentation and investigations carried out, nature and amount of radioactive material used in each investigation, the existing radiation protection, human resource development as well as waste disposal system. Information was also solicited regarding the gender and age distribution of the patients. The questionnaire was sent repeatedly to the heads of various nuclear medicine centres, and was also published twice in the Indian Journal of Nuclear Medicine^8,9.

Nuclear Medicine Centres

A total of 120 centres or clinics situated in 45 cities were stated to be functioning where in vivo and in vitro nuclear medicine was practiced, however, only 102 centres could be contacted. It was observed that although such centres/clinics were located through out the country, their spatial distribution was very uneven. Slightly less than half the centres were located in Mumbai, Calcutta, Delhi and Chennai. Table I gives the list of cities where four or more nuclear medicine centres/clinics are located.

Of the 102 centres contacted, 58 situated in 28 cities responded. These centres were well distributed through out the country. Of these, 14 were government institutions, 19 were government aided and the rest (25) were in the private sector. Chronological analysis of this limited data was suggestive of the trend that in recent times, growth of private medical institutions with nuclear medicine facilities had been faster in comparison to either government aided or government hospitals, however, the possibility of a better response selectively from private centres could not be ruled out. In the event that, this conclusion is confirmed on further studies and taking cognizance of the fact that most such medical institutions do not have a full time radiological safety officer on the staff, the apprehension, that under excessive patient load and working stress, radiation safety may be compromised, should be considered seriously. This apprehension was confirmed by a recent incident which occurred in one of the fairly large hospitals situated in the capital.

The available data showed that at 23 medical institutions (mostly in metropolises), independent nuclear medicine departments were carrying out the work. The patient is seen directly or is referred by other departments and hospitals for special investigations. In all such places, the department was headed by a professor or a consultant and on an average there were 7 persons (5-11) in the department. The average investigations carried out at these places were 1100 (500-1600) per month. At 20 other places, the departments were part of the radiotherapy and oncology, radiology, pathology or medicine departments. The departments headed by an associate professor or a consultant had on an average 4(3-6) persons and each gave service to about 450 patients per month. The remaining 15 centres (or clinics) were manned either by a single trained person or by one whole time trained clinician and one or two part time workers and each clinic, it was claimed, provided service to about 200 patients per month.

In vivo investigation for thyroid disorders were carried out at all the centers _ small or large. More than 50% of thyroid investigations were carried out using reactor produced radioactive iodine (Iodine - 131). In 26 centres (mostly in metropolises) the use of Iodine-131 has progressively decreased and due to many attractive features, most of such and other investigations are carried out using Technetium-99m and Technetium-99m based radiopharmaceuticals. In the centers for which the information was available, 87% of nuclear medicine in vivo investigations were carried out using Iodine-131 and Technetium-99m based radiopharmaceuticals. The other isotopes used at these centers for in vitro and for other clinical/research activities were Chromium-51, Thallium-201, Iodine-125, Phosphorus-32 Gallium-67 and Selenium-75. Thallium-201 and some Technetium-99m based radiopharmaceuticals for renal and cardiac studies were imported and the rest of the radioactive substances and radiopharmaceuticals were procured from local sources. None of the centres provided information on the use of Indium-111 although application of the radionuclide has been mentioned in a few publications. Organ imaging which accounted for more than 85% of administration of radioactive material to patients was a routinely performed investigation in the country. The most frequent radioimaging procedures that are being carried out in the country are for the thyroid (59%), kidneys (13%), heart (9%), bones (6%), brain (4%), liver and blood vessels (3% each) and lungs, GIT tumours/abscesses (1% each). Data obtained on in vitro studies were not adequate except to demonstrate that radioimmunoassay tests pertaining to thyroid disorders were far greater in number in comparison to other investigations.

Instrumentation

As per information, 75 gamma cameras and gamma cameras with single photon electrical computer tomography (SPECT) facilities were operating in the country, however, detailed information could be obtained for 45 gamma cameras and gamma cameras with SPECT facilities that were located in 21 centers. Besides thyroid disorder investigations, renal function tests, cardiac function studies, bone scanning and hepatobiliary and pulmonary investigations were also performed. Here the consumption of unsealed radioactive substances at each centre exceeded 500 mCi per month. The dose to a patient was so calculated that the dose per kg body weight remained more or less constant. At 17 places only thyroid disorders studies and renal function tests were carried out using rectilinear scanner and thyroid uptake system. Here the

consumption of radioactive material was between 100-500 mCi per month at each centre. At the remaining 18 centres, the patient investigations were confined to thyroid disorders and the activity of radionuclide varied from 2-6 mCi per month at each center. At all the centres in vitro tests were carried out using the standard radioimmuno-kits supplied either by Board of Radiation and Isotope Technology (BRIT) or by other companies.

Despite the fact that the Electronic Corporation of India Ltd (ECIL) has been functioning for the last three decades and has the mandate to develop and market nuclear medicine instruments in the country, yet its market presence for such instrumentation is very small. Most of the instruments used in private hospitals for clinical investigations, were imported. In all the places such instruments were placed in air conditioned areas. Quite a few government hospitals and government aided hospitals had imported as well as indigenous equipment. Regarding the equipment, the general complaint had been that (i) the supply schedule was hardly maintained and the instrument never became functional in time, and (ii) service facilities (except in a very few selected cities) were generally not good.

On account of the stringent stipulations of the Directorate of Radiation Protection, Bhabha Atomic Research Center, Mumbai, at all the places for which data were available at present, a good radiation protection system was operational. Each centre that responded had at least one person trained in radiation protection procedures and was covered under Thermo-luminiscence Dosimetry (TLD)/Film Badge type personnel monitoring. In addition, the centres had survey meters, contamination monitor, adequate waste disposal system and facilities required to meet radiation emergencies. However, the in-house training programmes were not very popular. The lack of such programmes affects radiation hazard awareness of the workers and perhaps might be one of the causative factors for the radiation incident that occurred in one such centre in the capital.

In all, based on 6 radionuclides, 20 radiopharma-ceuticals were being used in the country (Table II). At 13 places radiopharmaceuticals were prepared at the centre sites and some preparations were imported for medical and clinical research. Thallium-201 and some Technetium-99m based radiopharmaceuticals for renal, cardiac and cerebral studies were invariably imported. At the other places, radioactive diagnostic agents were procured from the Regional Radiopharmaceutical Centers of the BRIT, Department of Atomic Energy or directly from BRIT.

Table II : Radiopharmaceuticals used in the country (data upto 1996)

Conclusions

About 35,000 nuclear medicine in vivo investigations were being carried out per month at 58 centres located in 28 cities in the country, with slightly less than 50% of them being located in the four metropolises. Examination pertaining to thyroid disorders were carried out by all centres, however, in the metropolises, excellent facilities existed or were being build up to cahrry out the full spectrum of in vivo and in vitro nuclear medicine investigations. There appeared to be a rapid expansion of the facilities in the private sector. All the centres about which the information was available, had good radiation safety facilities for patients as well as for staff. Most of the centres used imported instruments and indigenous radiopharmaceutical preparations. None of the centres provided any worthwhile data on the distribution of patients as a function of age, sex and socio-economic status.

References

1. National Academy of Sciences. Health Effects of Exposure to Low Levels of Ionizing Radiation. BEIRV. Report National Academy Press, Washington, DC 1990.

2. Report of the National Institutes of Health Ad Hoc Working Group to Develop Radioepidemiological Tables. NIH Publication No. 85-2748. US Department of Health and Human Services, Washington DC 1985.

3. Upton, A.C. Risk estimates for carcinogenetic effects of irradiation . Ann ICRP 22: 1, 1991.

4. Smith, H. The detrimental health effects of ionizing radiation. Nucl Med Commun 13(4): 10, 1992.

5. UNSCEAR. Sources, Eeffects and Risks of Ionizing Radiation. Report to the General Assembly with Annexes. United Nations, New York, 1988.

6. UNSCEAR. Sources and Effects of Ionizing Radiation. Report to the General Assembly with Annexes. United Nations, New York, 1993.

7. Gupta, M.M., Nagaratnam, A., Jain, S.C. and Reddy, A.R. Nuclear medicine practice and radiation exposure therefrom : A synoptic view of world-wide scenario (summary of UNSCEAR 1993 data) Indian J Nucl Med 10: 145, 1995.

8. Gupta, M.M. Questionnaire to gather information about NM facilities in India. Indian J Nucl Med 8: 118, 1993.

9. Gupta, M.M. Questionnaire to gather information about NM facilities in India. Indian J Nucl Med 10: 227, 1995.

(To be contd.)

ABSTRACTS

Some Research Projects Completed Recently

Effects of apolipoprotein E polymorphism on the lipid and lipoprotein levels related to risk for cardiovascular disease.

The study was carried out on unrelated individuals of Kshatriya (182) and Mala (38) communities from Andhra Pradesh to identify the apolipoprotein (apo) E genotypes and allele frequencies in these population.

Among the Kshatriya, five apo E genotypes (3/3, 3/4, 3/2, 4/2 and 4/4) were observed in males and (3/3, 3/4 and 3/2) in females. But in Mala population only three genotypes (3/3, 3/4 and 3/2) were observed in both the sexes. There was no significant gender differences in the frequencies of apo E genotypes in both the populations as well as between two population groups. The 4/2 and 4/4 genotypes were found to be less frequent and observed only among 2 individuals each (missing in female Kshatriya and both sexes in Mala). The gene frequencies of the three alleles designated apo S2, S3 and S4 for the Kshatriya (male and female pooled together) were 0.0522, 0.8516 and 0.0962 and for Malas 0.0395, 0.9210 and 0.0395 respectively. Gene frequencies for three alleles for the pooled population of Kshatriya and Malas were 0.0500, 0.8636 and 0.0864 respectively.

In the apo E genotypes, the apo E4 homo or heterozygotes showed higher levels of cholesterol compared to other genotypes. The influence of each of the three common apo E alleles (S2, S3, S4) on cholesterol and HDL cholesterol levels was evaluated by the test o f average allelic effects. The S2 and S4 alleles showed lowering and elevating effects respectively on cholesterol levels. But there was no evidence for a consistent relationship between apo Egenotypes and HDL cholesterol. The study also supports the assumption that lower S4 frequency may be associated with lowered risk of cardiovascular disease in rural population.

P. Venkatramana
P. Chengal Reddy
Deptt. of Anthropology
S.V. University
Tirupati.

Study of the natural history and seizure outcome in patients with solitary cysticercus granuloma and seizure.

A prospective study was carried out in 183 patients with seizures to determine the natural history of solitary cerebral cysticercus granuloma (SCG) and seizure outcome after the resolution of the granuloma and simultaneous or early withdrawal (2 to 3 months after resolution) of antiepileptic drugs. Only those patients who fulfilled all the diagnostic criteria (clinical and computerised tomographic for SCG) were included in the study.

One hundred and twenty nine (70.5%) patients presented with partial seizures with or without secondary generalization, 53 (29%) with generalized seizure and 1 (0.5%) with partial complex seizure. Of these, 78.1% patients had 5 or less seizures, 16.9% had 6-10 and 4.9% >10 seizures at initial presentation. Most of the patients had their initial CT scan within one month of their first ictus. Majority (93%) of patients could be managed with a single antiepileptic drug (monotherapy). Breakthrough seizures occurred in 30 (16.4%) patients who needed increased dose of the drug or an additional drug.

ELISA for cysticercus antibodies in serum was of limited value as it was found to be negative in a majority of patients. The CT lesions were typically between 5-15 mm in maximal dimension and were usually associated with mild to moderate oedema. The parietal lobe was the most favoured site of lodgement of the granuloma.

SCG was found to have a varied natural history and the granulomas resolved spontaneously though at different rates in individual patients. Kaplan Meier analysis of lesion resolution in the present study showed that at 3 months after first CT scan, 96.7% patients had persistent granulomas (though smaller in size in nearly 40% patients), at 6 months 75.5% patients and even after 12 months 46.5% patients had persistent granulomas.

The shortest period recorded for the resolution of lesion was 64 days after the initial CT scan whereas the longest duration of a persistent lesion seen in the CT scan was 429 days. Antiepileptic drugs were withdrawn within 2-3 months, after resolution of granuloma was seen on the CT scan. Of the 60 patients who could be followed up after withdrawal of the drugs (median follow up period 10 months), 57 were symptom free, and recurrence of seizures was noted in 3 patients at 3 to 10 months after withdrawal of drugs.

It can be concluded that SCG, a common cause of seizures in Indian patients, is a spontaneously resolving lesion with a variable rate of involution ranging from weeks to a year or more. The first follow up CT scan can be delayed for up to 6 months to decrease the number of scan examinations. Patients with SCG generally have a benign seizure prognosis and the antiepileptic drugs can be withdrawn after resolution of granuloma. However, a longer follow up is necessary to arrive at a definite conclusion regarding the long-term seizure outcome in these patients.

V. Rajshekhar
Department of Neurosurgery
Christian Medical College
Vellore.

ICMR NEWS

Meetings of the Project Review Committee (PRC)/Task Force (TF) held at New Delhi:

PRC on Oncology and Pathology ( June 30, 1998 )

TF on Control Programme for Thalassaemia by Antenatal Screening( July 13, 1998)

Participation of ICMR Scientists in Scientific Events:

Dr. A. Roy Chowdhury, Dy. Director, Regional Occupational Health Centre, Calcutta, participated in the XXV National Work Medicine Conference at Strasbourg (June 23-26, 1998).

Dr. Srikanth Tripathy, Asstt. Director, National AIDS Research Institute, Pune, and Dr. M.A. Khan, Sr. Research Officer, Institute of Cytology and Preventive Oncology, New Delhi, participated in the XII World AIDS Conference at Geneva (June 28 - July 3, 1998).

Dr. K. Satyanarayana, Director and Dr. B.V. Babu, Sr. Research Officer, Regional Medical Research Centre, Bhubaneswar and Dr. K.D. Ramaiah, Sr. Research Officer, Vector Control Research Centre, Pondicherry, participated in the data analysis meeting of the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, on community directed treatment of filariasis (Phase I studies) at Pune (July 10-18, 1998).

ICMR AIDED SYMPOSIA/ SEMINARS/ WORKSHOPS/ COURSES/ CONFERENCES

Symposium/Seminar/Workshop/ Course/Conference	Date & Place	Contact Address
International Symposium on Frontiers of Genetics and Development	July 7-8,1998; (at Bangalore)	Dr. U. Vijayaraghavan, Convenor of the Symposium, Department of Microbiology and CellBiology, Indian Institute of Science, Bangalore-560012.
International Symposium on Temporomandibular Joint Disorders and Chronic Orofacial Pain	October 30-31,1998; (at Mangalore)	Prof. P.K. Dayal, Organising Secretary of the Symposium, KMC College of Dental Surgery, Mangalore-575001.
Symposium on Current Trends in Autoimmune Diseases Immunology	October 30-31,1998; (at Lucknow)	Prof. S. Naik, Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow-226014.

 

 

COUNCIL'S TRAINING PROGRAMMES FOR 1998-99

Leprosy

At the Central JALMA Institute for Leprosy, Agra:

• Multidrug Therapy Orientation Course in Leprosy for Medical Officers (August 17-28, October 26-November 6; and December 7-18, 1998).

Virology

At the National Institute of Virology, Pune:

• Diploma in Medical Virology (July 1998-May 1999).

Reproductive Biology

At the Institute for Research in Reproduction, Mumbai:

• Workshop on Andrology for Clinicians (November 16-30, 1998)

Endocrinology

At the National Institute of Nutrition, Hyderabad:

• Annual Certificate Course on Endocrinological Techniques and their Applications (August 1-September 15, 1998).

Nutrition

At the National Institute of Nutrition, Hyderabad:

• Postgraduate Certificate Course in Nutrition (December 1, 1998-February 28, 1999).

Occupational Health

At the National Institute of Occupational Health, Ahmedabad:

• Training Course on Environmental Hygiene Practice (November 16-20, 1998).

Medical Entomology

At the Vector Control Research Centre, Pondicherry:

• Postgraduate Diploma Course in Medical Entomology (from August 10,1998).

Biomedical Statistics

At the Institute for Research in Medical Statistics, Chennai:

• Basic Course in Statistics for Postgraduate Medical Students (July 1998).

• Basic Course in Statistics for Medical Officers (November 1998).

Haematology

At the Institute of Immunohaematology, Mumbai:

• Training Course in Transfusion Medicine for Blood Bank Medical Officers (August 11-October 9, 1998).

• Training Course in Blood Group Serology and Blood Bank Methodology for Blood Bank Technicians (August 11-September 10, 1998).

• Training Course in Advanced Haematology and Immunohaematology (September 21-October 9, 1998).

 

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	Cost
	(in Rupees)
Nutritive Value of Indian Fooods (1985), by C. Gopalan, B.V. Rama Sastri and S.C. Balasubramaniam, Revised and Updated (1989), by B.S. Narasinga Rao, K.C.Pant and Y.G. Deosthale ((Reprinted 1996)	23.00
Growth & Physical Development of Indian Infants and Children (1972, Reprinted 1989)	10.00
Studies on Weaning & Supplementary Foods (1974, Reprinted 1996)	15.00
A Manual of Nutrition (Second Edition 1974, Reprinted 1995)	6.00
Low Cost Nutritious Supplements (Second Edition 1975, Reprinted 1994)	4.00
Menus for Low Cost Balanced Diets and School Lunch Programmes (Suitable for North India) (Second Edition 1977, Reprinted 1994)	4.50
Menus for Low Cost Balanced Diets and School Lunch Programmes (Suitable for South India) (Fourth Edition 1996)	6.00
Some Common Indian Recipes and their Nutritive Value (Fourth Edition 1977, Reprinted 1995) by Swaran Pasricha & L.M. Rebello	10.00
Nutrition for Mother & Child (Fourth Edition 1994, Reprinted 1996) by P.S. Venkatachalam & L.M. Rebello	11.00
Japanese Encephalitis in India (Revised Edition 1980)	5.00
Some Therapeutic Diets (Fifth Edition 1996) By Swaran Pasricha	7.00
Nutrient Requirements & Recommended Dietary Allowances for Indians (1990, Reprinted 1998)	16.00
Fruits (Second Edition 1996) by Indira Gopalan & M. Mohan Ram	20.00
Count What You Eat (1989, Reprinted 1997) by Swaran Pasricha	15.00
*The Anophelines of India (Revised Edition 1984) by T.Ramachandra Rao	150.00
Depressive Disease (1986) by A.Venkoba Rao	58.00
*Medicinal Plants of India Vol.2 (1987)	136.00
Diet & Diabetes (Second Edition 1993, Reprinted 1997) by T.C. Raghuram, Swaran Pasricha & R.D. Sharma	18.00
Dietary Tips for the Elderly (1992, Reprinted 1997) by Swaran Pasricha & B.V.S. Thimmayamma	5.00
Diet and Heart Disease (1994, Reprinted 1995) by Ghafoorunissa and Kamala Krishnaswamy	26.00
Dietary Guidelines for Indian - A Manual (1998)	23.00

* 25 per cent discount allowed to individuals.

These publications are available on prepayment of cost by cheque, bank draft or postal order (bank and postal charges will be extra) in favour of the Director-General, Indian Council of Medical Research, New Delhi. Money orders are not acceptable. All correspondence in this regard should be addressed to

Postal Address	:	Chief
		Division of Publications & Information
		Indian Council of Medical Research
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	EDITORIAL BOARD
	Chairman	Members
	Dr.N.K. Ganguly	Dr.Padam Singh
	Director-General	Dr.Bela Shah
		Dr.Lalit Kant
		Dr.R.Ravi
		Dr.V.Muthuswamy

 

Editor

Dr. N. Medappa

 

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The decay of radionuclides following their administration to patients leads to deposition of energy within various organs, tissues, cells and subcellular fractions. The calculation of the absorbed dose, has therefore, been an important activity in nuclear medicine and forms the primary basis of any form of risk assessment for diagnostic nuclear medicine procedures^1,2. Besides the health risk(s) involved, such dose estimation also helps to determine the amount of radionuclide that should be administered to patients during routine procedures. Some dosimetric quantities and concepts are given in the Appendix.

