ICMR BULLETIN VOL.19-No.-11-NOVEMBER-1989
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- ICMR BULLETIN VOL.19-No.-11-NOVEMBER-1989
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ISSN 0377-4910
November, 1989
VoL19 No.11
HIV INFECTION—ONGOING STUDIES AND
FUTURE RESEARCH PLANS
AIDS was described as an obscure disease of
unknown etiology in 1981. The next five years witnessed a
rapid increase in the number of AIDS patients detected in
USA and Africa. By 1985 it was obvious that AIDS had
spread to Europe and Australia and had assumed the
shape of a major global public health problem. However,
no patient of AIDS was reported from Asia till 1985.
Even today Asia, the most populous continent of the
world has only 413 out of 1,77,950 patients of AIDS
reported to WHO (WHO update - AIDS cases, Sep
tember 1989). Asia appears to be the continent affected
last and least by HIV infection. Hence, India and other
Asian countries have, perhaps for the first time in the
recorded history of mankind, been given the opportunity
and challenge to contain and control a potentially lethal
infection very early in the course of the epidemic.
Surveillance for HIV Infection
Phase I
Sound epidemiological data on prevalence of infec
tion and mode of transmission are essential pre
requisites for evolving logical intervention strategies for
disease control. The Centre for Disease Control,
Atlanta, USA was the first organisation that initiated the
systematic epidemiologiocal data collection of AIDS
patients. Subsequently, several national registries for
AIDS patients were started and by 1986 WHO organised
a global reporting system of AIDS patients. Almost all
the available epidemiological data on AIDS are derived
from studies on AIDS patients. However, this approach
is not of much use in Asia where the number of patients
reported are very low. Studies on the natural history of
AIDS showed that a long asymptomatic period lasting
for one to 10 years precedes the development of clinical
symptoms of AIDS. Sensitive and specific tests for
detection of asymptomatic HIV infection became avail
able in 1985-86. Realising the potential threat posed by
HIV infection and the urgent need for finding out
whether the infection has reached India, the AIDS Task
Force of the Indian Council of Medical Research
(ICMR), New Delhi, recommended initiation of serosurveillance for HIV infection among asymptomatic per
sons belonging to high risk groups. The National
Institute of Virology (NIV), Pune and the Christian
Medical College (CMC), Vellore began the screening in
October 1985. By April 1986, a total of 3027 persons
from high risk groups were screened and 10 prostitutes
were detected to be seropositive. The first patient of
AIDS was detected by NIV, Pune in May 1986. On
completion of Phase I of the serosurveillance it was clear
that HIV infection had reached India.
Phase II
The AIDS Task Force of ICMR considered these
findings and recommended that a national serosurveil-
This issue commemorates the World AIDS Day (December 1, 1989)
Division of Publication & Information, ICMR, New Delhi - 110 0 29
lance and clinical surveillance for HIV infection should
be immediately initiated. The objective of this epidemio
logical study was to obtain information on prevalence
and major mode of transmission of HIV infection; these
data are essential for evolving strategies for control of
HIV infection in India. The Task Force emphasised the
need for immediate initiation of serosurveillance to gain
time, because control measures initiated early in the epi
demic when only a small proportion of population is
infected are likely to be more effective in containment
and control of infection.
Initiating a national clinical and serological surveil
lance for HIV infection in India was a major task. The
existing health and laboratory personnel had to be fami
liarised and trained in the detection of clinical case.
Laboratory diagnosis and serosurveillance are expensive
because of the cost of procurement of ELISA readers
and kits. Hence, it was decided that the national surveil
lance would be established as a collaborative effort of
ICMR, Directorate General of Health Services (DGHS),
New' Delhi and State Health Authorities. A network of
five reference centres and 43 surveillance centres were
established in six months within the existing health
infrastructure employing minimum essential additional
inputs (Fig). The second phase of serosurveillance began
in May 1986. Initially the emphasis was on screening of
prostitutes. Screening of a relatively small number of
these women revealed that HIV infection existed in dif
ferent parts of India. Subsequently, a wider coverage of
all the known risk groups was attempted. Some of the
landmarks in the serosurveillance for HIV infection are
given in Table I. By the end of 1986 it became obvious
that heterosexual promiscuity played a major role in the
transmission of HIV infection. During the second phase
(which ended in October 1987) 53,907 persons were
screened, 135 individuals were found to be seropositive
and 14 patients of AIDS were detected. It was obvious
that seropositivity rate even among high risk groups was
quite low. Consequent to finding seropositives among
pregnant women, infants, blood donors and blood recip
ients during this phase, the ICMR Task Force recom
mended that in the third phase of serosurveillance, blood
donors, and mother-infant dyad should be included in
addition to the high risk groups.
The second phase of serosurveillance demonstrated
that even in a developing country with limited resources
where very few AIDS patients existed, it is possible to
organise a national clinical and serosurveillance pro
gramme through the existing hospital and laboratory
infrastructure with minimum essential additional inputs.
With the information obtained from such surveillance,
appropriate intervention programmes including prepa
ration of appropriate health education material for pre
vention of infection could.be initiated. The data from the
study also provided the policy makers an idea about the
extent and nature of future activities and the resource
allocation needed for these.
Table 1. Landmarks in the National HIV Serosurveillance Programme
Period
First Detection
Steps Taken
April, 1986
Seropositive Indian (prostitute)
May, 1986
AIDS patient in India
August, 1986
Seropositive Indian male (STD clinic)
Screening in STD clinics intensified.
September, 1986
Seropositive pregnant woman
Screening of pregnant women initiated.
December, 1986
Patient of AIDS in homosexuals
Screening of homosexuals and jail inmates (men) attempted.
July, 1987
Seropositive Indian blood donor
Screening of blood donors and blood recipients augmented.
National clinical and serosurveillance programme for HIV infection
established.
Seropositive blood recipient
(from Indian donor)
October, 1987
116
Spouse to Spouse transmission
Efforts for contact tracing intensified.
Seropositive infant
Antenatal screening intensified.
Phase III A
The first part of the third phase of serosurveillance
began in November 1987 and lasted till October 31,
1988. During this period 1,09,632 persons from high risk
groups were screend and 387 seropositive individuals
including 11 AIDS patients were detected. There was a
steep rise in screening activities during this period not
only among high risk groups but also among blood
donors and pregnant women. The overall seropositivity
rate continued to be. low (3.8/1000), but it was obvious
that there was an increase in seropositivity rate among
blood donors and promiscuous men (Table II).
The IC MR Expert Group-reviewed these findings
and recommended that:(i)
Blood donor screening for HIV infection may be
initiated in a phase manner starting with the four
major metropolitan cities.
(ii) Health education of vulnerable and high risk
groups should receive adequte attention.
(iii) Clinical facilities for counselling and care of sero
positive individuals needed to be established.
(iv) Hospital policies for care of HIV infected persons
including AIDS patients should be drawn up.
AIDS Reference and Surveillance Centres and Centre for AIDS Research &
Control.