The Medical Internal Radiation Dose (MIRD) Committee of the American Society of Nuclear Medicine has developed the method of estimating organ absorbed dose which is generally referred to as MIRD Scheme³. This system of dose estimation assumes that the distribution of radionuclide in the organ/tissue of interest is uniform and that particulate radiation (beta and other electrons) are isotropic in their distribution and have ranges that are larger relative to typical cell diameters. Such conditions may not be always strictly true⁴, however, for most of the dosimetric purposes, MIRD scheme has given valuable data on absorbed dose estimation in most of the clinical situations. For the present study, the age-dependent absorbed dose coefficient values (S-factor values) as given in ICRP Publications^5,6 for various radiopharmaceuticals, have been utilized.

Effective dose (ie risk related radiation dose) estimation requires reliable information on S-factor values for all the organs and radiopharmaceuticals of interest, suitable tissue/organ weighting factor values and appropriate procedures for the dose estimation. There have been only marginal changes in the S-factor or absorbed dose coefficient values for the organs/tissues of interest for most of the radiopharmaceuticals, with a few exceptions like when a new organ or biokinetic model was accepted⁷ or when some discrepancies in values of basic data had occurred^8,9. However, significant modification had been effected in the tissue weighting factor values and in the methodology of effective dose computation from the earlier recommendations of the International Commission on Radiological Protection¹⁰. For the present study, the values of tissue weighting factor as given in ICRP 1990¹¹ have been used.

The effect of the new tissue weighting factor values on the effective dose (earlier known as effective dose equivalent) due to a large number of radiopharmaceuticals, has been studied extensively^12-19 and it was observed that in case of radiopharmaceuticals used in India, either the effective doses had remained unchanged or had become10-16 % lower than the previous values. On further scrutiny some discrepancies in the procedures recommended¹¹ for effective dose estimation, were noticed. These discrepancies and the problems that resulted by following these recommendations have been highlighted^20,21 and a new modified methodology suggested²². The modified methodology was further updated incorporating subsequent ICRP recommendations²³ and used for effective dose estimations. The salient features of the methodology are:

(i) Wherever the mean absorbed dose coefficients to an organ/tissue and the explicit value of tissue weighting factor assigned to it, are available, the contribution of the organ/ tissue to the effective dose is computed in the standard procedure recommended in ICRP 1990¹¹.

(ii) Since relative masses of the walls of the upper large intestine (ULI) and lower large intestine (LLI) are independent of age, the equivalent dose to colon - Hcolon is given as in ICRP 1995²³.

Hcolon = 0.57 H_ULI + 0.43H_LLI

(iii)Tissue weighting factor value assigned to gonads is allotted to testes or ovaries which ever is getting higher equivalent dose (ICRP 1995)²³.

(iv)Tissue weighting factor values assigned to the oesophagus and skin (for which age dependent absorbed dose coefficient for many radiopharmaceuticals used in India are not available) are considered to be part of the remainder.

(v)The remainder tissue weighting factor is thought of as consisting of 0.05¹¹ plus 0.05 (weighting factor value of oesophagus) plus 0.01 (weighting factor value of skin). Thus the total remainder tissue weighting factor is 0.11 which is to be apportioned as per guidelines (ICRP 1995)²³. Half the total remainder weighting factor ie 0.055 is assigned to any of the remaining organs/tissues that receives the highest equivalent dose of all organs, and the other half to the mass average committed equivalent dose in the rest of the remainder tissues and organs.

Using this methodology, the effective doses for a large number of radiopharmaceuticals were calculated^18,24,25.

Risk Related Radiation Dosimetry

About 35,000 nuclear medicine in vivo investigations were found to be performed per month at 58 centres located in 28 cities in the country. Investigations varied from simple thyroid uptake tests to sophisticated nuclear medicine procedures. The amount of radioactivity used for an investigation varied within wide limits from centre to centre, however, the amounts seldom exceeded the limits set by ARSAC²⁶. The list of radiopharmaceuticals and the range of radioactivity used for commonly performed imaging procedures in the country is given in Table I. Risk related radiation dosimetry was carried out for these radiopharmaceuticals.

Table I. Radiopharmaceuticals and range of radioactivity used for commonly performed imaging procedures in the country (data upto 1996)

Radiopharmaceutical	Use	Activity (MBq)
99mTc Pertechnetate	Thyroid imaging First pass study Brain scanning	40-400 700 500-1200
99mTc DTPA	Aerosol ventilation Cisterography Renal imaging Brain imaging
40 70-250 200-750 350-750
99mTc Gluconate Glucoheptonate	Renal imaging Brain imaging	200-750 350-750
99mTc HMPAO	SPECT cerebral studies	550
99mTc HSA	Blood pool studies	500-900
99mTc large colloid (Sulphur colloid)	Bone marrow Liver studies	200-350 200-350
99mTc DMSA	Renal imaging	200
99mTc Phosphates	Bone imaging	500-1000
99mTc RBC	MUGA	500-900
99mTc MAA	Lungs perfusion Venogram	80 200-350
67Ga Citrate	Tumour imaging	200
131I-Hippuran	Renal imaging	55-75
201Tl Chloride	Myocardial perfusion	50-100
131I Sodium iodide	Thyroid uptake Thyroid imaging	0.50 2.0
99mTc MAG3 (normal kidney function)	Renal imaging	200-750
99mTc denatured RBC	Spleen imaging	200-350
99mTc MIBI	Myocardial perfusion	500-1000
99mTc IDA	Hepatobiliary system	150-350
51Cr EDTA	Renal studies	2.0
75Sc Methionine	Pancreas imaging	4.0

MUGA : Multigated Acquisition

Age dependent effective dose coefficients calculated by indigenously developed modified dosimetry approach for the radiopharmaceuticals of interest are presented in Table II. It shows that most of the nuclear medicine investigations employing Tc-99m and Tc-99m based radiopharmaceuticals result in effective doses to patients of the order of millisievert or less. As different investigations employ different amounts of radioactivity, therefore, for calculating effective dose to the patient, these effective dose coefficients have to be multiplied by the actual amount of radioactivity (in MBq) used in the particular nuclear medicine investigation. The Table also shows that as the age of the patient increases, the effective dose coefficient decreases. This implies that for the same amount of administered activity, a one year old child may receive a higher effective dose (3 to 10 times) and therefore, may be at a higher risk of radiation detriment in comparison to an adult. The situation warrants greater care while carrying out nuclear medicine investigations in children.

A comparison has been made (Table III) of the effective dose coefficient values as calculated by the modified methodology and as given by ICRP⁶ for adults for radiopharmaceuticals used in India. The Indian values of effective dose coefficients are higher by about 10% (5-20%) than the values given by ICRP⁶. One of the reasons for lower ICRP values may be the ambiguous manner in which the remainder of tissue weighting factor and doses to remainder tissues or organs are treated. The values based on the modified method are in closer agreement with the ICRP values of 1987⁵ where the procedure for dose computation is more straight forward.

Superscript nos. refer to the serial nos. in the reference list.

Each nuclear medicine diagnostic investigation results in different effective dose to patients. In general, investigations employing Tc-99m and Tc-99m based radiopharmaceuticals result in lower effective dose to patients (unless the investigation demands very high activity) and those examination requiring I-131 and I-131 based radiodiagnostic agents with higher doses to patients. Some investigations that result in high effective doses to patients are shown in Table IV. A few of these investigations are performed frequently, specially involving I-131 at clinics/centres in smaller cities.

Conclusions

A new methodology was developed for effective dose estimation. Employing MIRD scheme and ICRP reference man data, age-dependent effective dose coefficients were calculated for all the radiopharmaceuticals used frequently in the country. The values arrived at by the new methodology were higher by 10% (5-20%) than the ones given in ICRP⁶. While employment of Tc-99m and Tc-99m based radiopharmaceuticals resulted in low radiation doses, other radiodiagnostic agents specially I-131 and I-131 based agents imparted significant radiation doses to patients . At most centres, the amount of radioactivity administered to a patient, was adjusted to his/her age and weight. In a significant number of clinics/centres particularly those located in comparatively smaller cities, investigations were being still carried out using I-131 and I-131 based radiopharmaceuticals resulting in unwarranted high radiation doses to patients.

References

1. Stabin, M., Stubb, J. and Watson, E. Recent controversy in radiation dosimetry. Eur J Nucl Med 20: 371, 1993.

2. Poston, J. Application of the effective dose equivalent to nuclear medicine patients. J Nucl Med 34: 714, 1993.

3. Loevinger, R., Budinger, T.F. and Watson, E. MIRD Primer for Absorbed Dose Calculations. Society of Nuclear Medicine: New York, 1989.

4. Makrigiorgos, G.M., Baraanowska-Kortylewiez, J. and Van den Abbeele, A.D. Microscopic spatial inhomogeneity of radiopharmaceuticals deposition in mammalian tissues : Dosimetry at the cellular level and comparison with conventional dosimetry. Radiat Prot Dosim 31: 319, 1990.

5. International Commission on Radiological Protection. Radiation dose to patients from radiopharmaceuticals. (ICRP Publication 53). Ann ICRP 18(1): 1, 1987.

6. International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals. Addendum to ICRP Publication 53, 1992.

7. Gupta, M.M., Kashyap, R. and Chakravarty, S.K. Radiation dosimetry in patients undergoing renal dynamic investigations at INMAS. Indian J Nucl Med 10: 82, 1995.

8. Gupta, M.M. and Nagaratnam, A. Effect of revised ICRP recommendations on Krypto-81m dosimetry _ or a discrepancy? Eur J Nucl Med 23: 227, 1996.

9. Gupta, M.M. and Nagaratnam, A. Dosimetry of N-13-l-glutamate: Basic information on age dependent absorbed dose coefficients. Eur J Nucl Med 23: 1554, 1996.

10. International Commission on Radiological Protection. Recommendations of ICRP (ICRP Publication 26) .Ann ICRP 1(3): 1, 1977

11. International Commission on Radiological Protection. 1990 Recommendations of ICRP : (ICRP Publication 60). Ann ICRP 21(1-3): 1, 1991.

12. Gupta, M.M. Radiation health and safety considerations in the clinical use of newer genre of radiopharmaceuticals. Indian J Nucl Med 6: 38, 1991.

13. Gupta, M.M., Jain, S.C. and Nagaratnam, A. Effect of new ICRP recommendations on effective dose of some new radiopharmaceuticals. In: Proceedings of the VIII International Congress of the International Radiation Protection Association. Montreal, Canada, (Vol.1), p.384, 1992.

14. Johansson, L. Mattsson, S., Nosslin, B. and Leide-Svegborn, S. Effective dose from radiopharmaceuticals. Eur J Nucl Med 19: 933, 1992.

15. Gupta, M.M. and Nagaratnam, A. Radiation safety aspects of some new generation of radiopharmaceuticals with special reference to 1990 ICRP recommendations. Bull Radiat Prot 15: 8, 1992

16. Gupta, M.M., Jain, S.C. and Nagaratnam, A. Comparative dosimetry of Tc-99m labelled diagnostic agents in view of the revised ICRP recommendations. AMPI Med Phys Bull 18: 8, 1993.

17. Jain, S.C., Gupta, M.M., Nagaratnam, A. and Reddy, A.R. Revised radiation doses to patients of different age groups from some indigenously available Tc-99m labelled radiopharmaceuticals. Indian J Nucl Med 7: 16, 1992.

18. Gupta, M.M. and Nagaratnam, A. Comparison of effective dose and effective dose equivalent from radiopharmaceuticals. Indian J Nucl Med 11: 50, 1996.

19. Jain, S.C., Nagaratnam, A., Reddy, A.R., Gupta, M.M. and Mehta, S.C. Revised age dependent doses to members of the public from intake of radionuclides as per new weighting factors. Radiat Prot Dosim 40: 111, 1992.

20. Nagaratnam, A., Jain, S.C. and Gupta, M.M. Effective doses from radiopharmaceuticals : Comparison between old and revised values and contribution from remainder organs. In: Proceedings of the XVII IRPA Regional Congress on Radiological Protection. Portsmouth U.K., p.133, 1994

21. Gupta, M.M. and Nagaratnam, A. Some practical difficulties in effective dose computation as per ICRP guidelines. Radiat Prot Dosim 69: 309, 1997.

22. Gupta, M.M. and Nagaratnam, A. Assessment of radiological safety of some new diagnostic agents used in nuclear medicine investigations. J Radiol Prot 13: 37, 1993.

23. International Commission on Radiological Protection. Age dependent dose to members of the public from intake of radionuclides : Part 3. Ingestion dose coefficients. Ann ICRP 25 (1): 1, 1995.

24. Gupta, M.M. and Nagaratnam, A. Estimation of age dependent effective dose coefficients for N-13-l-glutamate. Eur J Nucl Med 24: 346, 1997.

25. Gupta, M.M. and Nagaratnam, A. Revised age dependent effective dose coefficients for some selected radiopharmaceuticals. Indian J Nucl Med (in press), 1998.

26. Administration of Radioactive Substances Advisory Committee. Notes for Guidance on the Administration of Radioactive Substances to Persons for Purposes of Diagnosis, Treatment or Research. EN (93) 5, Department of Health and Social Security, London, 1993.

    (To be concluded)

Absorbed dose (D) : The basic physical quantity used in nuclear medicine dosimetry is the absorbed dose. For all types of radiation, the absorbed dose is a measure of the amount of energy from the radiation field which is deposited in unit mass of an organ or tissue. The SI unit of absorbed dose is joule per kilogram and is called gray (Gy). The method of calculating absorbed dose in nuclear medicine has been developed over many years by the Medical Internal Radiation Dose (MIRD) Committee of the American Society of Nuclear Medicine. In the MIRD scheme, a body is considered to consist of source organs (ie those with significant uptake of radiopharmaceuticals) and the target organs (ie those being irradiated by the source organs). For each pair of source and target organs, the following equation is used to calculate the absorbed dose in Gy to a target organ `T' from the activity in the source organ `S'.

A_s is the time-integrated, or cumulated activity, and is equal to the total number of nuclear transformations in S; and is the absorbed dose in T per unit cumulated activity in S and is referred as the S-factor which is the absorbed dose coefficient for that organ. Numerical values of or simply `S' have been tabulated for large number of organs and tissues in both standard man and children for a variety of radionuclides and radiopharmaceuticals. Age dependent 'S' values are given in ICRP publication 53 (ICRP 1987) and later in one of its addendum (ICRP 1992).

Equivalent dose (H) : Even when the energy is equal at a macroscopic level (ie, the absorbed dose is the same) different types and energies of radiation will produce different amounts of biological damage. To allow for this, a further quantity has been introduced. This is called the equivalent dose, H , which is the average absorbed dose in an organ or tissue multiplied by a dimensionless radiation weighting factor, W_R that is a function of linear energy transfer (LET) of the radiation. Radiation weighting factor of 1 is assigned to low LET radiation, including X-rays and gamma-rays of all energies. The SI unit of equivalent dose is joule per kilogram and is called sievert (Sv). Smaller unit of equivalent doses are millisievert (mSv) and microsievert (µ) that are one thousandh and one millionth of a sievert respectively. For almost all the radiation used in medical imaging, radiation-weighting factor is unity, so the absorbed dose and equivalent dose are numerically equal.

Effective dose : Effective dose equivalent is the risk related parameter to describe the overall effect of non homogeneous dose distribution (as takes place in nuclear medicine imaging), taking into account the relative radiosensitivity of each organ and tissue and is similar, in terms of overall risks , to a uniform whole body exposure in which each organ receives an equivalent dose equal to effective dose. The Effective dose is obtained by calculating a weighted average of the equivalent doses received by each organ or tissue in the body which has been irradiated (where W_T is the tissue weighting factor for organ T, H_T is the equivalent dose received by organ or tissue T and .

The relationship between the different dosimetric quantities are illustrated in the flow chart.

Organs or tissues which are at higher risk (or are more sensitive to radiation detriment) are given higher tissue weighting factor. The values of tissue weighting factor are given in Table A. The different dosimetric quantities used in nuclear medicine and their conversion from one unit system to another is given in Table B. Effective dose is also expressed in sieverts (Sv), millisieverts (mSv) and microsieverts (µ). Effective dose as defined by the International Commission on Radiological Protection¹¹, provides a possibility of expressing the radiation risk to patients undergoing different radiodiagnostic procedures by means of a single figure.

Table A.Tissue and organ weighting factor values (W_T) as given by ICRP 1990 for estimating effective dose.

Organ or tissue	WT
Bone surface and skin	0.01	0.02
Bladder, Breast, Liver Oesophagus, Thyroid and remainder	0.05	0.30
Bone marrow, Colon, Lung and Stomach	0.12	0.48
Gonads	0.20	0.20

ABSTRACTS

Some Research Projects Completed Recently

Action of cisplatinum on some unicellular organisms.

A study was conducted to investigate the mode of action of cisplatinum on unicellular ciliate species in order to understand the action of this drug on eukaryotic cells and some aspects of its metabolism. Several different species of genus Stylonchia collected from wild habitat were treated with anticancer drug, cisplatinum in the dose of 150 µg/ml for 2 h. Studies on macronucleus and micronucleus were carried out to study the mechanism of action of the drug. Different species of the unicellular ciliate protozoa viz isolated from wild habitats exhibited variable sensitivity towards the antitumour drug cisplatinum. Intracellular quantitative measurements of platinum in post-treatment resistant cells showed that higher resistance was not due to poor metal uptake; these cells showed comparatively higher uptake. Likewise, the germ line micronucleus of these cells was highly vulnerable to genetic damage in comparison to the somatic nuclei. The germ line nuclei bound at least 3 times more of platinum when cells were treated in situ.The DNA lesions in the micronucleus caused by extremely low platinum dosages were detrimental to the completion of meiosis and formation of a new functional somatic macronucleus. DNA characterization of platinum damaged micronuclei showed unusual fragmentation to low mol. wt. components. Such damage was irreversible leading to the loss of micronuclei and production of amicronucleate strains. It appeared that micronuclear components like non histone chromosomal proteins facilitate higher platinum binding leading to fragmentation of high mol. wt. micronuclear DNA.

G.R. Sapra
Department of Zoology
Delhi University
Delhi

Publications

1. Kamra, K. and Sapra, G.R. Morphometric and morphogenetic comparisons between Onychodromus indica sp.n. and O. quadricornutus Foissner, Schleget et Prescott, 1987; Phylogenetic note on Onychodromus and related genera. Acta Protozool 32: 107, 1993.

2. Sapra, G.R., Dutta, D. and Ammermann, D. Variable sensitivity of the micronuclear genome during different life cycle stages towards cis-dichlorodiammine platinum II in Stylonchia lemnae. Indian J Expt Biol 32: 470, 1994.

3. Kamra, K. and Sapra, G.R. Quantitative regulation of the ciliary structures in polymorphic states of the hypotrichous ciliate Onychodromus indica, Kamra and Sapra 1993. Eur J Protistol 30: 379, 1994.

Evaluation of the effectiveness of brief in-patient family intervention vs. out-patient intervention for mentally retarded children.

A prospective study was carried out on mentally retarded children to evaluate the effectiveness of brief in-patient and out-patient family focussed interventions (developed in-house) in terms of their impact on the child's development and behaviour, and family adaptation (perceived stress and coping). The components of the intervention included medical measures, family orientation, general parenting measures, and parent training. Outcome variables studied included child variables (intellectual/adaptive functioning and presence and severity of problem behaviour) and family variables (self report and observer rated stress in families and level of family adaptation).

A total of 157 mentally retarded children of either sex (75 in the in-patient group and 82 in the out-patient group) from low socio-economic group (both rural and urban) and with moderate to profound degree of mental retardation were recruited for the study. Children who had already undergone major intervention, those with severe hearing or vision impairment which was more disabling than the mental retardation and children with progressive neurologic disorders were excluded from the study. Thirty three (44%) children/families is the in-patient and 47 (57%) in the out-patient group could complete one year of follow up.