Table II. Trends in seropositivity rates in selected groups
Period
October, 85
to April, 86
May, 86 to
October, 86
November, 86
to April, 87
May, 87 to
October, 87
November, 87
to April, 88
May, 88 to
October, 88
3000
Number positive
Rate per 1,000
Cumulative rate/1,000
1072
0
0
0
0.3
0.2
852
2
2.3
0.7
7212
17
2.4
1.6
7105
53
7.5
3.8
5967
53
8.9
5.0
PROMISCUOUS FEMALES
Number tested
Number positive
Rate per 1,000
Cumulative rate/1,000
306
0
0
0
680
3
4.4
3.3
2863
4
1.4
1.8
7491
7
0.9
1.2
3375
14
4.1
1.9
3752
20
5.3
2.5
BLOOD DONORS
Number tested
Number positive
Rate per 1,000
Cumulative rate/1,000
872
0
0
0
2184
0
0
0
2340
0
0
0
5137
I
0.2
0.1
4413
3
0.7
0.3
12795
37
2.9
1.5
.Promiscuous males
“Number tested
T
117
(v)
Diagnostic facilities for HIV antibody detection
should be made availabe in more centres.
(vi) Systematic sentinel surveillance for HIV infection
should be initiated.
Responding to these recommendations, the DGHS
drew up the medium term plan for AIDS control with
the following major objectives:(i)
Reduction and later prevention in sexual, perinatal
and parenteral transmission of HIV infection.
(ii)
Reduction in morbidity associated with HIV infec
tion through early detection, prompt and adequate
treatment of seropositive individuals.
(iii) Minimise social and economic impact of HIV infec
tion by timely intervention measures. As a part of
the medium term plan the DGHS also drew up an
action plan for blood donor screening for HIV
infection in India.
Phase 111 B
The second part of the third phase started in
November 1988 and is continuing. On the advice of the
ICMR Expert Group all the surveillance/reference cen
tres intensified screening of blood donors. In January
1989. the DGHS requested all the reference/surveillance
centres to assist in initiating the first phase of the blood
donor screening programme by taking up training of
personnel from the newer centres and screening sera sent
by blood banks for HIV antibodies.
In January 1989. Hl'V antibodies were detected in a
blood product manufactured in India. The DGHS and
Drugs Controller of India (DCI) requested the ICMR
and the surveillance/reference centres for assistance in
testing blood products as well as blood product recip
ients. This additional work was also taken up by the
Council and the centres. Thus during the period from
November 1988 to October 1989, the major attention of
the surveillance/reference centres was on providing
assistance to the service programmes for screening of
blood donors, blood products and blood product recip
ients. Because of this sudden increase in the work load,
serosurveillance and screening of high risk groups had to
be curtailed in many centres. The ICM R postponed initi
ation of the proposed sentinel surveillance for HIV
infection.
Profile of Seropositive individuals
From the inception of the programme till October
31, 1989 the centres have screened 3,64,277 persons
from various groups; 1650 of these have been found to
be seropositive; 40 patients of AIDS have so far been
reported to ICMR by the centres (Table Ill & IV). •
Promiscuous men and women form the single larg
est group of seropositive individuals. Undoubtedly hete
rosexual promiscuity plays a major role in transmission
of HIV infection in India. Contact tracing and follow up
of families of seropositive persons have been stepped up.
This has facilitated detection of infections in the asymp
tomatic phase transmitted perinatally/spouse-to-spouse.
Blood donors are the second largest group of sero
positive individuals detected. This is mainly because the
blood donors (or more correctly donated blood) form
the single largest group screened. And partly, because
seropositive professional donors have donated blood
repeatedly under different names, in various blood
Table Ill. Serosurveillance for HIV infection
(October, 1985 to October, 1989)
No.
screened
•
Rate
per,
1,000
AIDS
patients
Phase 1
(October. 1985-ApriL 1986)
3027
10
3.3
0
Phase 11
(May. 1986-October. 1987)
53.907
135
2.5
14
Phase 111 A (November. 1987-October. 1988)
1.09632
387
3.5
11
*
Phase 111 B (November. 1989-October. 1989)
197711
1118
5.6
15
364277
1650
4.5
40
Total
*Data do not include blood donors screened after April 1989.
118
No.
seropositive
banks/cities. Following the detection of HIV antibodies
in blood products, some of the centres undertook screen
ing of professional blood donors who had been donating
blood for manufacture of blood products. The seroposi
tivity rate among these was very high and thus this group
also contributed to the relatively large number of sero
positive blood donors reported so far. With increasing
awareness about the possibility of transmission of HIV
infection through blood and blood products, voluntary
screening among blood product recipients has gone up
and large number of seropositive recipients are being
identified. Some, who were detected to be seropositive in
one centre sought testing in other centres without reveal
ing that they had been tested earlier. Thus, in this group
also some duplication exists among number of reported
seropositive individuals.
Table IV. Serosurveillance for HIV infection
(Period of reporting: from inception to October 31, 1989)
Institution
Number
Screened
Number positive
ELISA
(364277)
(2043)
Western
Blot
(1650)
0
225
0
Osmania Medical College, Hyderabad, A P.
291
1
1
S.V. Medical College. Tirupati. A P.
2986
17
13
Andhra Medical College, Visakhapatnam, A P.
4074
0
0
Rajendra Memorial Research Institute for Medical Sciences, Patna, Bihar.
2933
0
0
Postgraduate Institute of Medical Education & Research, Chandigarh.
8210
41
41
All India Institute of Medical Sciences (M). New Delhi *
17967
34
29
All India Institute of Medical Sciences (S). New Delhi.*
5601
55
51
1 Institute of Preventive Medicine, Hyderabad. A P.
Maulana Azad Medical College, New Delhi.
4521
4
4
National Institute of Communicable Diseases, Delhi.*
11391
14
9
Institute of Cytology and Preventive Oncology, New Delhi.
227
0
0
Armed Forces Transfusion Centre, Delhi.
97
8
0
Institute of Pathology, New Delhi.
665
0
0
Goa Medical College. Panaji. Goa.
11551
43
23
B.J. Medical College. Ahmedabad. Gujarat.
11733
9
9
Medical College. Rohtak, Haryana.
13976
3
2
I.G. Medical College. Shimla, H P.
.1318
1
1
Institute of Medical Sciences, Srinagar. J&K.
2906
2
2
Bangalore Medical College. Bangalore. Karnataka.
16821
21
15
S.A.T. Medical College, Trivandrum, Kerala.
3111
9
9
Gandhi Medical College, Bhopal, M P.
3404
15
6
Choithram Hospital and Research Centre, Indore, M P.
885
3
3
Regional Medical Research Centre, Jabalpur, M P.
2632
16
16
Grant Medical College, Bombay. Maharashtra.
13115
193
30
Institute of Immunohaematology, Bombay, Maharashtra.
10678
174
93
Seth G.S. Medical College, Bombay, Maharashtra.
8724
233
145
Government Medical College, Nagpur, Maharashtra.