Improvements or gains were noted on all outcome measures to a varying extent in both the groups. The gain in the child adaptive functioning was more pronouned in the in-patient group (10 points) as compared to the out-patient group (4 points). Problem behaviour came down by 55-60%, family stress reduced by 27-35% and family adaptation was improved by 30% in both the groups. Maximum gains occurred during the first 3-6 months of follow up and subsequently remained stable over the remainder of the follow up period. There were no major effects of age, sex, and residence on outcome.

It is therefore concluded that it is possible to formulate and test effective family focussed interventions in mental retardation which are suited for Indian conditions and such inerventions will produce long-lasting and significant improvements in both children and their families.

R. Satish Chandra Girimaji
Department of Psychiatry
National Institute of Mental Health and
Neurosciences, Bangalore

Girimaji, S.C.R. Family intervention in mental retardation: An overview. NIMHANS J 11: 21, 1993.

ICMR NEWS

Meetings of the Project Review Committee (PRC)/Task Forces (TFs) and other meetings held:

PRC for proposals in Non-Communicable Diseases July 17, 1998 (at New Delhi)

Meetings of the Investigators of the district nutrition project July 23-24, 1998 (at Mumbai)

Annual Review meeting of the Human Reproduction Research Centres August 10-11, 1998 (at Mumbai)

Meeting of the Investigators of the project on mobile unit approach to meet reproductive health needs of women August 13-14, 1998 (at New Delhi)

Participation of ICMR Scientists in Scientific Events:

Dr. B. Shiv Kumar, Dy. Director (Sr.Grade), National Institute of Nutrition, Hyderabad, participated in a conference on Iron Deficiency Anaemia at Colombo (July 19, 1998).

Exhibition:

As part of the commemoration of the 50th Anniversary of India's Independence the Department of Science & Technology, New Delhi, organised an exhibition at the lawns of India Gate during August 3-16, 1998 on the achievements of India in the field of Science & Technology during the last 50 years. The ICMR Hqs, in collaboration with its Delhi based Institutes/Centres and the National Institute of Nutrition, Hyderabad, participated in this exhibition depicting the achievements in the field of malaria, nutrition, cancer research, etc. This exhibition attracted a very large number of visitors daily including students and the general public.

CONTRACEPTIVE RESEARCH AND DEVELOPMENT DURING THE
FIFTY YEARS OF INDEPENDENCE IN INDIA:
ACHIEVEMENTS AND DESIRED GOAL

The Family Welfare Programme of India is to be complimented for substantially reducing the burden of reproductive ill-health of people during the last fifty years. Marked reduction in the infant and maternal mortality rates, decrease in the total fertility rate and increase in life expectancy for both men and women are testimonies to the achievements of the Programme. However, in spite of these achievements we are far away from the desired goals. The population of India has increased by over 600 million people since independence. Moreover, there is a visible large inbuilt momentum for continued growth of the population over the next several decades as over 45% of the women in India today are in the reproductive age group of 15-44 years. At the present growth rate of a little over 2%, the population will cross the one billion mark by the turn of the century. The coming years are thus very crucial for the survival of the people of India. The actions taken now to improve the reproductive health (RH) of people and particularly to control population growth will determine the quality of life in the years to come.

Numerous factors have contributed to the increase in population. Some of these are low age at marriage; unmet needs for contraception including poor access to health facilities; low status of women; low female literacy; perceiving children as assets for old age and not taking risk due to high infant mortality. Low contraceptive prevalence was probably the most killing factor responsible for high population growth and this in turn had a bearing on other components of RH such as high incidence of unwanted pregnancies and induced abortions, high infant and maternal mortality and increasing incidence of sexually transmitted diseases (STDs).

The Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994 has acknowledged the advances made in developing a greater range of safe and effective modern contraceptive technologies and has also emphasized that many people, particularly men, still cannot find a family planning method that suits their needs. The ICPD has emphasized the need for a wider range of safe and effective methods.

Indian scientists have played a commendable role in the development of contraceptive technologies over the last five decades. The Indian Council of Medical Research (ICMR) and some other national agencies including the Department of Biotechnology, Department of Science and Technology and Council of Scientific and Industrial Research have provided enormous technical and financial inputs for the success of research programmes in these areas.

This article is a tribute to the Indian scientists for their endeavours during the post independence era to develop contraceptive technologies to improve the RH of people. The article also addresses some of the desired changes in the expression and perception of needs for fertility regulating technologies, especially in relation to the new concepts of RH expressed at the ICPD and the Fourth World Conference on Women held in Beijing.

ACHIEVEMENTS

The research contributions by Indian scientists have led to evaluating and improving the safety, efficacy and acceptability of a number of contraceptive methods, and the development of new methods of fertility regulation. In addition, the studies elucidating the intricate mechanisms regulating fertility and the new hypothesis proposed by them have provided the fundamental base for the development of contraceptive technologies.

EVALUATION OF THE SAFETY AND EFFICACY OF CONTRACEPTIVE METHODS

The ICMR through a series of multicentric clinical trials and many scientists at their own initiative have carried out a number of studies evaluating newer contraceptive methods for their safety, efficacy, side effects and continuation rates. The information derived from such studies on the Indian population suggests that a number of contraceptives, in particular the use of oral pills and copper (Cu)-bearing intrauterine devices (IUDs), are safe, effective and reversible in preventing pregnancy. Some of the copper IUDs, such as CuT 220C and CuT 380A, are effective for as long as 12 years after insertion, thereby suggesting that the couples need not resort to terminal methods to control their fertility. Improved counselling and better quality of services are essential to improve the acceptance of the available methods and their continued use.

Vasectomy and its Long-term Sequelae

Vasectomy is used by approximately 40 million men world-wide as the preferred method of fertility regulation¹. In India almost 2% men of reproductive age rely on vasectomy for fertility regulation. It is highly effective and has a low complication rate. However, there have been sporadic reports about possible development of cardiovascular sequelae and an increased risk of prostate and testicular cancer among vasectomized men. Studies carried out under the aegis of the ICMR have shown that vasectomy had no adverse effects on the cardiovascular system². Similarly, a review by the ICMR has concluded that there was no consensus about an increased risk of prostate cancer among vasectomized men³. The overall morbidity and mortality rates due to cancer in vasectomized men are equal to or lower than those of community-matched controls. Regarding the association between vasectomy and testicular cancer, follow up of a study funded by the WHO in Denmark involving some 65,000 men who had had vasectomy demonstrated that there was no such association¹. These observations are quite reassuring to dispel any fear which vasectomized men or those thinking of opting for this approach for fertility regulation might have.

Oral Contraceptives

Oral contraceptives (OCs) containing estrogen and progestin were introduced over 35 years ago. During this period the content of these steroids in OCs has been considerably reduced to curtail the associated side effects without compromising the contraceptive efficacy⁴. The two most widely used OCs contain either a combination of ethinyl estradiol and levonorgestrel or norethisterone (COC) or only levonorgestrel (minipills). More recently OCs containing newer progestins such as norgestimate, gestodene or desogestrel have been developed which help to further reduce the side effects due to the intrinsic androgenic activity of levonorgestrel or norethisterone.

Indian scientists have undertaken a number of studies evaluating the contraceptive safety and efficacy of available preparations. Multicentre studies carried out by the ICMR have shown that OCs are generally safe and highly effective in preventing pregnancy ^5,6. Some of these studies have shown that the progestogen-only contraceptives have an advantage over the combination pills in that they can be used safely by lactating women and by those in whom the use of estrogens is contraindicated. However, the incidence of breakthrough bleeding and method failure rate was slightly more in the minipill users compared to the COC. Studies on the long-term follow up of infants and children exposed for short or long periods to low dose progestins in infancy through their mother's milk did not show any obvious adverse effects on the infants' or children's anthropometric measurements or major systems ⁷. However, subtle effects that could go unnoticed cannot be ruled out ⁸.

In addition to evaluating some of the oral contraceptives, the Central Drug Research Institute, Lucknow, has developed a nonsteroidal antiestrogen centchroman [3,4-trans-2,2-dimethyl-3-phenyl-4-p-(b-pyrrolidino-ethoxy) phenyl -7-methoxychroman], the postcoital or weekly use of which provides acceptable pregnancy protection. Centchroman is being marketed in India as a weekly contraceptive. A dose of 30 mg administered biweekly for the first three months and thereafter at weekly intervals to 377 women volunteers, covered for 3,932 months of use, provided excellent pregnancy protection. No drug related side effects were observed or reported⁹. Babies born to user-failures presented normal milestones. The contraceptive effect was readily reversible and subsequent pregnancies were normal.

In addition to providing contraceptive protection, the use of OCs also provides protection against some of the life threatening diseases and conditions that impair the quality of life. Their use has been shown to be associated with decrease in the incidence of epithelial ovarian cancer, endometrial cancer, pelvic inflammatory disease, ectopic pregnancy, benign breast disease, iron deficiency anaemia and formation of functional ovarian cysts^10,11.

However, there are some concerns and controversies about the long-term effects of the OCs on the development of neoplasia and on the cardiovascular system. A number of studies have found no overall association between OC use and the risk of breast cancer ^12,13. However, some¹⁴ have reported a weak association between long-term use of OCs and breast cancer in young women in general who had early menarche and those who have used the combination pill for long periods of time. The WHO supported multinational case-control study found that women who had ever used OCs had an overall relative risk of 1.15 of developing breast cancer compared with women who had never used OCs¹⁴. This issue of the possible association of breast cancer with OC use is still controversial and can possibly be resolved by further research in this area. However, considering that the risk of breast cancer in these age groups is low and that such cancers represent a very small proportion of all breast cancers, the association if real is not of significant public health importance. Similarly, it is still not resolved whether the use of OCs, particularly the third generation OCs, have any association with increased incidence of venous thromboembolism, myocardial infarction or stroke^15-17. It is, however, very clear that if women with risk factors for coronary heart disease are excluded from taking OCs, the incidence of myocardial infarction in healthy women who are taking the pill is not increased.

In spite of the fact that the OCs are quite safe and effective, less than 2% of the Indian women use oral pills to prevent a pregnancy. The issue of compliance deserves closer attention by family planning care providers. Proper counselling and providing balanced information on significant contraceptive and noncontraceptive benefits/risks associated with OCs and services should help improve compliance.

Long-acting Methods

Indian scientists have also made significant contributions to the development of contraceptives which once administered provide pregnancy protection for a long time. Such injectables include subdermal silastic implants, and intramuscular depot preparations containing either only-progestogen or estrogen-progestogen preparations.

Silastic implants

After evaluating silastic implants of varying length, wall thickness, the amount of progestin contained in them and the release rate, Srivastava and associates identified an implant (Implant D) which released norethindrone acetate at an average release rate of 128 µ/day and calculated functional life of 10 months¹⁸. Administration of these implants to 876 women, who were followed up for 3,975 woman-months, showed high contraceptive efficacy. The pregnancy rates at 7 and 8 months of use were 2.3 and 3.9 per 100 woman-months, respectively¹⁹. The cumulative removal rate, for medical and personal reasons, at the end of 8 months was 7.5%. These studies revealed that development of slow-releasing devices was an attractive option for long-term contraception.

The ICMR has also evaluated levonorgestrel-releasing Norplant^R, consisting of six capsules, and NorplantII, consisting of two covered rods which were developed by the Population Council, New York²⁰. No method failure was reported by the 172 women who had used these devices for a period of up to 2 years. The continuation rates with both devices were similar and were 80 and 65 per 100 users at the end of the first and second years of use, respectively. Norplant II was preferred as it was easier to insert two rods as compared to the six. In another phase III multicentre clinical trial Norplant ^R-II was evaluated over a 5-year of use. A total of 1,466 women were observed for 52,849 woman-months. The cumulative method failure rate was 0.8 per 100 users and continuation rate at 5 years was 42.1%²¹.

Over the years, clinical studies with Norplant^R have involved 55,000 women, the device has been registered in 60 countries and the method has been used by some 6 million women world-wide²². The cumulative pregnancy rate at the end of 5 years is approximately one per 100 women. Ectopic pregnancy rates are correspondingly low, 0.3 per 1,000 woman-years. The major advantage of this method is its long-term effectiveness. However, by the end of 5 years, almost 25% of the Norplant^R users had requested for its removal because of bleeding problems and another 15% for medical problems including headache and weight gain. Difficult removal of the implant is another associated problem of implant use. In addition to the levonorgestrel releasing implants, implants releasing 3-keto-desogestrel, nomegestrel or nestorone are being developed in an endeavour to further reduce the incidence of side effects and the number of implants to be inserted in a woman's body.

The use of subdermal implants form a good option for fertility regulation for programmes which have adequate service facilities including counselling and provision for training for the providers.

Progestogen-only injectables

A three-monthly injectable depot-medroxyprogesterone acetate (DMPA) has been approved for use as a contraceptive in over 100 countries where an estimated 10 million women have used this method. DMPA is highly effective in preventing pregnancy. In India, studies have been undertaken to assess its utility in the family planning programme. In a study in which 138 women participated for a total of 907 woman-months no pregnancy occurred²³. However, the discontinuation rates due to severe menstrual disturbances were very high. Almost 32% of women discontinued after the first injection and another 38.8% before receiving the third dose.

Similar observations were made in a multicentre study conducted by the World Health Organization (WHO) in 13 countries²⁴. A total of 1,587 women were observed for 20,550 woman-months over a 2 year period in which only 3 pregnancies occurred. The discontinuation rate in the 13 participating countries ranged between 33.3 to 75.0 and 49.5 to 91.3 per 100 women at one and two years of use, respectively. The major reasons for discontinuation were menstrual irregularities, weight gain, and headache.

A recent survey of first users of DMPA from the USA reported a continuation rate of 28.6% at one year of use²⁵. It seems that women who have wider choice of alternative contraception do not prefer to continue using DMPA. The Ministry of Health and Family Welfare, Government of India has not yet approved DMPA for the National Family Planning Programme but has approved its use by private physicians.

Norethisterone enanthate (NET-OEN, 200 mg) given at two or three-monthly interval has also been extensively evaluated for its efficacy and side effects in multicentre studies conducted by the ICMR^26,27. The method is as effective as DMPA. The discontinuation rates for bleeding disturbances and due to other medical and personal reasons were very high in NET-OEN users and seemed comparable to those with the use of DMPA.

Estrogen-progestogen combination

To overcome the problems of irregular bleeding observed with the progestogen-only injectables, combined estrogen-progestogen preparations have been developed. Several dose finding studies have been carried out in India to determine the optimum dose of the two steroids in the combination regimen²⁸. The two preparations which have undergone extensive clinical evaluation are Cyclofem (25 mg DMPA and 5 mg estradiol cypionate) and Mesigyna (50 mg NET-OEN and 5 mg estradiol valerate)²⁹. A phase III randomized clinical trial, on 849 subjects observed for 7,817 woman-months, comparing Mesigyna given at monthly or two monthly intervals showed that the pregnancy rates with one monthly injections (0.2 per 100 users) were less than with the two monthly injections (1.1 per 100 users)²⁶. Moreover, the subjects using the monthly preparation had a better bleeding pattern.

Phase III clinical trials carried out by the WHO and other agencies in some 9,793 women for 1,02,058 woman-months of use have also confirmed the high contraceptive efficacy of Cyclofem and Mesigyna²⁹. More than 65% of women had predictable regular cycles. Discontinuation due to bleeding related problems were less than half of those seen with progestogen only injectable. Both Cyclofem and Mesigyna are thus safe and effective contraceptives. With proper counselling and service delivery it should be possible to add these combination regimens to the existing range of contraceptive methods.

Vaginal rings

The use of a vaginal ring releasing small quantities of contraceptive steroids offers an attractive method of contraception. The device is long-acting, under user's control and is not limited by the constraints of daily administration or coitus related such as the use of condom. Silastic rings impregnated with either combination of estrogen and progestins or only progestins have undergone extensive evaluation. However, menstrual disturbances, vaginal irritation and lesions in some cases have so far hampered the widespread use of vaginal rings. In a large multicentre study carried out by the WHO on 1005 women the rate of intrauterine pregnancy in levonorgestrel-releasing contraceptive ring was 4.5 per 100 women. The discontinuation rate at one year was 66%. Since the vaginal lesions and irritation was thought to be due to the texture of the silastic ring, the WHO is considering the possible development of a new vaginal ring with higher dose of levonorgestrel ³⁰.

Vaginal ring releasing levonorgestrel has also been evaluated in India. Menstrual irregularity (36%), vaginal irritation or increased vaginal discharge (23%) and expulsion (6%) were the most common reasons for discontinuation³¹. Since most women find this method more suitable for their contraceptive needs, efforts to develop more safe, effective and acceptable rings need to be pursued.

Intrauterine devices

A number of studies have been conducted in India to develop new intrauterine devices (IUDs), to evaluate the contraceptive efficacy of available IUDs and to improve their utilization. Soonawala's CuY and Merchant's CuR are two devices developed by Indian scientists during 1970s. CuT 200 which is offered in the National Family Planning Programme has in particular been extensively investigated for its efficacy and side effects. A multicentre study initiated in early 1970s on 4,357 women, observed over 32,709 woman-months, showed high contraceptive efficacy of the device. The discontinuation rate at the end of two years due to expulsion and medical reasons were 9.4 and 15%, respectively. Almost 22% of the women had the device removed for non-medical reasons³². The discontinuation rates due to pregnancy and medical reasons including bleeding disorders and pain were less than those observed with the Lippes loop³³.

In a more recent study, CuT 200 was evaluated in comparison to CuT 220C, CuT 380Ag and a levonorgestrel releasing device ³⁴. In a multicentre study 1905 women were randomly allocated to one of these four types of IUDs and observed for 45,683 woman-months of use. While no method failure was reported with the levonorgestrel IUD, the cumulative failure rate per 100 users, at 36 months of use, was least with CuT 200C (0.3) as compared to CuT 380Ag (1.0) or CuT 220C (1.6). Continuation rates were significantly lower with the levonorgestrel IUD as compared to the other devices, which were primarily due to higher menstrual disturbances and amenorrhoea. The risk of expulsion ranged between 8.3 to 10.6 per 100 users and was comparable for the four devices.

WHO sponsored clinical research in multicentric, randomized studies have shown that CuT 220C and CuT 380A are effective for at least 12 years of use ³⁵. The cumulative 12-year intrauterine pregnancy rate per 100 women, with CuT 380A was less (1.9 + 0.5) as compared to the CuT 220C (7.0 + 0.6). However, the overall continuation rate at all intervals since insertion was higher with the CuT 220C device, mainly due to higher removal rates for nonmedical reasons with the CuT 380A.

These studies suggest that IUDs provide a reversible non-surgical alternative to sterilization for women requiring very long-term pregnancy protection. However, its use must be properly counselled and the device carefully applied.

DEVELOPMENT OF NEW METHODS OF FERTILITY REGULATION

Approaches for Male Fertility Regulation

Hormonal methods

Testosterone which is essential for the maintenance of spermatogenesis and libido when given in pharmacological doses has inhibitory effects on gonadotrophin secretion and consequently on spermatogenesis. These observations led Reddy and Rao in 1972 to evaluate the effects of long-term treatment with testosterone propionate on spermatogenesis in adult men³⁶. Daily intramuscular treatment of men, aged 23-38 years, with testosterone propionate (25 mg/day) resulted in complete suppression of spermatogenesis by 60 days. The libido and potency of these men were not affected. The inhibitory effects on spermatogenesis were reversed within 150 days of the stoppage of treatment. This study demonstrated the feasibility of a hormonal method for fertility regulation in normal men.