4512
23
2
•Reference Centre
COMMUNITY HEALTH CELL
326, V Main, I Block
Korameng ’ i
Bong or-560034
India
119
Table IV Contd.............
Institution
Number
Screened
Number positive
ELISA
Western
Blot
Armed Forces Medical College, Pune, Maharashtra.
2924
6
3
National Institute of Virology, Pune, Maharashtra.*
13337
134
109
Regional Medical College, Imphal, Manipur.
2392
1
0
S.C.B. Medical College, Cuttack, Orissa.
2285
0
0
Regional Medical Research Centre, Bhubaneswar, Orissa.
1166
0
0
Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry.
6554
96
64
S.M.S. Medical College, Jaipur, Rajasthan.
1109
0
0
Apollo Hospital, Madras, T N.
22774
15
15
Madras Medical College, Madras, T N.
59490
308
253
Institute of Child Health and Hospital for Children, Madras. T N.
6689
25
Government Royapettahi Hospital, Madras, T N.
200
0
21
0
Stanley Medical College, Madras, T N.
869
0
0
Madurai Medical College, Madurai. T N.
14816
176
156
Christian Medical College, Vellore, T N.*
54587
289
212
Central Jalma Institute for Leprosy, Agra, U P.
966
1
1
King George Medical College, Lucknow, U P.
2450
5
3
Institute of Medical Sciences. Varanasi. U P.
2010
0
0
National Institute of Cholera and Enteric Diseases. West Bengal.
1145
1
J
School of Tropical Medicine, Calcutta. West Bengal.
3960
4
3
Sera sent to reference centres for confirmation
21347
1517
1240
•Reference Centre
Data of blood donors screened after April 1989 have not been included.
Training and orientation sessions organised by var
ious agencies have augmented the awareness and shar
pened the diagnostic skills of clinicians. This has helped
Training and orientation sessions organised by
various agencies have augmented the awareness and
sharpened the diagnostic skills of clinicians. This has
helped in diagnosis of AIDS patients on the basis of
clinical criteria, the diagnosis being later confirmed by
serological testing. Foreigners (including students and
tourists) form another group of seropositives. Most of
them have already been repatriated (Table V).
AIDS Patients in India
Clinical surveillance for HIV infection was initiated
along with serosurveillance in October 1985. The first
120
patient of AIDS was reported in May. 1986 by NIV.
Pune. The source of infection was traced to blood
transfusion given in USA. where the patient had gone
for coronary bypass surgery. The second patient was
reported a month later. He was a haemophiliac who had
received Factor VIII infusion in USA. Till October 31.
1989. number of AIDS patients reported to ICMR was
40. Of these. 12 were foreigners; five of them died in
India, the rest were deported. All the 28 Indians hace
succumbed to the disease. Available data suggest triat
most of the Indians had acquired the infection mainly
through heterosexual promiscuity either in India or
abroad. One of them was the wife of an AIDS patient—
the first documented spouse-to-spouse transmission of
HIV infection in India.
•
Table V. Profile of seropositive individuals detected in India
Male
Female
Total
Heterosexually
promiscous
364
, 568
932
Homosexuals
2
—
2
386
15
401
Indians
Blood donors
(up to April. 1989 only)
2
0
2
Pregnant mothers
—
7
7
Recipients of blood/
blood products
40
4
44
Relatives of AIDS patients
9
13
22.
Suspected ARC/A IDS
patients
25
8
33
Others
88
18
106
916
633
1549
Students
50
11
61
Others
29
11
40
79
22
101
Total
Table VI. AIDS patients detected in India
Male
Female
Total
Indians
21
7
28
Foreigners
9
3
12
30
10
40
In India
Abroad
Heterosexual promiscuity
10
12
Blood transfusion
1
1
Blood products infusion
0
1
Homosexual contact
0
1
Spouse of an AIDS patient/sero
positive person
2
0
Total
Foreigners
sub total
The Union Ministry of Health, the DGHS and the
State Health Authorities have initiated .the necessary
steps to strengthen existing health care facilities, espe
cially the Department of Internal Medicine and Sexually
Transmitted Diseases Clinics, so that .adequate health
care for seropositive individuals and AIDS patients
could be provided in some major citieis in India.
(till October 31, 1989)
Patients on dialysis
sub total
Kenyan). To date none of the Indian patients have had
Kaposi's sarcoma.
995
655
1650
During 1988, five Indians with AIDS appeared to
have acquired the infection in India (two prostitutes, one
promiscuous man, a wife of of an AIDS patients, and a
transfusion recipient). By October 1989, eight more
AIDS patients among Indians who had never been
abroad have been reported. These included 3 prostitutes
(one who was detected to be seropositive since 1987), 4
promiscuous men, and wife of an asymptomatic promis
cuous man who was HIV seropositive (Table VI).
Almost all patients presented with weight loss,
fever, diarrhoea, repeated respiratory and skin infec
tions. Oropharyngeal candidiasis was detected in 32
patients; neurological/psychiatric manifestations includ
ing cryptococcal meningitis and encephalitis was noted
in 15 patients. Extensive disseminated tuberculosis was
seen in 2 patients. In one of these post mortem examina
tion revealed widely disseminated tuberculosis of the
lung, liver, spleen, kidney and lymphnodes. Kaposi's sancoma was seen in 2 foreigners (an American and a
Probable source of infection in Indians:
Screening of Blood Donors
HIV is the latest addition to the list of blood trans
fusion transmitted diseases. The very first patient of
AIDS reported from India was a person who had been
infected through multiple blood transfusions given dur
ing coronary bypass surgery in the USA. From the start
all surveillance centres have been screening blood
donors—especially professional donors for HIV anti
bodies. The first seropositive blood donor was detected
in July 1987 in Vellore. Intensification of serosurveillance amog blood donors especially in Tamil Nadu led to
the detection of four more seropositive donors in the
state by the end of 1987. During the first half of 1988
seropositive blood donors were detected in several towns
and cities in Maharashtra and Tamil Nadu. The AIDS
Task Force reviewed these findings in May 1988 and
recommended that all the centres may be advised to
intensify screening of donated blood and in some
121
selected centres screening of all blood donors may be
initiated. The Group also suggested that data so gener
ated may be reviewed by the end of 1988. Screening of all
blood donors was initiated in some institutions in Vel
lore, Madras, Pune, Bombay and Delhi in June 1988.
The IC MR Expert Group reviewed the data from serosurveillance among blood donors in November 1988 and
noted that there was a progressive increase in the seropo
sitivity rate among donors; though overall seropositivity
rate was still only 1.5/1000 (Table 11). The Group recom
mended that an attempt should be made to ensure safety
of blood used for transfusions in India by screening of all
donated blood for HIV antibodies. It was suggested that
the programme may start in major metropolitan cities
where large number of transfusions are given and later
may be expanded to cover the entire country in a phased
manner.
In December 1988, the DGHS in collaboration with
the ICMR and the State Health Authorities drew up the
action plan for blood donor screening for HIV anti
bodies. In the first phase, screening of donated blood
was to be initiated in the four major metropolitan cities
by linking all existent blood banks to selected centres
where facilities for detection of HIV antibodies were
available. The existing surveillance centres were
requested to assist in the blood donor screening pro
gramme in the cities in which they are located. The
action plan envisaged progressive expansion of the
screening centres in a phased manner over the next few
years so that all the donated blood in India is screened
for HIV antibodies (Table VII). In January 1989, the
nodal state government persons responsible for the
screening programme in Delhi, Bombay, Madras and
Calcutta were identified. They established specific lin
kages between screening centres and blood banks in the
city. The blood banks are required to send daily the sera
from blood donations to the testing centres. The centres
do the ELISA testing and inform the blood banks imme
diately if any sample is found ELISA positive. The blood
banks then take steps to ensure safe disposal of the
ELISA positive blood.
In order to ensure that the blood donor screening
programme starts without delay, the ICMR was
requested to assist the DGHS in the initial phase by use
of the established systems and network of HIV serosurveillance programme in (i) import of ELISA readers, kits
and other essential items for the programme; (ii) storage
and distribution of kits and readers to depot and screen
ing centres; and (iii) training of personnel in the screen
ing centres.
122
Table VII. Action plan for blood donor screening
Strategy:
LINK BLOOD BANKS TO HIV TESTING CENTRES.
Phase 1:
Metropolitan cities.
Phase II:
State capitals, cities with population of 1 million or
more.
Phase III: Cities with population of 0.5 million or more.
Responsibilities:
DGHS:
Drawing up phased programme, funding, supply of kits,
readers, quality control. monitoring and evaluation.
States:
Organise linkages, implement donor screening, quality
control. reporting on activities.
ICMR:
Technical help, training, review data, quality control,
look after reader and kit supply (until DGHS is geared
to take up the job).
Current Status (till October 31, 1989):
No. Screened:
2,17,428
ELISA positive: 2474
(
The surveillance and reference centres started
screening sera sent by blood banks from January 1989.
By April 1989 most of the centres have complied with the
request and so ICMR advised that the data on screening
of donated blood should be reported separately. Accord
ing to the reports received by the ICMR during the
period from April 1, 1989 to October 31, 1989, a total of
2,17,428 samples of donated blood have been screened;
of these 2474 were ELISA positive. Thus the programme
has substantially helped in ensuring the safety of trans
fused blood in the country.
The data from the blood donor screening pro
gramme, however, cannot be used for computing the
seropositivity rate among blood donors in the country
because of two reasons. The sera are screened by ELISA,
test and are not routinely subjected to confirmatory
Western Blot testing; some of the ELISA positives may
not be positive by Western Blot. Attempts to follow up
seropositive donors brought to light the fact that profes
sional donors, often donated blood several times within
three months in different blood banks, under different
names giving untraceable addresses and do not inform
the blood banks about their earlier donations. The data
from screening of blood thus pertains not to the number
of persons screened but the number of blood donations
screened. The ICMR is about to initiate a sentinel surveillance for HIV infection among blood donors which
will provide information on time trends in seropositivity
rate among blood donors.
In India it is estimated that about 1.5 million bottles
of blood are collected every year and the amount is
expected to increase. Organising screening of all these
samples of blood for HIV antibodies is a major and
expensive undertaking. Computations based on availa
ble global data suggested that only 4 per cent of HIV
transmission is due to blood/blood products infusion.
The question is, therefore, asked whether the effort, time
and money spent on donor screening is infact worth the
while? Blood donor screening is being taken up because
of the following reasons:
provide adequate counselling, health education and care
for these seropositive individuals. Even as early as 1986
the Government of India had made it mandatory that all
imported blood products should carry an AIDS-free cer
tificate. The DCI has subsequently issued necessary
guidelines to ensure that products manufactured in India
are free from HIV contamination. With these measures
and initiation of routine blood donor screening for HIV
antibodies in major cities in India it is expected that no
new case of blood/blood products transmitted HIV
infection will be encountered in future.
(i)
Blood/blood product infusion is one of the most
efficient means of transmission of HIV infection
(estimated transmission rales — blood transfusion:
90%. perinatal transmission: 30-50%: sexual trans
mission: 1 in 1000).
(ii)
Prevention of iatrogenic infection is an essential
ethical requirement.
In January 1989, one of the reference centres
delected HIV antibodies in a blood product (anti D
immunoglobulin) manufactured in India. The DCI
immediately ordered cessation of production of all indi
genously manufactured blood products. Instructions
were also issued to ensure that all blood products are
withdrawn from the market. At DCFs request, reference
centres and some of surveillance centres started testing
blood products for presence of HIV antibodies. Data
from these studies indicated that HIV antibodies were
present in some blood products. Some individuals who
had donated blood earlier for manufacture of blood pro
ducts were also tested and were found to be seropositive.
The DCI thereafter had issued necessary instructions to
ensure safety and availability of blood products (Table
VIII). At the request of the DGHS the surveillance/refer
ence centres screened persons who had received immutoglobulins during the last two years. Till June 1989 a
total of 503 individuals, who had received immunoglo
bulins were tested and none were found to be
seropositive.
(hi) Demonstration that the medical profession has put
in all its efforts to prevent this mode of transmis
sion, may stimulate all other segments of popula
tion to put in the necessary efforts to achieve HIV
containment and prevention of AIDS.
Alongwith screening of blood for HIV antibodies,
the Government of India is initiating steps to modernise
blood banking services in the country so that adequate
quantity of safe blood/blood products are available for
meeting the demand. Steps are also being taken to edu
cate the general public and professionals that transfusion
should only be done where absolutely needed.
Screening of Blood/Blood Products Recipients
Individuals such as thalassemic children and hae
mophiliacs receiving repeated blood transfusions and
blood products infusions have been recognised as a
group at risk of getting HIV infection through infected
blood or blood products. The second patient of AIDS
detected in India in 1986 was a haemophiliac who had
received Factor VIII infusion abroad. The surveillan
ce/reference centres have been screening such high risk
blood/blood products recipients. Several of these indi
viduals have also sought testing for HIV antibodies by
themselves. In fact, several had approached more than
one centre for testing without divulging their earlier test
results. Till October 31. 1989, the surveillance/reference
centres have reported that 44 blood/blood products
recipients were found to be seropositive. It is, however,
difficult to assess the seropositivity rate among blood
product recipients because of the problems in checking
and eliminating duplication in reporting. Testing centres
have taken all the steps to ensure confidentiality and to
Table VIII. HIV antibodies in blood products
January. 1989 :
Detection of HIV antibodies in anti D
immunoglobulin.
February. 1989 :
DCI stops production and withdraws all stocks
of blood products (BP).
DCI sends samples of products to reference'
surveillance centres for testing.
March. 1989 :
Centres report detection of antibody to HIV in
several samples.
Donors donating blood for BP found sero
positive.
April. 1989 :
DCI liberalises import of BP.
DCI issues guidelines for BP manufacture.
DGHS requests blood product recipients to
undergo HIV test.