The lead established by the Indian scientists was taken up by many research centres in the world to develop male hormonal methods of fertility control. The major emphasis of the research programme was to develop more potent androgens so that the need for daily administration of the drug could be avoided. Using a relatively longer acting androgen, testosterone enanthate, the WHO has completed two clinical multicentric trials and has confirmed the contraceptive potential of androgens in men^37,38. A total of 670 adult men from 9 countries volunteered for the two studies. Weekly administration of 200 mg testosterone enanthate caused azoospermia in 425 men and oligospermia in another 81. The 506 men started relying only on testosterone enanthate as a contraceptive after the treatment had induced either azoospermia or oligospermia in them. Only five pregnancies occurred in the partners of these men. The overall pregnancy rate in the two studies was 1.2 per 100 person years which was superior to that achieved with condoms or the withdrawal method. The fertility or sperm production was restored within 7 months after the treatment was stopped. High level of acceptability was found in both the recipients and their partners in spite of the need for weekly injections.

In addition, studies are on to evaluate androgen in combination with progestogen as a male contraceptive³⁹. In the combination strategy, progestogen is to primarily block gonadotrophin release and consequently steroidogenesis whereas low doses of androgens are to maintain libido. Studies have shown that oligospermia and azoospermia are achieved much faster and in more number of subjects using a combination regimen as compared to androgens alone. The combination regimen may be preferred over the androgen only regimen as it may reduce the potential for lipid, behavioural and prostate changes that could arise from the continued exposure to androgen alone.

These studies supported the idea that androgens either alone or in combination with progestins could be used as male contraceptives. However, availability of a longer acting preparation will be a distinct improvement and more attractive. Studies carried out with testosterone buciclate have shown that a single injection can provide sustained levels of testosterone for 3-4 months^40,41. Alternatively there is a need to develop formulations and delivery systems such as slow-release biodegradable implant; testosterone incorporated into sustained-release delivery systems such as the biodegradable copolymer microspheres; and long-acting testosterone esters which on hydrolysis release the biologically active form of testosterone in the body which can help obviate the need for frequent systemic administration.

Vas occlusion

Vasectomy is highly effective and has a low complication rate but its more widespread acceptability is affected by the need for a surgical intervention; and that the procedure must be considered permanent as reversal is difficult and the success rate, as determined by subsequent fertility, is low. Although the advent of no-scalpel vasectomy has considerably reduced these concerns, and the success rates of vasovasectomy are improving, an approach is needed that is easier to perform and more predictably reversible if a greater number of men and couples are to find this type of method attractive.

Guha and associates have shown that injection of styrene maleic anhydride (SMA, 60 mg) in a solvent system of dimethylsulphoxide into the vas deferens induces complete azoospermia⁴². The phase I clinical trial and continuing follow up of the subjects over a period of seven years have demonstrated that the procedure does not lead to any clinical complications in the urogenital system and other parts of the body. In the phase II study, 12 adult healthy men were administered the drug and followed up for a period of one year. These volunteers and their wives did not use any other form of contraception during the study period. Regular monthly semen examination showed azoospermia in all 12 men. The treatment was safe and provided pregnancy protection during the one year study period. The results of recent preliminary studies carried out in non-human primates and men have shown that the process can be reversed by flushing out the SMA plug into the urethra⁴³. Hopefully, vas occlusion using SMA will develop into an acceptable method of male contraception.

More recently, liquid silicone is also being tried to form cured-in-place plugs following injection in the vas. However, the results of the initial studies carried out in Indonesia and China have shown high frequency of vas rupture following percutaneous intravasal injection of silicone⁴⁴ and the studies carried out in the Netherlands have shown poor occlusion rate as evidenced by a relatively high number of sperm in the ejaculate compared to vasectomy cases¹. These studies need to be extended to determine the optimum volume and pressure characteristics needed to achieve complete vas occlusion without causing any damage to the vas.

Immunological methods

The antigenic nature of hormones, spermatozoa, secretory products of accessory glands and tissues of the reproductive system have been utilized to target them for contraception by using actively or passively induced antibodies to these substances. Rao and associates at the Institute for Research in Reproduction (IRR), Mumbai, showed that antibodies to spermatozoa could block fertility. These investigators proposed in early 1960s that the presence of autoantibodies to spermatozoa in men or iso-antibodies in some women could be the cause of infertility⁴⁵. These authors further demonstrated that the buffalo seminal plasma contained at least 16 antigens, and spermatozoa at least 7, of which 4 were common to seminal plasma. These pioneering observations by the Indian scientists have provided leads to develop a sperm vaccine based on identification of suitable surface-expressed epitopes that are sperm-specific, adequately immunogenic and involved in fertilization.

Sperm-surface antigens

The IRR scientists have identified a 80 kDa protein on the sperm surface using circulating antisperm antibodies from infertile women as probes⁴⁶. The preliminary studies show that active immunization with this protein results in infertility in both male and female rats. This protein has been sequenced and studies are being extended to determine the N-terminal or internal fragment of the native 80 kDa protein, immunization against which might have contraceptive potential.

Scientists at IRR have also generated a panel of monoclonal antibodies (MAb) to identify sperm membrane antigens which may play a role in sperm function⁴⁷. One of the MAbs, D₂G₄ was found to react with the 26 kDa protein present on the acrosomal region of mouse and human spermatozoa. This 26 kDa antigen is also present in the cauda epididymis and is regulated by androgens. The antibodies directed to the 26 kDa protein had antifertility effects in both male and female mice⁴⁸. These studies suggest that sperm maturation antigens are particularly suitable for immunocontraception as in the male the antibodies inhibit post testicular modulation and are not expected to interfere with testicular function. The gene encoding the 26 kDa epididymal protein has been cloned using a monkey epididymal cDNA library and is being sequenced. Working on similar approaches, Shaha and Seshadri at the National Institute of Immunology (NII), New Delhi, have identified two proteins of 94-96 kDa and 40 kDa on the sperm surface, the antibodies against which blocked sperm-oocyte interaction in rodents⁴⁹.

FSH vaccine

Another immunological approach being developed by Indian scientists is based on the bioneutralization of follicle stimulating hormone (FSH). FSH has specific receptors on the Sertoli cell membrane and blockade of FSH inhibits spermatogenesis without affecting testosterone biosynthesis. Moudgal and colleagues at the Indian Institute of Science, Bangalore, have shown that immunization of bonnet monkeys with ovine FSH (oFSH) generates antibodies which disrupt spermatogenesis, leading to oligospermia and infertility⁵⁰.

A limited clinical trial carried out on 5 adult men showed that active immunization with oFSH produced antibodies which bound and neutralized bioactive human FSH. The antibody produced was specific for FSH and no significant changes in the values of related glycoprotein hormones (LH/testosterone and TSH/thyroxine) were recorded. Seminal plasma transferrin, a marker of Sertoli cell as well as of seminiferous tubular function, showed reduction (30-90%) following immunization with oFSH. Preclinical and clinical toxicology studies revealed that oFSH vaccine at the doses tested was free from toxicity. Adopting such an approach for male contraception appeared attractive, as it had no effect on serum testosterone and libido, the problem that besets other steroid-based male contraceptive procedures.

Inhibin and related peptides

Inhibin was initially thought to be a protein of testicular origin and having a specific function of inhibiting the secretion of FSH. However, over the years, a number of inhibin and inhibin-like substances have been identified with multiple effects. Some of the inhibins have also been suggested to be secreted by the prostate or other male accessory reproductive organs⁵¹. Sheth and colleagues from IRR have undertaken extensive work on the human seminal plasma inhibin (HSPI)⁵². Following isolation and purification the primary structure of HSPI was determined. Further, HSPI (10.4 kDa) was shown to be sperm-coating protein of prostatic origin having potential for immunocontraception. This prompted the group to further identify and synthesize sequence segments that might mimic the immunobiological activity of the native protein. The N-terminal 1-17 (R-17) and C-terminal 67-94 (R-28) sequences are two such peptides. Studies (IRR-unpublished observations) have shown that active immunization with R-17 induced infertility in male rats.

Approaches to Female Fertility Regulation

Clomiphene citrate

Clomiphene citrate, a non-steroidal agent, was shown in early 1960s to have gonadotrophin-suppressing, ovulation inhibiting and blastotoxic actions in rats⁵³. These observations raised hopes of developing clomiphene citrate as a potential antifertility agent. However, subsequent studies by Roy and associates showed that clomiphene citrate had estrogenic and antiestrogenic actions which could be manifested at the same dose levels depending upon the hormonal milieu⁵⁴. These investigations also showed that its antifertility effects were limited to laboratory animals and could not be confirmed in humans. In none of the 11ovulatory women, who received clomiphene citrate in doses of 50 to 200 mg per day for varied duration ovulation was suppressed⁵⁵. On the contrary, administration of clomiphene citrate induced ovulation in women. Clomiphene administration to women with inadequate luteal phase resulted in improvement in luteal phase. It is the result of these observations that the clomiphene is being widely used for induction of ovulation in patients desiring pregnancy and in several other clinical conditions.

Antiprogestins

Antiprogestins such as RU 486, ZK 98.299 and ZK 98.734, intercept progesterone action at the molecular level of receptor binding, and have the potential to terminate early pregnancy⁵⁶. RU 486 which has undergone extensive clinical evaluation is commonly referred to as the "abortion pill" as its oral administration, followed 48 h later by a small dose of a prostaglandin analogue, terminates pregnancy in almost 95% of the women with an amenorrhoea of less than 63 days.

The studies carried out at IRR have shown that these antiprogestins have direct inhibitory effects on the endometrium as well as hypothalamo-hypophyseal axis and therefore have a potential for intercepting a wide range of progesterone-dependent reproductive processes⁵⁷. Moreover, their effects on the endometrium and the gonadotrophs are dose-related, the endometrium being more sensitive than the gonadotrophs. Low doses of the drugs retard endometrial development and consequently block implantation without affecting ovulation or other menstrual cycle parameters⁵⁸. These drugs have therefore shown potential for further development as a contraceptive where the drug could be taken either daily like a 'mini pill' or once-a-week throughout the menstrual cycle or just during the early luteal phase ⁵⁹. Antiprogestins have also shown potential for use as an emergency method of contraception. Studies carried out under the aegis of the WHO have shown that a dose of 10 mg RU 486 when taken within 72 hours of unprotected sex averts pregnancy in almost 80% of instances³⁰. The major advantage of developing antiprogestins as contraceptive is that the need for simultaneous administration of estrogens would be obviated and their use is likely to decrease the risk of endometrial and breast cancer through their antiproliferative effects on target organs. Even when used as an emergency contraceptive method the side effects were much fewer compared to the Yuzpe regimen.

Gonadal peptides

Nandedkar et al⁶⁰ at IRR have identified some novel proteins in the human ovarian follicular fluid which have shown potential as fertility regulating agents. Extensive efforts on the purification and characterization have resulted in the isolation of a 4 kDa protein which when injected into rodents and non-human primates impairs fertility⁶¹. Studies on sequencing of this protein are being conducted to embark upon extensive preclinical and clinical evaluation of this protein for its antifertility effects.

Immunological methods

Rao and Shahani⁶² from IRR had shown in 1961 that human chorionic gonadotrophin (hCG) can act as a true antigen and the antibodies against hCG can neutralise the parent molecule. Antiserum raised in a rabbit immunized with a mixture of hCG and Freund's adjuvant showed serological reactions, characteristic of an immune serum containing specific antibodies. These results provided evidence that protein hormones mixed with adjuvants and injected systemically can elicit serologically active antibodies in the blood which can neutralise the parent molecule. These observations have given impetus to the concept of developing immunocontraceptives.

hCG vaccine

Indian scientists have developed a hCG vaccine which has undergone phase II clinical evaluation⁶³. A vaccine consisting of a heterospecies dimer of the bsubunit of hCG associated noncovalently with the a subunit of ovine LH and conjugated to tetanus and diphtheria toxoids as carriers when injected to 148 women induced antibodies of high avidity against hCG. In 80% of the women, the antibody titre was more than 50 ng/ml; with only one pregnancy occurring in this group. Some of these women had completed up to 30 menstrual cycles of continuous exposure to the risk of pregnancy. On the other hand, in women in whom the antibody titre was less than 50 ng/ml, 26 pregnancies occurred. The antibody response declined with time, fertility was regained when the titres fell to less than 35 ng/ml. This study presents evidence of the feasibility of a vaccine for control of human fertility.

In this respect the work carried out by Indian scientists to develop a contraceptive vaccine is at the most advanced stage as compared to laboratories in other parts of the world engaged in similar studies.

WHO is also developing a synthetic peptide-based hCG immunocontraceptive^64,65. It is envisaged that a further 5-7 years of clinical testing and product improvement will be required before a first-generation product will be available. A second-generation, totally synthetic, bioengineered product is also under development by the WHO and could become available within a similar or a slightly more extended time-frame.

Some vaccines originally developed for fertility control are also being evaluated for treatment of hormone-dependent cancers⁶⁶. Recombinant hCG vaccine is in clinical trial in Mexico in lung cancer patients carrying a type of tumour that secretes hCG and its subunits. Similarly, LHRH vaccine is approved for trials in prostate carcinoma patients.

Zona pellucida antigens

The zona pellucida has generated considerable interest as a target for developing immunocontraceptive vaccine. The advantage of this approach would be of blocking pregnancy by acting at the pre-fertilization stage. In this direction, studies carried out by Gupta and coworkers at the NII have centred on delineating the epitopes recognised by MAbs generated against porcine ZP3a and ZP3b⁶⁷. The MAbs against these antigens delayed trypsin-mediated zona lysis and also inhibited the binding of ZP3 to sperm membrane vesicle. It is hoped that the leads taken by Indian scientists in this direction will help in the development of a new effective contraceptive vaccine.

Riboflavin carrier protein

Scientists at the Indian Institute of Science and the IRR have isolated riboflavin carrier protein, a novel estrogen-dependent protein, from the hen's egg white⁶⁸. Immunization against this protein has shown antifertility effects in laboratory animals and non-human primates⁶⁹⁷¹. Scientists at IRR have also identified some epitopes with potential antifertility effects. A synthetic peptide, based upon this epitope, was shown to have antifertility effects in rodents⁷¹.

Herbal Preparations

Indian scientists have identified a number of plants that possess antifertility effects. The ICMR had published a special report on "Plants with antifertility activity" way back in 1966 emphasing the need to explore the antifertility potential of herbal preparations⁷²⁷³. The Central Drug Research Institute, Lucknow has screened about 3,300 plant materials for antifertility activity of which some 67 have shown potential⁷⁴. The plants which have demonstrated interesting antifertility activity in clinical trials include Hibiscus rosa-sinensis and Embelia ribes. The extract of red petals of the plant Rudrapushpaka, collected between October and December, when given orally from day 7 to day 22 of the menstrual cycle prevented pregnancy in all the 22 women⁷⁵. Embelia ribes is being used in combination with Piper longum and borax as a contraceptive by practitioners of the traditional systems of medicine. When given in high doses for ten days in a cycle, Embelia ribes prevented pregnancy in 95% of the women observed for 2,051 cycles over 4 years⁷⁶. In addition, there are a large number of other plants, such as seeds of Daucus carota, Butea monosperma and Sapindus trifoliatis, which have demonstrated antifertility effects in rodents⁷⁷ and there are some, such as Vicoa indica known as banjhauri, which are being used by people in rural areas at their own initiative and risk to prevent pregnancy⁷⁸. The groundwork done by the Indian scientists in screening a large number of plants with antifertility effects and in identifying the few which need further testing has thus become extremely valuable. However, research in this area has not received continued support.

Immunodiagnostics

Scientists at IRR were the first in the world to develop a simple enzyme-linked immunosorbent assay (ELISA) for the detection of estrone-glucuronide and pregnanediol glucuronide^79,80. The assay methods for steroid hormones are of considerable diagnostic value in reproductive endocrinology. Similarly, they were the first to develop a pregnancy detection test based on ELISA technology⁸¹. This test allows detection of pregnancy within 30-35 days from the last menstrual period. The scientists at IRR have also done considerable work on the early pregnancy factor (EPF) which has been observed to be a promising biomarker of pregnancy, and allows detection of pregnancy even before the missed period or 48 hour after fertilization⁸². This method also has immense clinical value in assessing pregnancy wastage and in assisted reproductive technologies where it can be used for detection of fertilization.

DESIRED GOAL

The desired goal of contraceptive research and development should be to empower couples to control their fertility by choice rather than by chance. More and more people should therefore be provided with a greater range of safe, effective and affordable methods of fertility regulation. They should also be provided with information about the use of contraceptives and services to manage the possible side effects and contraceptive failure, if any. This will enable the couples to have a satisfying and safe sex life, the capacity to reproduce and the freedom to decide, if, when and how often to do so _ the essential ingredients of good RH. Fertility regulation in turn will also have bearing on other aspects of RH. The timely use of appropriate contraceptive technologies will help prevent unwanted pregnancy and its consequences, STDs, infertility, and will ensure infant survival and safe motherhood.

RESEARCH NEEDS

New research on developing safe and effective methods of fertility regulation must be guided by the user's needs and perspectives and after assessing the feasibility of product development and service delivery. The prevailing RH indicators should help identify the conditions or problems responsible for creating an unnecessary burden on the RH and decide on the research agenda to address those unresolved problems.

In our country, the infant and maternal mortality rates are still very high. The infant mortalilty rate is approximately 74 per 1,000 live births⁸³ which is almost ten times of that in many developed countries. Similarly, in India, 1 in 57 women has the chance of dying from complications of pregnancy, childbirth or unsafe abortion during her life time as compared to 1 in more than 17,000 in some of the developed countries⁸⁴. At the prevailing maternal mortality rate of 437 deaths per 100,000 live births more than 100,000 women in India die every year from causes related to pregnancy and child birth⁸³. It is estimated that 15,000-20,000 abortion-related deaths occur annually among married, multiparous women in India. Similarly, the incidence of reproductive tract infections (RTIs) and STDs is very high^85,86. Almost 20% of the eligible couples who do not want children or want to space their children are not using any method of contraception⁸³. Moreover, in south-east Asia only 57% of eligible couples have access to contraception at an affordable price as compared to 90% in east Asia.

The above mentioned RH indicators point to the need of integrating technology development with provision of services. Expanding family planning services is an important strategy for reducing the population growth rate, spacing the children and consequently decreasing the infant and maternal mortality rates and reducing the incidences of RTIs and STDs. High priority should be given to the development of male methods of fertility regulation; emergency contraception; and vaginal methods that provide dual protection against pregnancy and STDs. In addition, there is a need to promote basic research to understand the reproductive processes which may eventually lead to the development of newer treatments and technologies.

EXPANDING FAMILY PLANNING OPTIONS

Male Methods

In spite of the fact that a number of methods have been developed to allow women to control her fertility, the options available to men are rather limited. The male reproductive system, particularly the process of gametogenesis, maturation of spermatozoa and the sperm-egg interaction, is so complex that it has not so far been possible to find an effective intervention that can be converted into a product. Reversible hormonal method has shown promising results but still needs to be developed into a viable product. Antifertility vaccine directed against FSH has entered clinical trial and basic research is being continued on vaccines directed against specific molecules on the spermatozoa or the epididymal secretions. Development of a reversible male method which will help control fertility without affecting the potency will enrich the field of contraceptive research and development. The approaches targeting maturation of spermatozoa in the epididymis or sperm-egg interaction, without interfering with sperm production or secretion of testosterone, may be more acceptable to men.

In addition to the development of male methods of fertility regulation, it is essential to formulate strategies to increase male participation and responsibility in reproductive health. It will help to improve acceptance of available male methods and eventually the wellbeing of the entire family. Some of the ongoing studies at IRR show that lack of initiative, misconceptions about family planning methods, wives and family members objection, fear of surgery in case of vasectomy, lack of knowledge about the methods and poor quality of services contribute to low acceptance of male methods⁸⁷. Further research needs to be undertaken to study the attitude and sexual behaviour of men about fertility regulation, and the factors inhibiting their role and participation in reproductive health so that appropriate intervention studies could be planned to enhance their involvement and responsibility.