April-June. 1989 :
503 recipients tested: None found seropositive.
123
MCH Problems in HIV Infection
Reports from the WHO indicate that about 1.5 mil
lion of the estimated 5 million HIV infected individuals
in the world are women. About 1 million of these women
live in Africa. It has been estimated that till now about
80,000 infants have been found to be infected at birth
and 40,000 of these will not live to see their second
birthday.
Available data from serosurveillance for HIV infec
tion in India show that heterosexual promiscuity is the
major mode of transmission of infection in India. In our
country contraceptive use is quite low and birth rate
continues to be high. It is, therefore, hardly surprising,
that right in 1986, pregnancies among seropositive
women were reported. The first pregnancy was detected
in a prostitute who was earlier detected to be seroposi
tive. The second pregnancy was detected during contact
tracing of a promiscuos seropositive man. Follow up of
these women and their offsprings had shown that some
of the infants were infected. The serosurveillance of
women attending antenatal clinics was initiated in 1986
and further strengthened and intensified in 1987.
Reported seropositivity rate among pregnant women
attending antenatal clinics is quite low (1 /1000 or lower).
Efforts are underway to initiate sentinel surveillance
among pregnant women attending antenatal clinics so
that data on time trends in seropositivity rate in these
women in different regions could be obtained and as and
when needed appropriate intervention programmes
could be initiated.
Though it is possible that HIV testing could be
undertaken in recognised high risk groups, it is impossi
ble to screen all pregnant women for HIV infection. So a
substantial proportion of seropositive pregnancies will
continue to remain undetected. Two major questions
confronting health care personnel under these circum
stances are: (i) the advice and care to be given to sero
positive women and (ii) whether there is a need to change
the current MCH care policies because of the advent of
HIV infection?
Pregnancies in seropositive women are a matter of
concern because there is a 30 to 50 per cent chance that
the infant born to a seropositive mother is infected at
birth; 50 per cent of infected infants will die of AIDS
before the age of two. It is therefore essential that as a
part of counselling and care, efforts are made to provide
adequte contraceptive care to all seropositive women.. if
pregnancy is detected early and the woman has com
pleted her family, medical termination of pregnancy with
concurrent contraception might be an appropriate
124
option. Pregnant seropositive women who want to con
tinue their pregnancies require adequte antenatal and
intrapartum care. Precautions need be taken to ensure
that accidental HIV infection does not occur during
antenatal or intrapartum care.
Transmission of HIV through breast milk is very
rare; breast feeding is essential for infant survival and
growth in developing countries like India; in an infected
infant, breast feeding may play a crucial role in prolong
ing the survival. It is therefore, essential to ensure that all
seropositive mothers breast feed their infants irrespective
of the HIV status of the infant.
During the first year of life it is difficult to find out
whether the infant is infected; because of transplacental
transfer of antibodies even uninfected infants are ELISA
and Western Blot positive. Persistence of antibodies
beyond the first year, demonstration of viral antigens.
virus isolation and development of clinical symptoms of
paediatrics AIDS are suggestive of HIV infection.
I
Available data suggest that the risks and known
consequences of natural infection in infants are likely to
be graver than the risks associated with vaccination even
with live attenuated vaccines. Taking all these factors
into consideration WHO has recommended that:
(i)
All asymptomatic HIV infected infants should
receive all standard vaccines — both live and
inactivated.
(ii) Those with symptoms of ARC/AIDS should not
receive BCG, but measels, OPV and all inactivated
vaccines should be given.
(in) Inactivated polio vaccine may be used as an alter
native to live vaccines in children with ARC/AIDS.
Advent of HIV infection in the community should ,
act as yet another stimulant to the efforts to provide
optimal MCH care. Providing appropriate contraceptive
care to all eligible women would substantially reduce
birth of infected infants. It is essential that all aseptic
precautions are meticulously adhered to during provi
sion of antenatal, intrapartum and contraceptive care so
that accidental HIV infection is prevented. Breast feed
ing is the best form of infant feeding and is to be encour
aged as the method of ensuring infant survival and
growth and birth spacing. Irrespective of the HIV infec
tion status (known or unknown) all apparently healthy
infants should continue to receive immunisation against
the six major vaccine preventable diseases. Thus, the
advent of HIV infection and the presence of undetected
HIV infected nreenant women and infants in the com
munity only serve to emphasise the need to provide opti
mum MCH care and does not in any way require major
modification in guidelines for provision of MCH
services.
Follow up of Seropositive Individuals
At present, there is very little information available
on the natural history of HIV infection in India. Efforts
are underway to follow up all seropositive individuals
systematically. Apart from clinical examination, virological and immunological studies are being planned and
carried out.
There have been reports that prevalence of tubercu
losis and gastrointestinal infections might be increased in
seropositive individuals. Investigations on prevalence of
these infections in seropositive individuals and seroposi
tivity rate in persons with these infections are underway
to determine the magnitude of the association, so that
appropriate intervention strategies could be initiated in
seropositive individuals.
There is an urgent need to document the clinical
course of HIV infection in India. Apparently the pattern
of infections in these immuno-compromised individuals
in India would include not only opportunistic infections
but also common pathogenic infections such as tubercu
losis and amocbiasis. Two centres had reported that sus
pected cases of AIDS—one with disseminated tuberculo
sis and other with amoebic liver abscess responded well
to standard chemotherapeutic regimens and gained
weight. They are currently asymptomatic and their
T4 T8 ratio has come back to near normalcy. If con
firmed in larger series the above findings may have
major relevance to the management of AIDS patients ip
India.
Available data suggest that there may be marked
differences in the type of opportunistic infections in
AIDS patients in developing countries. Efforts are
underway to build up facilities to investigate and docu
ment the pattern of opportunistic infections in seroposi
tive individuals, so that these infections could be
diagnosed and treated appropriately.
With the intensification of the serosurveillance
activity, increasing number of seropositive individuals
are being detected. Efforts are being made by all the
centres to follow up all seropositive persons, provide
them with essential health education and appropriate
health care. as and when needed. Because of the social
stigma associated with the disease and the lack of cura
tive therapy, all seropositive individuals require psycho
logical support and counselling. A centre for counselling
seropositive persons has been functioning in CMC, Vel
lore, for nearly two years, and has provided valuable
insights into the psychosocial problems of seropositive
individuals. Several surveillance centres have established
functional linkages with the psychologists/psychiatrists
in the medical colleges and have been providing the
necessary counselling for seropositive individuals.
Hospital Policies on Care of HIV Seropositive Persons
Although seropositive individuals may remain
asymptomatic for periods as long as ten years, most of
them may require health care during this period. There is
an urgent need to draw up hospital policies for care of
seropositive individuals. Humane sympathetic care of
seropositive individuals should be ensured without incur
ring any risk of accidental spread of HIV infection. A
beginning in this direction has been made by the All
India Institute of Medical Sciences (AU MS). New Delhi:
CMC, Vellore and Postgraduate institute of Medical
Education and Research. Chandigarh. The Council is
assisting the health services in evolving suitable national
guidelines for care of HIV infected persons in India.