Emergency Contraception

Currently available emergency contraceptive methods when used shortly after unprotected coitus can prevent 75% or even more pregnancies⁸⁸. Unfortunately, however, these methods have not been used to their full potential. Research needs to be directed to assess the reasons why these methods are not available to or used by the potential users. This also necessitates research on the risk taking behaviour of people, determinants and consequences of induced abortion including its effects on subsequent fertility, reproductive and mental health and contraceptive practices.

In addition, more biomedical research is needed to overcome the limitations of the most commonly used emergency contraceptives (estrogen-progestin combination, levonorgestrel or danazol) such as: (i) effective only when started within 48 or 72 hours after unprotected intercourse; (ii) two doses must be taken; (iii) relatively high incidence of nausea and vomiting; and (iv) prevents only about 75% of unplanned pregnancies that would have occurred otherwise. Research should be aimed to increase the window of effectiveness of the available methods of emergency contraception, and to increase their contraceptive efficacy to almost 100%. The development of better methods for emergency contraception is therefore a challenging task requiring high priority.

Barrier Methods

CONCLUSIONS

The contributions of Indian scientists over the past 50 years have enriched the field of contraceptive research and product development. Some of their contributions were targeted towards the evaluation and improvement of the safety, efficacy and acceptability of promising methods of contraception so that they could be incorporated in the National Family Planning Programme; the development of newer methods of fertility regulation for both men and women; and understanding of the reproductive processes and proposing new hypothesis which may lead to the development of newer technologies. Achievements in these areas have helped in improving the RH of the people and have made us more optimistic for further development of newer contraceptive technologies. It is time that we review our research activities and orient ourselves to meet new challenges resulting from the paradigm shift from a narrow focus on family planning and population control to the broader, holistic concept of RH. Contraceptive research should be viewed in relation to the overall health, social and service context and should have the involvement of potential users in determining the research needs and priorities. Moreover, high priority contraceptive research should be decided after assessing the feasibility of product development and service deliveries.

Author's Note

A sincere and unbiased attempt has been made in this article to acknowledge all those efforts which have contributed substantially to contraceptive development. In view of the large body of data available on this subject, omission of any other significant contribution from this article is inadvertent.

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56. Puri, C.P. and Van Look, P.F.A. Newly developed competitive progesterone antagonists for fertility control. Front Horm Res 19: 127, 1991.

57. Puri, C.P. Antiprogestins: Useful investigative tools and novel contraceptives. Curr Sci 68: 407, 1995.

58. Katkam, R.R., Gopalkrishnan, K., Chwalisz, K., Schillinger, E. and Puri, C.P. Onapristone (ZK 98. 299): A potential antiprogestin for endometrial contraception. Am J Obstet Gynecol 173: 779, 1995.

59. Puri, C.P. Effects of antiprogestins on folliculogenesis, corpus luteum function and endometrium of primates: Emerging contraceptive strategies. In: Current Concepts in Fertility Regulation and Reproduction. Eds: C.P. Puri and P.F.A. Van Look. Wiley Eastern Ltd, New Delhi, p 445, 1994.

60. Nandedkar, T.D. and Raghavan, V.P. Control of ovarian follicular maturation during menstrual parameters: New approaches to female contraception. Adv Contracep Del Syst 5: 117, 1989.

61. Nandedkar, T.D., Parkar, S.G., Iyer, K.S.N., Mahale, S.D., Moodbidri, S.B., Mukhopadhyaya, R.R. and Joshi, D.S. Regulation of follicular maturation by human ovarian follicular fluid peptide. J Reprod Fertil 50 (Suppl): 95, 1996.

62. Rao, S.S. and Shahani, S.K. The antigenicity of human chorionic gonadotrophin. Immunology 4: 1, 1961.

63. Talwar, G.P., Sharma, N.C., Dubey, S.K., Salahuddin, M., Das, C., Ramakrishnan, S., Kumar, S. and Hingorani, V. Isoimmunization against human chorionic gonadotropin with conjugates of processed b-subunit of the hormone and tetanus toxoid. Proc Natl Acad Sci USA 73: 218, 1994.

64. Griffin, P.D. The immunoregulation of fertility: Changes in perspectives. Am J Reprod Immunol 35: 140, 1996.

65. Stevens, V.C. Progress in the development of human chorionic gonadotropin antifertility vaccines. Am J Reprod Immunol 35: 148, 1996.

66. Talwar, G.P., Singh, O., Rahul, P., Chatterjee, N., Suri, A.K. and Shaha, C. Vaccines for control of fertility. Indion J Exp Biol 30: 947, 1992.

67. Gupta, S.K., Bagavant, H., Koothan, P.T., Talwar, G.P. Yurewicz, E.C. and Sacco, A.G. Characteristics of monoclonal antibodies against porcine zona pellucida-3 and their functional relevance. Indian J Exp Biol 30: 1000, 1992.

68. Adiga, P.R., Karade, A.R., Visweswaria, S.S. and Sheshagiri, P.B. Carrier protein mediated transplacental riboflavin transport in the primate. In: Perspectives in Primate Reproductive Biology. Eds. N.R. Moudgal, K. Yoshinaga, A.J. Rao and P.R. Adiga, Wiley Eastern Ltd, New Delhi, p 129, 1991.

69. Natraj, U. Role of riboflavin carrier protein in the maintenance of pregnancy in common marmosets (Callithrix jacchus). In: Perspectives in Primate Reproductive Biology. Eds. N.R. Moudgal, K. Yoshinaga, A.J. Rao and P.R. Adiga, Wiley Eastern Ltd, New Delhi, p 141, 1991.

70. Mahale, S.D., Kadam, L.R., Pereira, J., Natraj, U. and Iyer, K.S.N. Studies on the delineation of the antigenic determinants of chicken riboflavin carrier protein (cRCP): Identification of determinant in the region of 10-24 of the protein. Int J Pept Protein Res 42: 28, 1993.

71. Natraj, U., Sabnis, T.M., Mahale, S.D. and Iyer, K.S.N. Termination of pregnancy in mice following administration of antibodies to the pentadeca peptide 10-24 of chicken riboflavin carrier protein. Identification of bioneutralysing epitope of chicken riboflavin carrier protein. Vaccine 12: 431, 1994.

72. Chaudhury, R.R. Plants with possible antifertility activity. Special Report Series No. 55. Indian Council of Medical Research, New Delhi, 1966.

73. Chaudhury, R.R. The quest for a herbal contraceptive. Natl Med J India. 6: 199, 1993.

74. Kamboj, V.P. A review of Indian medicinal plants with interceptive activity. Indian J Med Res 87: 336,1988.

75. Tewari, P.V. Preliminary clinical trial on flowers of Hibiscus rosa-sinensis as an oral contraceptive. J Res Indian Med Yoga Homeopath 9: 96, 1974.

76. Tewari, P.V., Sharma, S.K. and Basu, K. Clinical trial of an indigenous drug as an oral contraceptive. J Natl Integ Med Assoc 18: 117, 1976.

77. Chaudhury, R.R. A tale of six plants. In: Lectures in Contraceptive Pharmacology. Ed. R.R. Chaudhury, Arun and Rejive Printers, Chandigarh, p 36, 1981.

78. Chaudhury, R.R., Mathur, V.S. and Sankarnarayanan P. Clinical evaluation of plant contraceptives: Translating folklore into scientific application. In: Pharmacology for Health in Asia. Eds. B.N. Dhawan., K.K. Agarwal., R.B. Arora. and S.S. Parmar. Allied Publishers, New Delhi, p 432, 1988.

79. Khatkhatay, M.I., Sankoli, G.M., Meherji, P.K., Chowdhary, V. and Joshi, U.M. Excretion of estrone glucuronide in spontaneous and induced ovulatory cycles. Int J Fertil 33: 181, 1988.

80. Khatkhatay, M.I., Desai, M.P., Meherji, P.K., Sankoli, G.M. and Joshi, U.M. Screening of infertile women for detection of occurrence of ovulation and assessment of corpus luteum function by ELISA of pregnanediol. Eur J Obstet Reprod Biol 38: 213, 1991.

81. Joshi, U.M., Raghavan, V.P. and Sheth, A.R. Development of an enzyme linked immunoassay for human chorionic gonadotropin. Indian J Med Res 65: 607, 1977.

82. Shahani, S.K. and Moniz, C.L. Early pregnancy factor: Mini review. Indian J Exp Biol 30: 951, 1992.

83. National Family Welfare Programme: Achievemnts, Challenges and Strategies. Department of Falmily Welfare, Mnistry of Health and Family Welfare, Government of India, New Delhi, 1997.

84. Reproductive Risk: A World-wide Assessment of Women's Sexual and Maternal Health. 1995 Report on Progress Towards World Population Stabilization. Population Action International, Washington D.C., 1995.

85. Joshi, J.V., Mali, B.N., Hazari, K.T., Chitlange, S., Shah, R.S., Chadha, U. and Gokral, J. Abnormal cytology indicating sexually transmitted diseases in women attending family welfare clinic. J Obstet Gynaecol India 41: 521, 1991.

86. Mali, B.N., Joshi, J.V., Bhave, G.G. and Wagle, U.D. Cervical cytology in prostitutes of Bombay, India. Genitourinary Med 68: 62, 1992.

87. Balaiah, D., Ghule, M., Naik, D.D., Parida, R.C. and Hazari, K.T. Fertility attitudes of men in an urban setting: A cross sectional survey analysis. Adv Contracep Del Sys 13: 1, 1997.

88. Puri, C.P. and Van Look, P.F.A. Editorial. In: Emergency Contraception. The Federation of Obstetrics and Gynaecological Societies of India, Mumbai, p 2, 1996.

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This write-up has been contributed by Dr. C.P. Puri, Deputy Director (Sr.Grade), Institute for Research in Reproduction, Mumbai.

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ICMR NEWS

The following meetings of various technical groups/committees of the Council were held:

Meetings of the Scientific Advisory Committees:

Institute for Research in Medical Statistics, Chennai	September 28-29, 1998
ICMR Genetic Research Centre, Mumbai	October 7, 1998
Institute for Research in Reproduction, Mumbai	October 8-9, 1998
Regional Medical Research Centre for Tribals, Jabalpur	October 12-13, 1998
National Institute of Virology, Pune	October 15-16, 1998

Meetings of the Expert Group/Technical Advisory Group/Sub-Group and other meetings:

Expert Group on Argemone mexicana toxicity	September 19, 1998 (at New Delhi)
Technical Advisory Group on Pharmacology and Toxicology including Traditional Medicine	September 22-23, 1998 (at New Delhi)
Sub-Group on Hepatitis	September 25, 1998 (at New Delhi)
Meeting of the Principal Investigators of the district nutrition project	October 14-15, 1998 (at New Delhi)

Participation of ICMR Scientists in Scientific Events:

Dr. Neeru Singh, Dy. Director, Malaria Research Centre (MRC), Delhi, participated in the II European Congress on Tropical Medicine at Liverpool (September 14-18, 1998).

Dr. A. Roy Chowdhury, Dy. Director, Regional Occupational Health Centre, Calcutta, participated in the X International Symposium on Biological Monitoring in Occupational and Environmental Health at Seoul (September 23-25, 1998).

Dr. A.K. Jain, Senior Research Officer, Institute of Pathology, New Delhi, participated in the V conference of the International Society for Trace Element Research in Humans at Lyon (September 26-30, 1998).

Dr. S.K. Subbarao, Dy. Director (Sr.Grade), MRC, Delhi, participated in the V meeting of the WHO Committee on Molecular Entomology at Geneva (September 27-28, 1998).

Dr. Aruna Dewan, Dy. Director, National Institute of Occupational Health, Ahmedabad, participated in the meeting of the Expert Group on Women and Health_ Mainstreaming the Gender Perspective into the Health Sector at Tunis (September 28 to October 2, 1998).

Dr. Vasantha Thavaraj, Asstt. Director, All India Institute of Medical Sciences, New Delhi, participated in the International Conference of the Society of Paediatric Oncology at Yokohama (October 4-8, 1998).

Dr. N.K. Ganguly, Director-General, ICMR, co-chaired the XII meeting of the Joint Working Group of the Indo-US Vaccine Action Programme at Washington D.C. Dr. D.A. Gadkari, Director, National Institute of Virology, Pune and Dr. P.R. Narayanan, Director, Tuberculosis Research Centre, Chennai, also participated in the meeting.

Dr. U.M. Donde, Dy. Director, Institute for Research in Reproduction (IRR), Mumbai, participated in the VIII Asia-Pacific Congress of Clinical Biochemistry at Kuala Lampur (October 11-16, 1998).

Dr. H.S. Juneja, Director, IRR, Mumbai, participated in the regional symposium on Inter-regional Cooperation on Reproductive Health Research : Asia and Pacific at Shanghai (October 12-13, 1998).

Appointments:

Dr. S.K. Subbarao took over as the Director of the Malaria Research Centre, Delhi w.e.f. October 9, 1998.

Honours/Awards:

Dr. G.B. Nair, Dy. Director, National Institute of Cholera and Enteric Diseases, Calcutta, has been awarded the 1998 Shanti Swarup Bhatnagar Prize in Medical Science by the Council of Scientific and Industrial Research for his outstanding work in characterizing a novel toxin in Vibrio cholerae and identifying and chacracterizing a new serogroup 0139 causing a cholera pandemic.

Dr. Kalyan Banerjee, former Director of the National Institute of Virology, Pune and Dr. N.K. Ganguly, Director-General, ICMR, have been awarded the Om Prakash Bhasin Awards for Health and Medical Sciences for the years 1996 and 1997 respectively.

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ICMR AIDED SYMPOSIA/SEMINARS/WORKSHOPS/COURSES/CONFERENCES

Symposium/Seminar/Workshop/ Course/Conference	Date & Place	Contact Address
Symposium on Alzheimer's Disease and Neurocognitive Disorders	October 3-4, 1998; (at Delhi)	Col. D.S. Goel, Senior Advisor (Psychiatry), Base Hospital, Delhi Cantt-110010.
International Symposium on Temporomandibular Joint Disorders and Chronic Orofacial Pain	October 30-31, 1998; (at Mangalore)	Prof. P.K. Dayal, Organising Secretary of the Symposium, KMC College of Dental Surgery, Mangalore-575001.
Symposium on Current Trends in Autoimmune Diseases Immunology	October 30-31, 1998; (at Lucknow)	Prof. S. Naik, Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow-226014.
XXXI Annual Conference of the Indian Pharmacological Society	December 17-20, 1998; (at Lucknow)	Dr. V.N. Puri, Organisng Secretary of the Conference, Division of Pharmacology, Central Drug Research Institute, Lucknow-226001.

COUNCIL'S TRAINING PROGRAMMES FOR 1998-99

Leprosy

At the Central JALMA Institute for Leprosy, Agra:

• Multidrug Therapy Orientation Course in Leprosy for Medical Officers (October 26-November 6; and December 7-18, 1998).

Reproductive Biology

At the Institute for Research in Reproduction, Mumbai:

• Workshop on Andrology for Clinicians (November 16-30, 1998)

Nutrition

At the National Institute of Nutrition, Hyderabad:

• Postgraduate Certificate Course in Nutrition (December 1, 1998-February 28, 1999).

Occupational Health

At the National Institute of Occupational Health, Ahmedabad:

• Training Course on Environmental Hygiene Practice (November 16-20, 1998).

Biomedical Statistics

At the Institute for Research in Medical Statistics, Chennai:

• Basic Course in Statistics for Medical Officers (November 30-December 6, 1998).

Haematology

At the Institute of Immunohaematology, Mumbai:

• Training Course in Advanced Haematology and Immunohaematology (September 21-October 9, 1998).

	EDITORIAL BOARD
	Chairman	Members
	Dr.N.K. Ganguly	Dr.Padam Singh
	Director-General	Dr.Lalit Kant
		Dr.Bela Shah
		Dr.R.Ravi
		Dr.V.Muthuswamy

 

Editor

Dr. N. Medappa

 

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ISSN 0377-4910

Vol. 28, No. 11                                                                           November, 1998

NUTRITION: A CRITICAL DETERMINANT OF RESPONSE TO VACCINES IN CHILDREN

Information available from epidemiological and clinical studies supports the association of inadequate diet and infection and forms the basis for the modern concept of the vicious cycle of malnutrition and infection ^1-2 (Fig.1).

Poverty through food deprivation is the root cause of malnutrition while infectious diseases act as aggravating factors. This interaction assumes greater significance in developing countries where both malnutrition and infection are widely prevalent and often coexist. Infections precipitate malnutrition particularly in an already marginally nourished child. While nutritional supplements bridge the dietary deficits, prevention and control of infections ensure optimal utilisation of the nutrients. Thus, prevention of infections should take an important place in national programmes aimed at controlling malnutrition in children.

Immunization is the most powerful and costeffective tool for preventing infections and promoting child survival and health in developing countries. However, the efficacy of various vaccines depends upon the ability of the host to mount an adequate and appropriate immune response to the concerned vaccine. Nutrition is an important modulator of immune response. Severe protein energy malnutrition (PEM) among preschool children is a nutritional problem of public health concern which induces immunosuppression and increases the susceptibility of the child to infections. It also contributes to the severity of illness in a malnourished child.

The host's immune mechanisms may generally be classified as innate and acquired immune responses. While innate mechanisms are nonspecific and do not carry memory of the infecting organisms, acquired immune mechanisms are endowed with the characters of specificity and memory to the concerned antigen. These two fundamental characters of acquired immune mechanism form the basis for vaccination.

ACQUIRED IMUNNE RESPONSES OF CHILDREN WITH SEVERE PEM

Humoral Mechanisms

Children suffering from severe forms of clinical PEM, such as kwashiorkor/marasmus, have poor response to typhoid vaccine and certain other bacterial and viral antigens³. Nevertheless, these children are found to raise adequate antibody responses to protein antigens like diphtheria and tetanus and certain viral antigens like measles⁴. Total immunoglobulin levels of IgG, IgM and IgA classes have been documented to be normal or elevated in such children⁵. Their B lymphocyte counts also remain unaltered. This indicates that humoral mechanisms in children with severe PEM are partly impaired and the magnitude of the response probably depends upon the nature of the antigen administered, the route of administration, dose and cellular interactions required for raising optimal immune response.

Cell Mediated Immune Mechanisms

Thymolymphatic atrophy has been well documented in autopsy studies conducted on children dying during the acute phase of kwashiorkor⁶. The peripheral blood T cell count, along with the helper cell subset (CD⁺₄) and their in vitro response to various mitogens and antigens were found to be impaired, which explain their increased susceptibility to viral, fungal and intracellular bacterial infections like tuberculosis^7,8.

Macrophage Function

Children with severe PEM also exhibit a number of functional deficits of macrophages. Macrophages which play a significant role as accessory cells in cell mediated immune reactions, carry out the functions of antigen processing and presentation to T cells in addition to providing maturation signals (through interleukins) to the T cell. This apart, macrophages are powerful phagocytic and bactericidal cells. On in vitro activation, peripheral blood monocytes, obtained from children with kwashiorkor were significantly less mobile and less bactericidal compared to those in normal children. Their ability to produce nitrite, an important intracellular bactericidal agent, was low^9-13.

Based on extrapolation of these results on immunosuppression in severe PEM, doubts have been expressed whether immunization programmes would be successful in communities where malnutrition is widely prevalent. Persistence of infections like measles and poliomyelitis in underprivileged communities has been attributed to the prevailing malnutrition. Concern has also been expressed regarding the efficacy and safety of using live attenuated vaccines in malnourished children for fear of precipitating vaccine induced illness. Use of live measles vaccine has been viewed with concern in communities which are endemic for both malnutrition and tuberculosis because of the potential danger of activation of latent tuberculosis in immunocompromised children.

Severe PEM is considered a public health problem in India. It constitutes only the tip of the iceberg of the problem of malnutrition among preschool children. A recent report on the profile of PEM in the country, by the National Nutrition Monitoring Bureau (NNMB), indicated that the extent of severe PEM (<60% weight for age) in the community is not more than 10% of the preschool child population, while more than 80% of the children look apparently normal but suffer from mild to moderate grades of malnutrition presenting with growth retardation (Fig. 2)¹⁴. These children constitute the major beneficiaries of any national health programme, including the immunization programme, and their response to various vaccines determines the success of the latter.

MILDMODERATE MALNUTRITION AND IMMUNE RESPONSE

Clinical and experimental studies have been conducted at the National Institute of Nutrition (NIN), Hyderabad, using immunological methods to determine the degree of nutritional status that modulates immune responses in children in general, and the response to various vaccines used in the National Immunization Programme in particular. Children aged 15 years were investigated and their nutritional status assessed using Gomez classification and NCHS Standards. Humoral and cell mediated immune responses to various vaccines were investigated. Immune responses of children with severe and mild-moderate grades of malnutrition compared to normal children are summarised in the Table.

General Cellular and Humoral Immune Response

Contrary to the observation of immunosuppression in severe PEM, children with mild and moderate malnutrition showed both T cell number and proliferative responses adequate on stimulation with mitogens/antigens and were comparable to those of normal children. IgG, IgM and IgA levels were also in the normal ranges³.

Immune Response to Specific Antigens

Diphtheria and tetanus vaccine

Two doses of diphtheria and tetanus toxoid were administered at an interval of one month and specific antibody titres were determined prior to the administration of the first dose and one month after the second dose. The antibody titres to both these antigens were found to be in the protective range and the mean titres were comparable among all groups of children irrespective of their nutritional status.

TAB vaccine

Antibodies to `H' and `O' antigens of Salmonella typhi were measured in response to two doses of TAB vaccine administered one month apart. Children with severe PEM had low mean titres of antibodies to both these antigens, while mild and moderately malnourished children had higher antibody titres which were comparable with that of normal children.

BCG vaccine

Though BCG vaccine has been in use for a long time, its efficacy has been under constant debate, particularly in children of developing countries. However, in view of its protective efficacy against extrapulmonary forms of tuberculosis in children, routine BCG vaccination is recommended.

Response to BCG vaccine is generally measured by (Mantoux) skin reaction to PPD following administration of the vaccine. Very often the Mantoux reaction is negative in children with severe PEM and is attributed to the observed immunosuppression. Contrary to this, children with mild and moderate grades of malnutrition have positive Mantoux conversion as in normal children¹⁵. Positive response to a skin test depends on two components viz., the inflammatory response and immune reaction to the injected antigen.

Studies were conducted to assess the status of these two components under the influence of PEM. Inflammatory response to a superficial injury was studied in children with kwashiorkor, using the skin window technique. Mobilisation of neutrophil leukocytes and monocytes to the site of injury was studied periodically over 72 h. In normal children, initially the neutrophils move to the site of inflammation in large numbers and are replaced by monocytes by 24 h which persist even at the end of 72 h⁹. The mononuclear infiltration is responsible for the induration observed. However, in children with kwashiorkor, mononuclear mobilization was impaired, and this dysfunction of macrophages could be contributing to the negative skin test reactions in these children (Fig.3).

Further studies were also conducted to explore the effect of malnutrition on immune response to PPD. Lymphocytes, collected from severely malnourished children 12 weeks after they had received BCG vaccine, were stimulated in vitro with PPD and the production of leukocyte migration inhibition factor (MIF) was measured. It was observed that despite severe malnutrition, these children were able to produce a positive migration inhibition response. This study demonstrated that the sensitization of the lymphocytes to tubercular antigens is successful even in children with severe malnutrition¹⁵. However, due to lack of macrophage mobilisation, the Mantoux test was negative. Children with milder grades of malnutrition developed both inflammatory and immune responses positively. These results indicate that BCG vaccination even in a malnourished community could achieve the expected degree of protection against tuberculosis. This observation was further strengthened by recent clinical studies by Bhaskaram et al¹⁶ in children suffering from tuberculosis.

BCG vaccinated children had a more localised infection confined to either the cervical or the mediastinal lymphnodes. While most of the unvaccinated malnourished children suffered from more severe/progressive forms of tuberculosis, BCG vaccination produced similar effects of localising the disease even in children with malnutrition. This observation further strengthened the laboratory studies. BCG was found to prevent progressive forms of tuberculosis in malnourished children as effectively as in wellnourished children¹⁶.

Measles vaccine

It is well established that measles is a major contributor to malnutrition in Indian children. Measles infection is known to cause severe and persistent immunosuppression leading to recurring morbidity in the post measles period¹⁷. Activation of latent tubercular lesions and worsening of the existing forms of tuberculosis are common phenomena observed after measles. Doubts have therefore been expressed and concern has been voiced regarding administration of measles vaccine to malnourished children living in communities where tuberculosis is prevalent. Specific immune responses were determined in children after administering measles vaccine and were correlated with the nutritional status. Haemagglutination inhibition (HI) antibodies to measles and in vitro T cell proliferative response to measles antigen were measured. The results showed that both the antibody production and T cell responses were adequate in all the children irrespective of their nutritional status⁴. This also suggests that unlike infection with natural measles virus, vaccine induced infection did not have immunosuppressive properties. Further, malnourished children did not exhibit any side-effects following vaccination and there was no evidence of any activation of latent tubercular lesions over a 3 month period of follow up. These observations indicate the effectiveness of measles vaccination and its safety even in communities simultaneously carrying the load of malnutrition and tuberculosis.

Measles vaccination and morbidity

Apart from these beneficial effects, measles vaccination was found to significantly reduce morbidity in children probably due to non specific stimulation of immune mechanisms by activating macrophages⁴. It has been reported that measles vaccine not only reduces morbidity and mortality related to measles but also prevents the risk of severe malnutrition in children who are already undernourished¹⁸.

Measles vaccine was introduced in India through the Universal Immunization Programme (UIP) during 1985-86. In a recent retrospective case analysis (Bhaskaram P. et al, Unpublished observation), it was observed that the hospital admissions of children with measles and its complications were significantly (69%) reduced from the prevaccination to the postvaccination period. However, this reduction was far from the mid decade goal of 90%reduction of measles from the prevaccination prevalence. Mortality, however, registered a decline of 90% from the prevaccination to the postvaccination period. The observations also demonstrated that the incidence of measles significantly increased in older children (above 5 years) compared to the prevaccination period where almost 100% of the children were affected by measles before 5 years of age. Though the UIP focuses on infants, the prevalence of measles in infancy has not shown any significant decrease over the years. These observations demonstrate the changing pattern of measles in the community following the introduction of the immunization programme. Persistence of measles in infants despite vaccination at 9 months suggests inadequate coverage while periodic large outbreaks in the community indicate the accumulation of susceptible children who trigger the outbreaks. However, to achieve the goal of elimination of measles by at least 2010, there is need to intensify the measles vaccination programme and modify it so as to cover all susceptible children upto 5 years of age. This strategy is very essential not only to promote child survival but also to reduce malnutrition.

Poliomyelitis

Persistence of poliomyelitis in India has often been attributed to associated malnutrition. In a recent outbreak in Andhra Pradesh, it was observed that the prevalence of the infection was not related to the nutritional status¹⁹. Out of 400 patients of acute paralytic poliomyelitis investigated, 49.5% were wellnourished and 50.5% malnourished. In addition, it was observed that oral polio vaccine (OPV) conferred low herd immunity²⁰. Lower antibody titres and also inadequate local immune response were noticed in natural infection as well as with OPV²¹. These impaired responses were not related to the nutritional status of the children. Thus, suboptimal vaccine efficacy and interference by the enteroviruses in the gut, both being unavoidable problems in tropical countries, could be the factors responsible for the development of low levels of immunity leading to persistence of poliomyelitis in the country. Malnutrition does not seem to play any role in the persistence of poliomyelitis. Though the load of poliomyelitis has been significantly reduced following the implementation of the Pulse Polio Programme, a strong disease system has to be established to prevent resurgence of the disease.

ROLE OF NUTRIENT SUPPLEMENTS IN VACCINE RESPONSES

Certain nutrients like b carotene, vitamins A and D₃ are known to act as immune adjuvants. Among these, b carotene and vitamin A have been found to reduce morbidity and mortality due to certain clinical conditions characterised by immunosuppression.

Immune Adjuvant Effects of Vitamin A

The immunological adjuvant effects of administration of vitamin A/b carotene are well documented . In a study carried out in preschool children, administration of 100,000 and 200,000 units of vitamin A was found to significantly enhance the production of bactericidal molecules like hydrogen peroxide (H₂O₂) by phagocytes. Non specific activation of immune cells resulted in increase in antibody production on antigenic challenge²². The large dose of 100,000 IU also led to increase in interleukin 1 production by in vitro activated macrophages²².

Interactions between Vitamin A and the Viral Vaccines

Vitamin A deficiency is widely prevalent among children in developing countries. Apart from xerophthalmia in 510% of preschool children, there appears to be a much larger problem of subclinical vitamin A deficiency as evidenced by lowered serum retinol levels without obvious clinical manifestations in nearly 30-40% of the children including infants. Several studies have reported that even mild/subclinical forms of vitamin A deficiency could increase child morbidity by increasing susceptibility to mucosal infections and also increase mortality^23,24. Vitamin A supplements were found to reverse these effects significantly²⁵. In view of these beneficial effects of vitamin A, WHO has recommended the routine administration of 100,000 IU of vitamin A to infants above 6 months of age in developing countries to improve vitamin A status and also child survival. To achieve the maximum costeffectiveness, this supplementation programme is linked with the Universal Immunization Programme²⁶.

Vitamin A supplements and seroconversion to measles vaccine

Recent studies from Indonesia, however, raised concerns about the possible immunosuppression that could be caused by large dose vitamin A administration along with measles vaccine in young infants who still possess transplacentally acquired maternal antibodies²⁷. Thus the combined schedule of large dose vitamin A administration along with live viral vaccine administration to young infants has become a subject of intense debate²⁸.

In India, administration of 100,000 IU of vitamin A to infants of 9 months age at the time of measles vaccination has been introduced into the Expanded Programme on Immunization.

In a recent study conducted by Bhaskaram and Rao²⁹, seroconversion rates and vitamin A status of infants who received vitamin A dose at the time of measles vaccine were compared with those of the infants who received only the vaccine. Under existing field conditions, seroconversion to measles vaccine is generally low. However, in children who received vitamin A, a significantly higher percentage seroconverted to measles (84%) compared to those who received only the vaccine (63%). Vitamin A status of all the infants improved over the one month period of the study, the improvement being significantly higher in children who received vitamin A²⁹.

Vitamin A administration to mothers in puerperium and response to neonatal dose of OPV

In recent times, in countries with endemic vitamin A deficiency, the usefulness of administering a large dose of vitamin A with each dose of DPT and OPV to infants below the age of 6 months is suggested as a strategy to improve their vitamin A status. However, such an exercise frequently resulted in the intracranial tension being raised in a number of infants. Though the neurological significance of a transient rise in intracranial tension at this age is not known, it is not an acceptable phenomenon. Administration of about 200,000 IU of vitamin A to mothers soon after delivery has been suggested as an alternative strategy to improve the vitamin A status of the breastfed infants³⁰.

The WHO has recommended the routine administration of a dose of OPV to new borns within the first 3 days of life to supplement the routine 3 dose schedule in order to achieve better seroconversion rates³¹.

About 100 women along with their infants were studied to examine the effect of administering a large dose of vitamin A to the mother soon after delivery and the seroresponse to OPV administered to the breastfed newborns. Administration of a large dose of vitamin A to lactating mothers increased vitamin A levels in breast milk for a short period, thus increasing the vitamin A intakes of the infants. There was, however, no effect on the sero-response to OPV. Seroconversion rates to all the 3 types of polio viruses in the vaccine were comparable between infants belonging to mothers who received vitamin A and those who did not³². Thus, these studies document the safety of administration of live viral vaccines along with a large dose of vitamin A. This observation is of practical relevance in developing countries where the interactions between infection and malnutrition pose a serious threat to child health and survival.

Thus, malnutrition does not appear to be a contraindication to immunization programmes. Judicial supplementation of nutrients having immunoadjuvant properties could improve the results with certain vaccines.

References

1. Venkatachalam, P.S., Srikantia, S.G. and Gopalan, C. Clinical features of nutritional oedema syndrome in children. Indian J Med Res 42: 555, 1954.

2. Brown, K.H., Gilman, R.H., Gaffar, A., Alamgir, S.M., Strife, J.L., Kapikian, A.Z. and Sack, R.B. Infections associated with severe protein calorie malnutrition in hospitalised infants and children. Nutr Res. 1: 33,1981.

3. Reddy, V., Jagadeesan, V., Raghuramulu. N., Bhaskaram, C. and Srikantia, S.G. Functional significance of growth retardation in malnutrition. Am J Clin Nutr 29: 3,1976.

4. Bhaskaram, P., Madhusudan, J., Radhakrishna, K. V. and Raj, S. Immunological response to measles vaccination in poor communities. Hum Nutr Clin Nutr 40 C: 295, 1986.

5. Rosen, E.V., Geefhuysen, J. and IPP, I. Immunoglobulin levels in protein calorie malnutrition. S Afr Med J 45: 980, 1971.

6. Smythe, P.M., Schonland, M., Brereton-Stiles, G. G., Coovadia, H.M., Grace, H.J., Loening, W.E.K., Mafoyane, A., Parent, M.A. and Vos, G.H. Thymolymphatic deficiency and depression of cell mediated immunity in protein calorie malnutrition. Lancet ii: 939, 1971.

7. Bhaskaram, C. and Reddy, V. Cell mediated immunity in protein calorie malnutrition. J Trop Paediatr Environ Child Health 20: 284, 1974.

8. Chandra, R.K., Gupta, S. and Singh, H. Inducer and suppressor T cell subsets in protein energy malnutrition: Analysis by monoclonal antibodies. Nutr Res 2: 21, 1982.

9. Bhaskaram, P. and Reddy, V. Cutaneous inflammatory response in kwashiorkor. Indian J Med Res. 76: 849, 1982

10. Bhaskaram, P. Macrophage function in severe protein energy malnutrition. Indian J Med Res. 71: 247, 1980.

11. Bhaskaram, P. and Reddy, V. Macrophage functions in kwashiorkor. Indian J Paediatr. 49: 497, 1982.

12. Bhaskaram, P. and Sivakumar, B. Interleukin1 in malnutrition. Arch Dis child. 61: 182, 1986.

13. Bhaskaram, P. Nitrite production by lymphokine activated peripheral blood monocytes in malnourished patients with tuberculosis. J Nutr Immunol. 4: 71, 1995.

14. Reddy, V., Rao, N.P., Sastry, J.G. and Kasinath, K. Nutrition Trends in India, National Institute of Nutrition, Hyderabad P.31, 1993.

15. Satyanarayana, K., Bhaskaram, P., Chitti Seshu, V. and Reddy, V. Influence of nutrition on postvaccinial tuberculin sensitivity. Am J Clin Nutr. 33: 2334, 1980.

16. Bhaskaram, P., Hemalatha, P. and Rao, K.V. BCG vaccination in malnourished child population. Indian Paediatr 29: 39, 1992.

17. Bhaskaram, P., Raj, S. and Reddy, V. Effect of measles on cell mediated immunity. Indian J Med Res 77: 83, 1983.

18. Faechem, M and Koblinsky, M. A. Interventions for the control of diarrhoeal diseases among young children. Measles immunization. Bull WHO 61: 641, 1983.

19. Murthy, N., Bhaskaram, P., Murali, M. V., Sukanya, M and Srinivasa Rao, C.R. An outbreak of poliomyelitis in Andhra Pradesh, south India. Indian Paediatr 31: 533, 1994.

20. Murthy, N. and Bhaskaram, P. Serology of unvaccinated population against polio viruses _ A study from Andhra Pradesh, south India. Infect Dis Immunol. 4: 60, 1994.

21. Bhaskaram, P., Nair, M., Murthy, N., Hemalatha, P., and Nair, P. Efficacy of administration of OPV in the new born period. J Trop Paediatr 43: 232, 1997.

22. Bhaskaram, P., Jyothi,A. S., Rao, K.V. and Narasinga Rao, B.S. Effects of subclinical vitamin A deficiency and administration of vitamin A as a single large dose on immune function in children. Nutr Res 9: 1017, 1989.

23. Sommer, A., Katz, J. and Tarwotjo, I. Increased risk of respiratory disease and diarrhoea in children with pre existing mild vitamin A deficiency. Am J Clin Nutr 40: 1090, 1984.

24. Milton, R.C., Reddy, V. and Naidu, A.N. Mild vitamin A deficiency and childhood morbidity _ An Indian experience. Am J Clin Nutr 46: 827, 1987.

25. Sommer, A., Tarwotjo, I., Djunaedi, E., West, K.P. Jr., Loeden, A.A., Tilden, R., Mele, L. and The Aceh study group. Impact of vitamin A supplementation on childhood mortality: A randomised controlled community trial. Lancet i: 1169, 1986.

26. World Health Organization. Using Immunization Contacts to Combat Vitamin A Deficiency. A discussion document submitted to EPI Global Advisory Group Meeting, Jakarta. (October 12-16, 1992). Expanded Programme on Immunization, World Health Organization, Geneva 1992 .

27. Semba, R.D., Munasir, Z., Beeler, J., Akib, A., Muhilal, Audet, S. and Sommer, A. Reduced seroconversion to measles in infants given vitamin A with measles vaccination. Lancet 345:1330 1995.

28. Ross, D. Vitamin A plus measles vaccination. The downside of convenience? Lancet 345: 1317, 1995.

29. Bhaskaram, P. and Rao, K.V. Enhancement in seroconversion on simultaneous administration of measles vaccine and vitamin A in 9 months Indian infants. Indian J Paediatr 64: 503, 1997.

30. WHO/UNICEF/IVACG Task Force. Vitamin A Supplements: A Guide to Their Use in the Treatment and Prevention of Vitamin A Deficiency and Xerophthalmia. World Health Organization, Geneva, 1988.

31. Expanded Programme on Immunization. Global Advisory Group Summary of Conclusions and Recommendations. Wkly Epidemiol Rec 60: 13, 1985.

32. Bhaskaram, P. and Balakrishna, N. Effect of administration of 200,000 IU of vitamin A to women 24 h after delivery on response to OPV administration to the new born. Indian paediatr 35: 217, 1998.

ABSTRACTS

Some Research Projects Completed Recently

Role of `S' transactivator in hepatocarcinogenesis: In vitro expression and purification of transactivating proteins.

The study was carried out to elucidate the effect of `S' (463-851) transactivator on various promotor enhancer systems; raise monoclonal/polyclonal antibodies against this transactivator protein prepared either by recombinant DNA method or by using synthetic peptides; and demonstrate and localize the transactivator protein in hepatocarcinoma cells.

The association of hepatitis B virus (HVB) in hepatocellular carcinoma (HCC) is well established. Insertional mutagenesis, transactivation by truncated X or pre S2/S regions and activation of growth regulated genes or oncogenes have been suggested as possible mechanisms for carcinogenesis. The transactivating properties of a frequently detected fragment, which form part of the `S' reading frame, extending from 426 nt. to 855 nt., has been reported.

The clones were sequenced and subcloned into pRSET vectors in all the three reading frames and expressed using IPTG induction. A Western blot analysis was done using polyclonal anti HBsAg and the presence of 19.24 kDa functional protein in the correct reading frame was obtained. The expressed protein was checked for by commercial ELISA. However, the antigen could not be detected by ELISA in any of the three reading frames. The `S' protein was purified by SDA-PAGE and was used to raise polyclonal antibodies in rabbits. These polyclonal antibodies were then used to screen the presence of `S' protein in hepatocellular carcinoma tissues. The `S' region being a very small part of the surface region of the virus (426-824 ntds), could not be detected by immunofluorescence. The region, extending from 426-824 ntds was proved to be a generalized transactivator of the viral promoters and enhancers. Using chloramphenicol acyl transferase as a reporter gene, in transfection assays it was found to be capable of activating HIV promoter, HTLVI promoter, RSV promoter and enhancer, c-Fos and c-Jun promoter to a high degree.