These will have to be widely disseminated among health
service personnel and implemented through the health
care system.
Prevention of Accidental Infection
Ample data exist to indicate that HIV infection
could be transmitted through contaminated syringesand
needles. This factor is in fact, responsible for most of the
cases of HIV infection in intravenous drug addicts. In
India fortunately intravenous drug addiction does not
appear to be very common. Among a small number of
intravenous drug addicts screened, none were found to
be seropositive. However, there might be a risk of trans
mission of HIV infection due to improper sterilisation of
syringes and needles. Apart from medical and paramedi
cal persons, practitioners of various indigenous system
of medicine and even quacks are known to administer
parenteral injections. There is an urgent need, therefore
to educate the general public and all those who provide
parenteral therapy regarding the necessity of ensuring
proper sterilisation of syringes and needles to prevent
transmission of infections including HIV.
Three categories of HIV infected persons are likely
to seek health care. The smallest of these are persons
with symptoms suggestive of AIDS who need medical
aid. It is relatively easy to ensure that proper precautions
arc taken to prevent accidental spread of HIV infection
from individuals with clinical symptoms because they
are small in number and could be recognised readily.
125
The larger group consists of seropositive individuals who
are not suffering from AIDS but seek health care for
other ailments or prophylactic measures. If proper fol
low up care and counselling services are built in as an
integral part of the HIV antibody screening services, it
may not be difficult to ensure that the necessary precau
tions are taken while providing health care to this cate
gory of persons also.
Asymptomatic HIV infected persons who have
never been tested for HIV antibodies (and are conse
quently not aware that they are infected), with unrelated
health problems, are likely to form by far, the largest
group of infected persons seeking health care. To ensure
that accidental contamination does not occur from these
as yet unrecognised seropositive individuals, the entire
range of health service activities regarding asepsis, sterili
sation and disposal of soiled articles need be streamlined
and strengthened. It is essential that clear cut guidelines
are provided to medical, paramedical and laboratory
persons so as to ensure humane and sympathetic hand
ling of persons seeking health care and at the same time
preventing accidental spread of infection. The Council
continues to provide assistance to health services in
evolving guidelines suitable for Indian conditions, to pre
vent accidental infection.
HIV 2 Infection
Two types of HIV infections viz HIV 1 and HIV 2
have been described. There had been speculations
whether the asymptomatic period and severity of clinical
course might be different in HIV 2 infections. Specific*
kits for detection of HIV 2 infection became commer
cially available in 1988. Studies carried out in the refer
ence centres using the first lot of commercially available
kits showed that these kits lacked specificity and there
was a great deal of cross reactions with HIV 1. The
second lot which were tested in early 1989 were also not
satisfactory. Because of this, the question whether HIV 2
infection exists in India and if so, the magnitude of HIV 2
infection remains unanswered. During 1989 newer
HIV 2 kits and combined HIV 1 and HIV 2 kits have
been marketed. As soon as a sufficiently sensitive and
specific kit becomes available, surveillance for HIV2
infection will be taken up.
Surveillance for Hepatitis B Infection
The ICMR Task Force on AIDS had recommended
that as and when possible, serosurveillance of some com
mon infections like hepatitis B and syphilis should be
carried out along with the ongoing serosurveillance for
HIV infections. The surveillance centres were encour
126
aged to screen the sera for hepatitis B using whatever kit
they were currently using for detection of HBsAg in the
centres. In addition, the Council provided HBsAg
ELISA kits to four of the five reference centres to screen
a panel of 1500 sera from high risk groups. Preliminary
results from CMC, Vellore, indicate that HBsAg is
present in about 3 per cent of voluntary blood donor and
10 per cent of promiscous men and women. Prevalance
of HIV antibodies in these groups was 1.5/1000 and
4/1000 respectively. It is expected that the study will
provide some useful preliminary data on -prevalence of
HIV and HBV infection in different groups in different
regions of India. If funds are made available for
procuring sensitive specific kits for H BsAg detection and
for serological diagnosis of sexually transmitted
diseases, the sera collected during the proposed sentinel
surveillance for HIV infection could be tested for some
of the STD and hepatitis B infection. The study would
provide valuable regional, group-wise data on preva- A
lence of these infections, based on which effective *
specific intervention strategies could be devised and
implemented.
Evaluation of Immunodiagnostic Kits
It is expected that the serosurveillance programme
will continue to expand. There is a felt need for HIV
screening as a part of the service programme in blood
banks and antenatal clinics. There might also be increase
in demands for diagnostic HIV tests for suspected
ARC/AIDS patients. The prohibitive cost of the testing
is one of the major constraints that limit wider
availability and use of HIV diagnostic tests. During the
last two years, several newer immunodiagnostic tests
have been developed, some of which are reported to be
more sensitive and specific. Some of the newer tests are
visual assays and do not require an ELISA reader. The
newer kits are periodically evaluated by the reference
centres, so that a test that is most suitable and
economical under existing conditions in India could be
chosen for use in the serosurveillance network.
In view of the increasing demand for HIV screening
in India, there is an urgent need to explore feasibility of
bringing down the cost of kits by indigenous
manufacture. At the request of the Ministry of Health
and Family Welfare and the Department of Biotechnology (DBT), the ICMR had undertaken evaluation of
some of the commercially available immunodiagnostic
tests for HIV antibody detection, with the objective of
selecting the suitable kit kits for indigenous production.
The reference centres completed the evaluation of nine
kits chosen for evaluation by DBT in June 1989. Of
0))
these, 3 were found to be suitable on the basis of sensiti
vity and specificity. Neither of the two visual assays tested
were sensitive and specific enough for use in screening
programmes. The results of the evaluation have been
communicated to DBT; it is expected that DBT will
soon be initiating the necessary steps regarding manufac
ture of kits in India.
Virus Isolation
Facilities for isolation of HIV from seropositive
individuals and AIDS patients are being created in the
reference centres for AIDS. Personnel from these
laboratories have been sent abroad for training. The
necessary kits, chemicals, glass-ware and equipments
have been imported and supplied to 3 of the reference
centres. ICMR has provided grants for setting up a P3
facility at the All MS, New Delhi. P2 facilities are
available at the NIV, Pune and the CMC, Vellore.
Two of the reference centres viz All MS, New Delhi
and NIV, Pune have reported successful isolation of
HIV from seropositive individuals and AIDS patients.
This is the first step towards characterisation of the
causative organism. During the last two years,
researchers abroad have reported marked variations in
antigens of the envelope protein of HIV isolated from
different persons and from different regions. Antigenic
variations in envelope protein may pose problems in
terms of effective vaccine development and use against
HIV. Establishment of facilities for undertaking virus
isolation and characterisation of virus in India is an
important step in this context.
Infrastructure and Manpower Development
A phased inservice training programme for
scientists in the field of virology, immunology and
epidemiology of HIV infection and training of health
services personnel in the care of seropositive individuals
and AIDS patients is being carried out. Linkages are
being established between surveillance, research and
health service infrastructures, so that optimal use of
available expertise and facilities for management of
seropositive individuals could be built up.