S.K. Panda
Department of Pathology
All India Institute of Medical Sciences
New Delhi.

Interaction of melatonin and circadian rhythmicity in Antarctic conditions.

The study was carried out to evaluate the coupling pattern of melatonin and other circadian rhythmicity in the human subjects in Antarctic conditions and on rats under simulated Antarctic exposure of diversifying light and dark cycle. The experimental study was carried out on 42 male Wistar strain rats (200-300 g) divided into 3 groups viz normal (control without surgical intervention);sham operated; and superior cervical ganglionectomized. The human study was conducted on eight volunteers from the 12th Indian scientific expedition to Antarctica (Antarctic winter _ extended dark conditions) and six volunteers from the 13th expedition (Antarctic summer _ extended light conditions). The human volunteers, divided into two groups were given either beta adrenergic blocker (atenolol) or placebo.

The results of both the animal and human studies showed that under the influence of constant dark and light, sympathetic innervation to the pineal primarily has tonic inhibitory influence on the suprachiasmatic nucleus, the biological clock, which alters the amplitude and mean level of various rhythms to keep the synchrony and coupling of various physiological and hormonal rhythms. The rat study also provided convincing data for the presence of extra-sympathetic inputs (probably neuropeptide-Yergic and cholinergic) to the pineal which are stimulated only if melatonin level is severely depressed as in cases of absence of sympathetic innervation or on exposure to continuous light.

U. Sachdeva
Department of Physiology
All India Institute of Medical Sciences
New Delhi.

Publications:

ICMR NEWS

The following meetings of various technical groups/committees of the Council were held:

Meetings of the Scientific Advisory Committees of the following ICMR Institutes/Centres:

Meeting of the Project Review Committee (PRC) held at New Delhi:

Participation of ICMR Scientists in Scientific Events:

Dr. D.A. Gadkari, Director, National Institute of Virology, Pune, participated in a joint meeting of the United Nations Programme on HIV/AIDS (UNAIDS), WHO Global Programme on Vaccines and Immunization and the Japanese National Institute of Infectious Diseases, to discuss AIDS Vaccine in Asia : Needs and Opportunities at Tokyo (October 28-30, 1998).

Dr. Z.M. Patel, Dy. Director and Officer-in-Charge, ICMR Genetic Research Centre, Mumbai, participated in the VIII International Conference on Ultrasound at London (November 1-5, 1998).

Dr. N.K. Ganguly, Director-General, ICMR, delivered the keynote address at the International Symposium on Biotechnological Approaches to Parasitic and Bacterial Diseases at the Indian Institute of Chemical Biology, Calcutta (November 6, 1998).

Dr. K.D. Ramaiah, Sr. Research Officer, Vector Control Research Centre, Pondicherry, participated in a workshop on Economic Research Agenda for the Global Programme to Eliminate Filariasis at Atlanta (November 12-13, 1998).

Dr. Kamala Krishnaswamy, Director, National Institute of Nutrition (NIN), Hyderabad, participated in a consultative meeting on Severe Anaemia in Pregnancy in India and Bangladesh at Dhaka (November 15-17, 1998).

Dr. B. Sivakumar, Dy. Director (Sr.Grade), NIN, Hyderabad, participated in a workshop on Micronutrient Fortification at Dhaka (November 18, 1998).

Workshop:

The ICMR-WHO Workshop on New Challenges in Intellectual Property Rights in Medical Research was organised in New Delhi during November 17-18, 1998. It was attended by Directors of ICMR Institutes, Chiefs of Technical Divisions of ICMR Hqrs, senior professionals from sister agencies and WHO representatives.

Annual Day Celebrations:

As part of the ICMR's Annual Day celebrations, the Council organised orations on (i) Molecular Biology: The Continuing Challenge by Prof. Asis K. Datta, Vice Chancellor, Jawaharlal Nehru University, New Delhi, and (ii) Perspectives in Medical Research in India by Prof. P.N. Tandon, Emeritus Professor, All India Institute of Medical Sciences, New Delhi on November 19, 1998.

ICMR AIDED SYMPOSIA/SEMINARS/WORKSHOPS/COURSES/CONFERENCES

Symposium/Seminar/Workshop/ Course/Conference	Date & Place	Contact Address
International Symposium on Major Histocompatibility Complex.	October 29 - November 1, 1998; (at New Delhi)	Dr. N.K. Mehra, Prof. and Head, Department of Histocompatibility and Immunogenetics, All India Institute of Medical Sciences, New Delhi-110029.
Precongress Workshop on Andrology and Male Infertility and National Congress on Andrology and Reproductive Medicine.	October 29 - November 2, 1998; (at Calcutta)	Dr. A.K. Bhattacharya, Organising Secretary of the Congress, Department of Biochemistry, University College of Science, Calcutta-700019.
Continuing Medical Education-cum-Workshop on Brachytherapy for Head and Neck Cancers and Breast Cancer	October 30 - November 1, 1998; (at Imphal)	Dr. Th. Tomcha Singh, Organising Secretary of the Workshop, Department of Radiotherapy, Regional Institute of Medical Sciences, Imphal-795004.
International Congress and Workshop on Recent Advances in Medical Toxicology and Legal Medicine	November 2-7, 1998; (at New Delhi)	Dr. O.P. Murthy, Organising Secretary of the Conference, Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi-110029.
International Conference on Medical Physics and XIX Annual Conference of Association of Medical Physicists of India	November 6-9, 1998; (at New Delhi)	Dr. M.M. Rehini, Organising Secretary of the Conference, Medical Physics Unit, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi-110029.
Indo-Japanese Symposium on Frontiers of Electron Microscopy in the 21st Century and XXII Annual Meeting of Electron Microscopy Society of India	November 9-11, 1998; (at Hyderabad)	Dr. P.D. Gupta, Convenor of XXII EMSI Meeting, Centre for Cellular and Molecular Biology, Hyderabad-500007.
International Workshop on Adverse Drug Reaction Monitoring	November 9-12, 1998; (at Aligarh)	Prof. K.C. Singhal, Organising Secretary of the Workshop, Department of Pharmacology, J.N. Medical College, Aligarh-202002.
International Workshop on Medical Mycology	November 16-21, 1998; (at Chandigarh)	Dr. A. Chakrabarti, Organising Secretary of the Workshop, Department of Microbiology, Post- graduate Institute of Medical Education and Research, Chandigarh-160012.
Seminar on Integration of Advances in Biostatistics into Medical Research	November 19-21, 1998; (at Vellore)	Dr. J. Richard, Prof. and Head, Department of Biostatistics, Christian Medical College, Vellore- 632002.
International Conference on Organization and Management of Blood Transfusion Service, Plans and Policies	November 22-24, 1998; (at Mumbai)	Dr. Z.S. Bharucha, Prof. and Head, Department of Transfusion Medicine, Tata Memorial Hospital, Mumbai-400012.
Workshop on Ending Malnutrition by 2020: An Agenda for Change in the Millennium	November 23-26, 1998; (at Chennai)	Dr. S. Rajagopalan, Distinguished Fellow, M.S. Swaminathan Research Foundation, Chennai- 600113.
Symposia on (i) Public Health Nutrition Problems; (ii) Frontiers in Nutrition Science; and (iii) Growth and Development of Children of South- East Asia	November 26-28, 1998; (at Hyderabad)	Dr. T.C. Raghu Ram, Joint Secretary, Nutrition Society of India, National Institute of Nutrition, Hyderabad-500007.
XI Annual Conference of Indian Society for Atherosclero- sis Research and International Symposium/CME on Prevention of Coronary Artery Disease : Concerns and Perspectives	November 27-29, 1998; (at New Delhi)	Dr. S. Dwivedi, Organising Secretary of the Conference, Prevention Cardiology Clinic, Univer- sity College of Medical Sciences, Delhi-110095.
XXXV Guha Research Conference 1998	December 1-5, 1998; (at Port Blair)	Dr. Lalji Singh, Convener, GRC 1998, Centre for Cellular and Molecular Biology, Hyderabad- 500007.
All India Workshop/Training Course on Application of Direct Methods in Crystallography for Solving Small/ Medium sized Molecules	December 1-21, 1998; (at Chennai)	Dr. D. Velmurugan, Convener of the Workshop, Department of Crystallography and Biophysics, University of Madras, Chennai-600025.
International Conference on Quality of Psychiatric Care	December 2-4, 1998; (at Calcutta)	Dr. A.N. Chowdhury, Prof. and Head, Department of Psychiatry, Institute of Postgraduate Medical Education and Research, Calcutta-700025.
Seminar on Responsiveness in Pulmonary Tuberculosis Clinical Relevance	December 12, 1998; (at Chandigarh)	Dr. S.K. Jindal, Head, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160012.
XXVIII Annual Conference of the Endocrine Society of India	December 14-16, 1998; (at Varanasi)	Dr. S.K. Singh, Organizing Secretary of the Conference, Department of Endocrinology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005.
XXXI Annual Conference of the Indian Pharmacological Society	December 17-20, 1998; (at Lucknow)	Dr. V.N. Puri, Organisng Secretary of the Conference, Division of Pharmacology, Central Drug Research Institute, Lucknow-226001.
V International Symposium on Biochemical Roles of Eukaryotic Cell Surface Macromolecules	January 4-8, 1999; (at Bangalore)	Dr. A. Surolia, Convener of the Symposium, Molecular Biophysics Unit, Indian Institute of Science, Bangalore-560012.
National Symposium on Biological Control of Insects in Agriculture, Forestry, Medicine and Veterinary Science	January 21-22, 1999; (at Coimbatore)	Dr. K. Murugan, Organising Secretary of the Symposium, Division of Entomology, Department of Zoology, Bharathiar University, Coimbatore- 641046.
VII Annual Meeting of Molecular Immunology Forum - 1999	February 13-15, 1999; (at Hyderabad)	Dr. Ashok Khar, Convener of the Meeting, Centre for Cellular and Molecular Biology, Hyderabad- 500007.

COUNCIL'S TRAINING PROGRAMMES

Leprosy

At the Central JALMA Institute for Leprosy, Agra:

· Multidrug Therapy Orientation Course in Leprosy for Medical Officers (October 26-November 6; and December 7-18, 1998).

Reproductive Biology

At the Institute for Research in Reproduction, Mumbai:

· Workshop on Andrology for Clinicians (November 16-30, 1998)

Nutrition

At the National Institute of Nutrition, Hyderabad:

· Postgraduate Certificate Course in Nutrition (December 1, 1998-February 28, 1999).

Occupational Health

At the National Institute of Occupational Health, Ahmedabad:

· Training Course on Environmental Hygiene Practice (November 16-20, 1998).

Biomedical Statistics

At the Institute for Research in Medical Statistics, Chennai:

· Basic Course in Statistics for Medical Officers (November 30-December 6, 1998).

ICMR PUBLICATIONS

	Price(Rs.)
Nutritive Value of Indian Foods (1985) by C. Gopalan, B.V. Rama Sastri and S.C. Balasubramanian, Revised and Updated (1989) by B.S. Narasinga Rao, Y.G. Deosthale and K.C. Pant (Reprinted 1996)	23.00
Growth and Physical Development of Indian Infants and Children (1972, Reprinted 1989)	10.00
Studies on Weaning and Supplementary Foods (1974, Reprinted 1996)	15.00
A Manual of Nutrition (Second Edition 1974, Reprinted 1995)	6.00
Low Cost Nutritious Supplements (Second Edition 1975, Reprinted 1996)	5.00
Menus for Low-Cost Balanced Diets and School-Lunch Programmes Suitable for North India (Second Edition 1977, Reprinted 1994)	4.50
Menus for Low-Cost Balanced Diets and School-Lunch Programmes Suitable for South India (Fourth Edition 1996)	6.00
Some Common Indian Recipes and their Nutritive Value (Fourth Edition 1977, Reprinted 1995) by Swaran Pasricha and L.M. Rebello	10.00
Nutrition for Mother and Child (Fourth Edition 1994, Reprinted 1996) by P.S. Venkatachalam and L.M. Rebello	11.00
Japanese Encephalitis in India (Revised Edition 1980)	5.00
Some Therapeutic Diets (Fifth Edition 1996) by Swaran Pasricha	7.00
Nutrient Requirements and Recommended Dietary Allowances for Indians (1990,Reprinted 1995)	16.00
Fruits (Second Edition 1996) by Indira Gopalan and M. Mohan Ram	20.00
Count What You Eat (1989, Reprinted 1997) by Swaran Pasricha	15.00
*The Anophelines of India (Revised Edition 1984) by T.Ramachandra Rao	150.00
Depressive Disease (1986) by A. Venkoba Rao	58.00
*Medicinal Plants of India Vol.2 (1987)	136.00
Diet and Diabetes (Second Edition 1993, Reprinted 1997) by T.C. Raghuram,Swaran Pasricha and R.D. Sharma	18.00
Dietary Tips for the Elderly (1992, Reprinted 1997) by Swaran Pasricha and B.V.S. Thimmayamma	5.00
Diet and Heart Disease(1994,Reprinted 1995) by Ghafoorunissa and Kamala Krishnaswamy	26.00
Dietary Guidelines for Indians _ A Manual (1998)	23.00

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*25 per cent discount allowed to individuals

These publications are available on prepayment of cost by cheque, bank draft or postal order (bank and postal charges will be extra) in favour of the Director-General, Indian Council of Medical Research, New Delhi. Money orders are not acceptable. All correspondence in this regard should be addressed to the Chief, Division of Publication and Information, Indian Council of Medical Research, Post Box No.4911, Ansari Nagar, New Delhi-110029 (India).

	EDITORIAL BOARD
	Chairman	Members
	Dr.N.K. Ganguly	Dr.Padam Singh
	Director-General	Dr.Lalit Kant
		Dr.Bela Shah
		Dr.R.Ravi
		Dr.V.Muthuswamy

Editor

Dr. N. Medappa

 

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As of 1 July 1998, a cumulative total of nearly 1.9 million AIDS cases had been officially reported to WHO. This represents a 15% increase over the number reported in July last year. Currently an estimated 30.6 million adults and children have HIV/AIDS, 5.8 million having been newly infected in 1997. An estimated 11.7 million deaths have occurred due to AIDS since the beginning of the pandemic, 2.3 million of them in 1997. Trends in AIDS incidence show significant difference between the regions of the world. The numbers have been falling in the industrialized countries, whereas in the developing world, the numbers appear to be increasing and the spread of HIV is most profound¹.

Of the 1.5 billion young people between 10 and 24 years in the world today, 85% live in developing countries. It is estimated that every 12 seconds a young person somewhere in the world acquires HIV infection. There are about 10 million young people living with HIV/AIDS. About half of all new HIV infections occur in this age group (WHO Fact Sheet No.186, 1997). With adequate support and proper interventions, the young people can change the course of this epidemic. They can play a crucial role in promoting HIV/AIDS prevention by educating their peers, discussing issues related to sex and sexuality and facilitating safer sex behaviour.

Vulnerability of Young People

Experimentation, discovery, emerging feelings and exploration of new behaviour and relationships are a normal part of adolescent development which exposes them to health risks. Some young people are at greater risk of HIV like those who are out of school, who live on the streets, who share needles with other injecting drug users, engage in commercial sex, or are sexually and physically abused. (World AIDS Campaign Briefing Paper, UNAIDS, 1998).

The results of this potent mix of risk and vulnerability show up in country statistics. The HIV rates in pregnant women under 20 years in Maharashtra rose from 2.3 to 3.5% between 1994 and 1996. (World AIDS Campaign Briefing Paper, UNAIDS, 1998). An important indicator of the scale of unprotected sex, and hence of potential exposure to HIV is the incidence of other sexually transmitted diseases (STDs). Not only are the other STDs markers for HIV infection, the genital sores and lesions that result from some STDs may facilitate HIV infection during heterosexual transmission. Young people are vulnerable because of the biological immaturity of the female genital tract. If HIV infection follows the course of other STDs among young people, they are likely to soon represent the largest age group of HIV infected individuals in the nation. Of the estimated 333 million new STD cases that occur in the world every year, nearly half are in the young people (including male and female) under 25 years of age (WHO Fact Sheet No.186, 1997). A study in Pune found that 75% of males attending a STD clinic were aged 18-19 years². The sexual relations are often unplanned and typically occur before adolescents have gained experience and skill in self protection, and before they have acquired knowledge about STDs.

In a study conducted for the International Centre for Research on Women, a quarter of the adolescent girls in Brazil reported having first sex before the age of 13. In Malawi, the mean age was 13.6 years, and in Papua New Guinea it was 11 years. (World AIDS Campaign Briefing Paper, UNAIDS, 1998)

Girls and boys can often be infected through sexual abuse by relatives, family friends, teachers and strangers. Rape and forced prostitution are other forms of abuse and exploitation known to fuel the HIV epidemic. Young people who inject drugs are exposed to high HIV risk if they share needles. In Manipur, the proportion of young drug injectors (median age : 25 years) infected with HIV zoomed from virtually zero in 1989 to 56% within six months and to over 67% by 1992³. Even the non-injecting drugs do play a substantial role in disinhibitng sexual behaviour and placing youth in contexts that increase sexual risk-behaviours.

The long delay between initial HIV infection and the onset of symptoms, supports the belief that many of these people may have contracted the virus during an earlier period of their life, particularly during their teenage years. Therefore, the population group of adolescents and young adults needs to be addressed by prevention programmes. It is becuase of ignorance, myths and disbelief that they are ending up in situations that may endanger their health, or even their lives.

Prevention of sexual and substance-use risk acts remains the most effective strategy against HIV infection. Comprehensive interventions that emphasize responsible sexuality have reduced sexual risk for HIV in Europe, Australia, and the USA. A relatively large number of national social marketing campaigns have been launched, and about half have been evaluated with positive results.

Some Recent Research Studies on Sexuality and Youth

(i) A study is being conducted at the National AIDS Research Institute (NARI), Pune, which aims to understand youth sexual behaviour and possible risks to HIV/AIDS to address the knowledge, attitude and practice(KAP) gap to plan sustainable interventions from ethnic perspectives. Undergraduates from six co-ed colleges of Pune were covered (996 girls and 825 boys) using qualitative and quantitative methods. The results of the study are of major concern that despite adequate knowledge of AIDS, youth reported risky behaviour. The results suggest that AIDS awareness needs to be integrated with youth programmes involving both boys and girls where sexuality, and gender relationships are openly discussed along with reproductive health matters and responsible safe behaviour. Participatory approaches like workshops for information dissemination through peers leaders be planned for youth enabling democratic and responsible decision making by both boys and girls.

The base-line data have provided valuable insights into why certain behaviours occur and also why certain beliefs and attitudes are held. This has also enabled in understanding the vocabulary used by college students which is an important consideration when intervention programmes are planned. There is a need to integrate the efforts with other activities in colleges like the National Service Scheme (NSS)and the National Cadet Corps (NCC), where students take an active part. The Friendship Networks of the students can pave a way for a wider dissemination of information on several aspects that include sexuality and reproductive issues in the context of AIDS/HIV/STD. The second part of the study is the intervention phase through peer educators' training programme among college students. These interventions which aim to bring about behavioural change rather than increasing knowledge alone would pave the way to harm reduction among the youth⁴.

(ii) Youth need complete information on HIV/AIDS within an open, and sensitive vision of human sexuality. However, interventions aimed at adolescents have largely been moralistic and rigid laying down patterns of sexual behaviour in terms of "dos and don'ts". Recognizing this Deepam Educational Society for Health (DESH), Chennai designed, after extensive field testing a loosely structured package for youth on issues related to sex and sexuality. A simple and watertight classification does not provide adolescents with full and complete information on the degree of `risk' and `no risk' attached to a particular sexual behaviour. A level of risk continuum is called for if information is to be translated into safe behaviour and practice. In this continuum, sexual behaviour may be broadly classified on a scale from high risk to low risk to no risk. DESH's intervention in some educational institutions led to an increase in understanding of the level of risk continuum among adolescents⁵. (iii) In a study on 2000 college students from 20 colleges in Mumbai regarding sexual terminologies, sexual initiation, and sexual and condom use behaviour, it was reinforced that it is necessary to evolve a peer based programme to educate the youth as to how to resist pressure from their peers and to provide a comprehensive contraceptive knowledge package and basic sex/family life education⁶.