It is now well recognised that seropositive indivi
duals encounter legal, social as well as economic prob
lems. HIV infection may thus have a profound impact
on demographic and economic profiles especially in
developing countries. Close interagency linkages and
collaboration are being sought and maintained by the
health services, in order to evolve effective methods to
combat the multi-dimentional problems associated with
HIV infection.
Health Education
Health education plays a crucial role in the control
and containment of HIV infection. Medical and
paramedical personnel need to be provided with clear
guidelines dealing with these aspects so that they give
correct information to all seropositive individuals. The
high risk groups need to be provided with information
about the risk involved in their life style and methods of
prevention of HIV infection.
An intensive programme of education of the public
about HIV infection will have to be initiated, using all
available modes of communication. Selection of appro
priate messages and appropriate media for reaching the
target audiences need to be investigated and defined.
ICMR is providing the necessary technical inputs for
various agencies involved in this exercise of preparation
of health education material for dissemination.
There had so far been very few attempts to assess
the impact of the ongoing health education programme
on HIV infection. CMC, Vellore carried out a pilot
survey among persons attending the medical OPD
(MOPD), STD clinic and prostitutes coming to hospital
for various ailments in 1988. The survey showed that
over 58 per cent of persons attending MOPD; 76 per
cent of those attending STD clinic; and 90 per cent of
prostitutes have not heard of AIDS. Most of these
patients are from the low income group and are illiterate.
It would appear that the current health education
campaign through the mass media has not yet reached
the vulnerable but illiterate segments of population.
There is an urgent need to explore alternative strategies
for dissemination of vital health education messages for
AIDS control, so that the amenable segments of high
risk groups take necessary precautions to limit the
spread of infection. Since heatlh education plays the
crucial role in AIDS control, it is important that
adequate organised and sustained support for health
education is provided as a part of the national AIDS
control programme. At the same time, it is essential to
ensure that fear and psychosis about AIDS does not
occur and prevent people from seeking timely screening
and medical aid.
Efforts should be made to highlight benefits to
individuals belonging to high risk groups from seeking
screening for HIV antibodies. These include information
about (i) the chances of being found seropositive are less
than 1 in 100 even in promiscuous men and women; if
found seronegative, they could avoid future exposure to
HIV infection; (ii)if found seropositive, care in
127
prevention and prompt treatment of common infection
could result in symptom free life upto a decade.
Sentinel Surveillance for HIV Infection
Global data on epidemiology of HIV infection show
that following the early phase when seropositivity rates
are low and very few AIDS patients are reported, a steep
increase in the infection rate occurs; subsequently after a
variable period the steepness of the slope of the epidemic
curve undergoes a reduction until a plateau is reached.
The steepness of the slope of the epidemic curve and the
rapidity with which the plateau is achieved, determine
the load of infection in the community and these data
give an indication about the number of AIDS patients
who are likely to require health care in any given period.
Since HIV infection persists lifelong, two major factors
that determine the shape of the epidemic curve are the
number of vulnerable uninfected individuals in the
community and the impact of prophylactic measures
adopted to contain the spread of infection.
In India, available data from clinical and
serosurveillance indicate that the country is still in the
early phase of the HIV epidemic. The first three phases
of serosurveillance for HIV infection were aimed to
obtain information on prevalence of the disease in some
definded population groups and identify the major mode
of transmission of infection; these have been achieved.
These studies have also shown that prevalence of HIV
infection varies in different groups and different regions
and also changes over time. In data collection during the
first three phases, there were substantial differences in
number of persons screened in different centres and also
the type of individuals screened at different time points
in the same centre; it is difficult to use the data so far
obtained to compute time trends or estimate regional
differences.
There is, therefore, an urgent need to organise
systematic epidemiological studies to define time trends
in prevalence of HIV infection among some well defined
groups in different regions of the country. ICMR has
drawn up a protocol for such a study and it is expected
that the sentinel surveillance activity would begin
shortly. This study is expected to generate data that will
help in evolving timely intervention strategies for control
of HIV infection and also provide valuable tools for
impact assessment of specific intervention programmes.
Future Research Plans
Results from the ongoing clinical and serosurveillance
studies have clearly demonstrated that HIV infection has
128
gained a foot hold in India. The council has initiated
studies on a wide range of problems associated with HIV
infection. It is also proposed to establish a multi
disciplinary Institute for Research in AIDS with the
following objectives:-
(i)
To coordinate the serosurveillance and epidemio
logical studies already initiated by the Council;
(ii) To carry out virological, immunological and
clinical studies in the entire- spectrum of HIV
infection ranging from asymptomatic HIV infection
to terminal AIDS, so that natural history of the
disease in India will be documented;
(iii) To provide a model centre for care of .HIV infected
persons and to train clinicians in management of
HIV infection;
(iv) To undertake clinical trials of chemotherapeutic,
immunotherapeutic and immunoprophylactic drugs g
as and when they become available; and
(v)
To provide technical information and support for
preparation of health education material so that an
intensive health education campaign to control
HIV infection could be undertaken using all
available channels of communication.
Studies that will be carried out by the proposed
Institute are expected to provide vital leads for mounting
appropriate intervention programmes aimed at contain
ment and control of HIV infection in India.
Summary
India has the distinction of having conducted a
systematic nation wide serosurveillance for HIV
infection from 1986 for defining epidemiology of HIV
infection at a very early stage of the epidemic when only
a few patients of AIDS has been reported. Within a
short span of 24 months the serosurveillance data
showed that the magnitude of infection even in the high
risk groups was low (4.5 per 1000); heterosexual promis
cuity was the major mode of transmission of infection in
India. The data from these studies provided the rational
basis for formulating the national medium term plan for
AIDS control. Detection of seropositives among blood
donors led to the timely initiation of blood donor
screening to ensure safety of transfused blood. The data
also provided the technical information needed for
designing appropriate health education material for
AIDS control among high risk and vulnerable groups. It
is expected that the sentinel surveillance to be initiated
shortly will assist in monitoring time trends in HIV
01
infection and help in timely initiation of appropriate
intervention strategies.
It is noteworthy that all along, the AIDS
programme is being carried out through the existing
health infrastructure, essential inputs were added
wherever necessary. It is expected that the trained and
sensitized medical and paramedical personnel in the sur
veillance centres will be able to take care of increasing
need for serodiagnosis and also act as nodal training and
quality control centres in the respective states. The
sensitised and strengthened clinical departments especi
ally of Internal Medicine and STD clinics will take up
responsibility of counselling, care, and follow up of
seropositive individuals including AIDS patients.
Organisation of the national AIDS control
programme has posed a formidable challenge to the
health care delivery systems even in developed countries.
Problems in screening and identifying seropositive
individuals, difficulties in persuading high risk groups to
change their life styles, absense of specific therapy and
high cost of therapeutic measures to prolong survival are
some of the difficult issues that confront the health
planners and policy makers. Mounting an AIDS control
programme in developing country is a daunting task.