Empowering the Youth

The Government of India is focussing on young people through a multi-prong attack. It is using a combination of media campaign, education on AIDS for those attending school and those out of school and provision of supportive services like counselling. Five regional workshops covering all States and Union Territories have been organized for developing an action plan for introduction of AIDS education in the school system.

AIDS Education in Schools

In consultation with the National Council of Educational Research and Training (NCERT), New Delhi, State Councils for Educational Research and Training and State Institutes of Education, projects for introduction of AIDS education in schools have been prepared and implemented in seven States.

The NCERT has also undertaken the development and introduction of "adolescence education" in the school system in secondary schools on a pilot basis in 1998. This has been done by adding it to population education, which already exists in the school curriculum. It has three components, the process of growing up, AIDS education and drug abuse. It is too early to evaluate the impact of the sexual health education programme on risk behaviour of young people as these programmes are in their infancy. However, many programmes have shown encouraging evidence of change in knowledge and attitudes. For example, the State of Maharashtra has three concurrently running programmes that cover almost the whole state. Evaluation reports of the programmes indicate an increase in knowledge and a positive impact on attitudes.

To assess the impact of HIV and sexual health education on the sexual behaviour of young people, the joint UN programme on AIDS carried out a literature review in 1997 of 68 reports from developed and developing countries. It was found that in one third of the studies HIV/AIDS and sexual health education neither increased nor decreased sexual activity and attendant rates of pregnancy and STDs. Another third of the studies reported that HIV and sexual health education either delayed the onset of sexual activity, reduced the number of sexual partners or reduced unplanned pregnancy and STD rates⁷.

AIDS Education for Young Adults

The prevention measures for youth in India were initiated in 1991 in a phased manner under the banner of "Universities Talk AIDS". This was through an intersectoral collaboration of the National AIDS Control Organization (NACO) with the Ministry of Human Resource Development, Department of Youth Affairs and Sports. Creating AIDS awareness among youth through social marketing methods based on participatory approaches was a major objective of this programme. A great deal of AIDS educational material was generated which was later developed into posters, booklets, etc. Starting with about 50 universities in the first phase (1991), 168 universities were participating in this Programme by 1996-97.

This is the first governmental programme for the youth to spread the message of AIDS prevention. Social marketing strategies involved the university officials, college principals, youth officers in colleges, the non-governmental organizations (NGOs) and through them the peer educators. The Programme envisaged that the bands of peer educators would create AIDS awareness in colleges using participatory approaches.

It was realized that social marketing methods can prove effective in making the AIDS education programme low-cost and sustainable. The need to overcome information gaps, to involve parents and teachers and to introduce sexuality and AIDS prevention education in the curriculum was felt^8,9.

In order to make information youth-friendly, an entertainment programme on the FM radio channel is being broadcast in four cities _ Delhi, Mumbai, Calcutta and Goa. NACO has also established a National AIDS Helpline 1097. Through this service young people are being provided correct information on HIV/AIDS/STDs. The service is already being implemented in Delhi, Chennai and Hyderabad and is expected to be expanded to all the major cities of the country.

NACO is supporting a programme to reach rural youth through a network of 700 Nehru Yuvak Kendras for spreading awareness on family life, education, responsible attitudes to sex and safer sex options. Workshops have also been held in several States to integrate AIDS/STD into their programme activities. In addition, the Vishwa Yuvak Kendras have trained NGOs working with the youth in seven major Indian cities.

Programmes have been developed using rural art forms to disseminate information on HIV/AIDS. Puppetry, magic, harkatha, qawali, nautanki, folk dance and music have been used to develop messages. These are being used in outreach activities of the National Service Scheme and Universities Talk AIDS¹⁰.

Non-governmental Efforts

AIDS awareness efforts for youth were also made by NGOs, though a little later, for example in Chennai, Delhi, Pune, Calcutta and Ahmedabad. The YR Gaitonde Centre for AIDS Research and Education (YRG), Chennai was the first to initiate a youth programme through training community-based organizations for starting sexuality and sex education in schools, involving parents and teachers in discussing these problems. Subsequently, other NGOs such as the Deepam Educational Society for Health, Chennai and ASHA, and Indian Health Organization, Mumbai also started this for the school going adolescents, and college women, involving younger children, through religious festivals, street children etc. for creating cost-effective and culturally sensitive AIDS awareness. These interventions have been carried out to increase knowledge. However, efforts to measure the changes have been limited.

The YR Gaitonde Centre for AIDS Research and Education, Chennai has worked with schools, colleges and youth in informal settings through sexuality workshops. It was an uphill struggle for the organization to convince school and college principals to initiate education programmes on sexuality. For illiterate youth, 3-5 days programme using various art forms was conducted. The main objectives of the module were to impart information, motivate students for action, clarify myths and misconceptions, foster positive attitudes about HIV related issues and living with HIV infection. Despite several constraints with time the programme has gained a great deal of popularity among the youth who are also fairly active in peer education¹¹.

Using Youth as an Instrument of Change : Some Examples

Creating awareness and knowledge among young people about HIV/AIDS is not an end by itself. Not only can they lead a safer life-style but also be an instrument of change in their family, lives of their friends, and even in the community.

There are some eloquent examples of approaches that have utilized young people to their fullest potentials.

(i) The Asian Red Cross and Red Crescent AIDS Task Force trained 1000 young people as peer educators using the life-skill approach. Culturally sensitive training manuals on sexual and reproductive health and HIV/AIDS were prepared. In consultation with national Red Cross and Red Crescent Societies in Asia, these materials were finalized and are used for conducting sexual and reproductive health training to young people (World AIDS Campaign Briefing Paper, UNAIDS, 1998).

(ii) The Clear Skies Project was initiated in a rural district outside Chiang Mai, Thailand, to provide emotional and practical support for people with HIV infection/AIDS. The project is run entirely by people who are themselves living with HIV/AIDS, many of them under 25 years of age. Weekly meetings are arranged where HIV positive people come together to discuss common concerns; the project provides home care for people with AIDS; and the project works closely with health care provides to increase their sensitivity to the need of people living with HIV/AIDS for caring, sensitive, and confidential care, in addition to other activities (World AIDS Campaign Briefing Paper, UNAIDS, 1998).

(iii) The ASHA project, Mumbai, observed that more than 25% of persons attending the sex clinic of the project were aged between 16 and 22 years. This prompted launching of a programme on youth and life-styles with focus on college students. It addressed HIV/AIDS in the context of sex, sexuality and life-styles. Seventeen colleges participated in the programme. The experience indicated that working with youth on HIV/AIDS is most important and if addressed properly, the AIDS prevention activity with this group could be very effective¹².

(iv) More than 150 Campaigns Among Students on AIDS (CASA) in different high schools, and colleges of Chittoor district have been organized. CASA has provided IEC material on AIDS to more than 89,000 students. The students were enthusiastic to know more about HIV/AIDS. They learned about sexual behaviour, safer sex and preventive methods. Two hundred students have undergone one month training on AIDS, and are actively spreading the awareness to other students and to the society¹³.

(v) A young student properly motivated and guided as to the basic information on HIV/AIDS development_ mode of transmission and consequences could effectively share education gained with people. In a project in the Philippines, students are taught to join in discussing HIV/AIDS when presented in their classroom, and attend a workshop on `Why-When-Who-and How' HIV/AIDS becomes a community problem. If each student reaches out to two members of his/her family who in turn will reach out to two of their relatives and two of their friends and lastly two of their neighbours, 40 students (usual size of a class) will be able to spread information about the incurable disease to 320 students. The study recognizes the power of students to participate in the prevention and control of HIV/AIDS¹⁴.

(vi) In Lagos, Nigeria, counselling booths/centres were erected at strategic locations in the community. Peer health educators (PHEs) and reproductive health counsellors were available for 9 h, 6 days a week and disseminated information on issues concerning reproductive health. This entails education on HIV/AIDS, STDs, early marriage, teenage pregnancy, and use of contraceptives with emphasis on proper use of the condom. To promote information dissemination to all parts of the community, PHEs carry out house-to-house visits and work place visits and distribution of IEC materials to youth. Counselling has brought about an amazing increase in the number of youth willing to live risk-behaviour free lives, and sale of condoms; and a decrease in the number of cases of HIV/AIDS/STDs, teenage pregnancy and abortion¹⁵.

(vii) Through training 30,808 peer educators in 1,188 high schools, a voluntary organization in Chennai, the Deepam Educational Society for Health, improved condom awareness from 3 to 40%, besides, 261 street youths were trained to function as street educators. The peer educators focussed on STD diagnosis and treatment¹⁶.

(viii) In Bhubaneshwar, Orissa, an NGO has a State-wise network of 300 other NGOs dealing with the youth. In order to educate the youth outside the formal structure of education, it trained a representative each from 45 NGOs to multiply the message of sex and sexuality to the local and district level. About 500 peer educators have been trained¹⁷.

(ix) An experimental intervention with HIV/AIDS prevention in mind was initiated in the Philippines, to address the HIV/AIDS problem of children and youth. Implemented by children and youth for children and youth the project includes building capabilities of a core of volunteer children and youth in educating, facilitating and advocating with peers on HIV/AIDS and their issues, and concerns using the convention on the Children's Right as the framework and with alternative form of education techniques. Child action desks were set up by the young members of the Society in seven communities to monitor abuses and provide service to their peers¹⁸.

Lessons Learnt

Interventions are important to sensitize the target population about the AIDS problem. If timely action is not taken it may jeopardize their future interests. Such information need to be given in a cultural milieu in which the interventions are accessible and acceptable. Social marketing strategies are useful as they are participatory and involve the individual. Sustained efforts can help in making behavioural changes. There is a need to monitor these changes for a meaningful impact of these programmes. The indicators for assessing these changes should also be meaningful and sensitive. For example merely assessing the knowledge of HIV/AIDS may not be enough but what is required is how the problem of AIDS/HIV is perceived by the youth and what changes in their behaviour has the intervention brought about.

The HIV/AIDS problem to a large extent deals with sex. Therefore, an emphasis on sexuality is crucial to address the issues of behaviour modification. Research, specially formative research has to be built in with the interventions to get the desired results. Research on these aspects would then depend on qualitative methods to get the insight rather than the counting of numbers through survey data, although this when complemented with qualitative data can give more power to the interpretation of the situation. Formative research for interventions is important although this is still in its infancy in India.

The young adults are the pillars of society, any investments on them goes a long way for the future of countries. Youth can be prepared to have positive health attitudes that can pave the way for better mental, physical and spiritual health.

The youth have energy, enthusiasm and a commitment, and with proper support they can face greater challenges. To achieve more difficult tasks like promoting good health, their positive energies can be put to a great use by involving them in activities of their concern like prevention of AIDS/HIV. Using the potentials of young, "A youth to youth programme" has been started by the Ministry of Human Resource Development, Govt. of India. This programme covers the junior college students and is still in the early stages of implementation. Such initiatives would first help the youth themselves and through them spread to their peers and then to a wide network of their friends. What is important is that they should have the correct knowledge and develop a positive attitude to change behaviour themselves first and only then can they contribute in the prevention of HIV. Experience of student volunteers to create awareness in their own colleges on the harmful effects of drugs, smoking, alcohol and recently AIDS and HIV through seminars, talks, exhibition, street plays etc has been effective.

The young people are hesitant to talk about matters like their own physical and physiological growth and related issues (masturbation, safe sex, condom use, STDs, contraceptives) with others. Due to the lack of correct information and knowledge they practice behaviours that put them at risk. They strongly feel the need of having someone they can talk to about these matters with ease. A brigade of student volunteers, both boys and girls to be peer educators who are concerned about the welfare of their friends and peers would be a great asset for the AIDS prevention programmes.

Conclusions

HIV/AIDS is a health problem of the young. The solution to which should also be found by the young. The adults can work in partnership with the young, show them the way, provide them support, set an example, but the ultimate force for change is the young people themselves. They are resilient, open to change, creative and enthusiastic. The youth can better appreciate the importance of making their own life-style safe, and encourage their friends to adopt safer behaviour practices. They can bring compassion and help to those living with HIV/AIDS. Young people are a force, and if channelized properly, this force can change the course of the HIV/AIDS pandemic.

References

2. Urmil, A.C., Dutta, P.K., Sharma, K.K. and Ganguly, S.S. Medico-social profile of male teenager STD patients attending a clinic in Pune. Indian J Publ Health 33: 176, 1989.

3. Sarkar, S., Das, N., Panda, S., Naik, T.N., Singh, B.C., Ralte, J.M., Aier, S.M. and Tripathy, S.P. Rapid spread of HIV among injecting drug users in North-eastern states of India. Bulletin of Narcotics, Vol.XLV, p.91, 1993.

4. Mawar, N., Tripathy, S.P., John, J.K., Sinha, S.K., Quraishi, S.Y., Bagul, R. and Gadkari, D.A. Youth sexuality study for behaviour change interventions for AIDS/HIV in college youth, Pune, India. XII World AIDS Conference, Geneva, 1998. Abstract No.14333.

5. Sankaran, L. and Sankaran, S. Level of risk continuum as a tool in HIV/AIDS prevention education. XII World AIDS Conference, Geneva, 1998. Abstract No.13511.

6. Gurumurthy, R. and Verma, R.K. Risk taking sexual behaviour in the age of AIDS: A study among college youth in Mumbai. XII World AIDS Conference, Geneva, 1998. Abstract No.14331.

7. Andersson, A. UNESCO's contribution in the field of sexual health education _ Programme on preventive education agailnst HIV/AIDS. Indian J Popul Educ 7 (April-Sept): 23, 1998.

8. Quraishi, S.Y. Social marketing of AIDS education for youth. The Indian experiment. International Conference on AIDS, 1994. Abstract No.472D.

9. Bhagbanprakash, Quraishi, S.Y. and Binodini, D. AIDS education: A study on perceived prejudices and media habits of students and teachers. International Conference on AIDS, 1996. Abstract No.MoD-1821.

10. Country Scenario - An Update. National AIDS Control Organization, Ministry of Health & Family Welfare, Govt. of India, December, 1996.

11. Proceedings of the Indo-US Workshop on Behavioural Research Priorities : Developing Effective Strategies for Prevention of HIV in India. Eds. V.Nadkarni and Subadra. Cell for AIDS Research, Action and Training, Tata Institute of Social Sciences, Mumbai, p.17, 1995.

12. Nigudkar, P. Youth and life-style, in relation to HIV/AIDS _ A programme for student youth. International Conference on AIDS, July 7-12, 1996. Abstract No.Th.C.4451.

13. Babu, R. Campaign among students on AIDS.International Conference on AIDS, July 7-12, 1996. Abstract No.Th.C.4450.

14. Angeles, R.E. The development of students as HIV/AIDS educators reaching out to their peers in school, members of their family, relatives, friends and neighbours. XII World AIDS Conference, Geneva, 1998. Abstract No.24287.

15. Ita, M.M. Counselling in reproductive health among young people in Shitta Community, Lagos State. XII World AIDS Conference, Geneva, 1998. Abstract No.60857.

16. Sankaran, S. Research as a tool for effective Social action programme. XII World AIDS Conference, Geneva, 1998. Abstract No.14225.

17. Misra P.C. Peer education for youth groups/NGOs. XII World AIDS Conference, Geneva, 1998. Abstract No.60763.

18. Esguerra, R. Child rights and HIV/AIDS. XII World AIDS Conference, Geneva, 1998. Abstract No.44147.

ICMR AIDED SYMPOSIA/SEMINARS/WORKSHOPS/COURSES/CONFERENCES

Symposium/Seminar/Workshop/ Course/Conference	Date & Place	Contact Address
XXXV Guha Research Conference 1998	December 1-5, 1998; (at Port Blair)	Dr. Lalji Singh, Convener, GRC 1998, Centre for Cellular and Molecular Biology, Hyderabad-500007.
All India Workshop/Training Course on Application of Direct Methods in Crystallography for Solving Small/ Medium sized Molecules	December 1-21, 1998; (at Chennai)	Dr. D. Velmurugan, Convener of the Workshop, Department of Crystallography and Biophysics, University of Madras, Chennai-600025.
International Conference on Quality of Psychiatric Care	December 2-4, 1998; (at Calcutta)	Dr. A.N. Chowdhury, Prof. and Head, Department of Psychiatry, Institute of Postgraduate Medical Education and Research, Calcutta-700025.
Seminar on Responsiveness in Pulmonary Tuberculosis Clinical Relevance	December 12, 1998; (at Chandigarh)	Dr. S.K. Jindal, Head, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160012.
XXVIII Annual Conference of the Endocrine Society of India	December 14-16, 1998; (at Varanasi)	Dr. S.K. Singh, Organising Secretary of the Conference, Department of Endocrinology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005.
XXXI Annual Conference of the Indian Pharmacological Society	December 17-20, 1998; (at Lucknow)	Dr. V.N. Puri, Organisng Secretary of the Conference, Division of Pharmacology, Central Drug Research Institute, Lucknow-226001.
V International Symposium on Biochemical Roles of Eukaryotic Cell Surface Macromolecules	January 4-8, 1999; (at Bangalore)	Dr. A. Surolia, Convener of the Symposium, Molecular Biophysics Unit, Indian Institute of Science, Bangalore-560012.
National Symposium on Biological Control of Insects in Agriculture, Forestry, Medicine and Veterinary Science	January 21-22, 1999; (at Coimbatore)	Dr. K. Murugan, Organising Secretary of the Symposium, Division of Entomology, Department of Zoology, Bharathiar University, Coimbatore-641046.
VII Annual Meeting of Molecular Immunology Forum - 1999	February 13-15, 1999; (at Hyderabad)	Dr. Ashok Khar, Convener of the Meeting, Centre for Cellular and Molecular Biology, Hyderabad-500007.

COUNCIL'S TRAINING PROGRAMMES

Leprosy

At the Central JALMA Institute for Leprosy, Agra:

• Multidrug Therapy Orientation Course in Leprosy for Medical Officers (December 7-18, 1998).

Nutrition

At the National Institute of Nutrition, Hyderabad:

• Postgraduate Certificate Course in Nutrition (December 1, 1998-February 28, 1999).

ICMR BULLETIN INDEX
VOL. 28, 1998

Main Feature	Page No.	Month
Menopause and HRT	1	January
Diurnally Subperiodic Bancroftian Filariasis in Andaman and Nicobar Groups of Islands, India	13	February
Malaria Situation in North-Eastern Region of India	21	March
Epidemiology and Surveillance of Japanese Encephalitis in Tamil Nadu	33	April
Clinical Features, Pathogenesis and Management of Lymphatic Filariasis	41	May
Health Hazards of Fumonisin Mycotoxins and its Prevention	55	June
Nuclear Medicine Practice and Radiation Doses to Patients in India : I. Status of Nuclear Medicine in the Country	63	July
Nuclear Medicine Practice and Radiation Doses to Patients in India : Part II. Risk Related Radiation Doses to Patients	71	August
Nuclear Medicine Practice and Radiation Doses to Patients in India : Part III. Calculation of Radiation Doses to Indian Patients	81	September
Contraceptive Research and Development during the Fifty Years of Independence in India: Achievements and Desired Goal	89	October
Nutrition: A Critical Determinant of Response to Vaccines in Children	105	November
Campaign against HIV/AIDS : Youth as Force for Change	117	December

	EDITORIAL BOARD
	Chairman	Members
	Dr.N.K. Ganguly	Dr.Padam Singh
	Director-General	Dr.Lalit Kant
		Dr.Bela Shah
		Dr.R.Ravi
		Dr.V.Muthuswamy

Editor

Dr. N. Medappa

 

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