However, the last three years have shown that India has
the potential and capability of meeting the challenge and
raise the hope that our country will be able to contain
and control HIV infection.
ICMR NEWS
The annual Review Meeting of the National Cancer
Registry Project was held at All MS, New Delhi
(November 15-18, 1989).
Honours/A wards
Dr. A.S. Paintai, Director-General, ICMR, was presented
a Fellowship Scroll by USSR Academy of Sciences, at New
Delhi (November 16, 1989).
Dr. Mahtab, S. Bamji, Director Grade Scientist,
National Institute of Nutrition (NIN), Hyderabad, has
been elected Fellow of the Indian National Science
Academy.
***
Participation of ICMR Scientists in Scientific Events:
International Vitamin A Consultative Group, at Kath
mandu (November 5-10, 1989).
Dr. S.P. Tripathi, Addl. Director-General, ICMR,
participated in the Indo-EEC Symposium on Leprosy
and Mycobacterial Infections, at Lonavala, Maharashtra
(November 6-9, 1989).
Dr. P.K. Rajagopalan, Director, Vector Control
Research Centre, Pondicherry, participated in the
meeting of the WHO Expert Committee on Malaria, at
Geneva (November 6-14, 1989).
Dr. A.S. Paintai participated in the World Congress
of Pulmonary and Critical Care Medicine and presented
papers on (i) Significance of Dry Coughs, Breathlessness,
and Muscle Weakness—Present Status; and (ii) Lung
Affarents, at Bombay (November 12-15, 1989). Dr. S.P.
Tripathi also presented a paper on Recent Advances in
the Treatment of Tuberculosis at this Congress.
Dr. B.N. Saxena, Sr. Deputy Director-General,
ICMR, participated in the International Medical
Advisory Panel (IMAP) meeting of the International
Planned Parenthood Federation, at Ottawa (November
1-7, 1989). Dr. Saxena also participated in the meeting of
the Committee for the Study of Ethical Aspects of
Human Reproduction, at Athens (November 13-14,
1989).
Dr. Paintai delivered a talk on Some Issues Involved
in International Cooperation in Science & Technology, at
the International Seminar on S&T for National
Development, International and Regional Cooperation,
at New Delhi (November 14-16, 1989).
Dr. Leela Raman, Deputy Director, NIN, Hyderabad,
participated as a Guest Counselor in the meeting of the Council
of Scientific Advisors of the Children’s Nutrition Research
Centre, at Houston (November 1-3, 1989).
Dr. Tripathi delivered a lecture on AIDS, at the
International Union of Immunological Society (IUIS)—
WHO Advanced Immunology Course, at New Delhi
(November 20, 1989).
Dr. Vinodini Reddy, Director as also Dr. K.
Vijayaraghavan and Dr. P. Bhaskaram, Asstt. Directors,
NIN, Hyderabad, participated in the XIII Meeting of the
Dr. V.P. Sharma, Director and Dr. Aruna
Srivastava, Research Officer, Malaria Research Centre,
Delhi, visited USSR for two weeks under Indo-USSR
129
Agreement in the Field of Medical and Public Health
(November 12-25, 1989).
Dr. Usha K. Luthra, Addl. Director-General,
ICMR, gave a lecture on Control of Oral Cancer—A
National Priority, at the International Congress on Oral
Cancer, at New Delhi (November 13, 1989).
Dr. S.K. Kashyap, Director, National Institute of
Occupational Health, Ahmedabad, participated in the
International Conference on Total Human Exposure
Monitoring and Assessment, at Las Vegas, USA
(November 27 to December 1, 1989).
Dr. Prema Ramachandran, Deputy Director-General,
ICMR, participated in the WHO Consultative Group
meeting to Review Technical and Managerial Guidelines
on Maternal and Child Health and AIDS Prevention, at
Geneva (November 20-22, 1989). She also participated in
the International Conference on Implications of AIDS
for Mother and Children, at Paris (November 25-30,
1989).
***
ICMR Headquarters and the Council’s Malaria
Research Centre at Delhi, participated in a Science &
Technology Exhibition, at Allahabad,between November
11 and 19, 1989 organized to commemorate the 40th
Anniversary of India’s Independence and the Birth
Centenary of Pandit Jawaharlal Nehru.
ICMR AIDED SYMPOSIA/SEMINARS/WORKSHOPS/COURSES/CONFERENCES
Symposium/Seminar/Workshop/
Course/ Conference
Date & Place
Contact Address
Brachytherapy Workshop for Cancer Cervix.
November, 1989;
Betul (M.P.)
Dr. Anand Vijay Kumar, Secretary, Paramedical
Section, Christian Medical Association of india,
Smruti Theatre Compound, Nagpur.
National Workshop on Advances in Flexible
Fiberoptic Bronchoscopy.
November 4-5, 1989;
Chandigarh
Dr. S.K. Jindal, Department of Chest Diseases,
Postgraduate Institute of Medical Education and
Research, Chandigarh.
All India Symposium on Biophysics of Cell
Structure and Function.
November 6-8, 1989;
Chandigarh.
Dr. P.C. Mangai, Chairman, Department of BioPhysics, Punjab University, Chandigarh.
International Symposium on Levels of Aware
ness and Conscious Experiences.
November 6-9, 1989;
Visakhapatnam
Prof. P.V. Krishna Rao, Director, Institute for Yoga
& Consciousness, Andhra University, Vijayanagram
Palace, Visakhapatnam.
Seminar on Zoonoses.
November 9-10, 1989;
Dibrugarh
Dr. L.P. Datta, Director, Regional Medical Research
Centre (ICMR), P.B. No. 105, Dibrugarh.
National Symposium on Social and Legal As
pects for AIDS Prevention and Control.
November 9-11, 1989;
New Delhi
Dr. T.R.C. Sinha, General Secretary, National En
vironmental Sciences Academy, Bettiah.
XVI Biennial Conference of the Indian Asso
ciation of Leprologists.
November 9-12, 1989;
Trichur
Dr. P. Vijay Shanker, Damien Institute, Ayyappankavu, Trichur.
Seminar on Pathology of Cardiomyopathies.
November 11, 1989;
Bhubaneswar
Professor L.N. Mohapatra, Convenor, Indian Asso
ciation of Pathologists and Microbiologists (Orissa
Chapter) and Director, Regional Medical Research
Centre (ICMR), Bhubaneswar.
Seminar on Modern Biology: Genetic Re
combination.
November 19-26, 1989;
Mahabaleshwar
Dr. John Barnabas, Scientist (Director's Grade).
National Chemical Laboratory, Pune.
Conference on Health Care for the Villagers
and Urban Slums.
November 23-25, 1989;
Calcutta
Dr. Ashok Sahani, Professor & Hony. Executive
Director, Indian Society of Health Administrators,
104 (13/37), Cambridge Road Cross, Ulsoor,
Bangalore.
National Seminar on Squint and Amblyopia.
November 25-27, 1989;
New Delhi
Dr. Vimla Menon, Dr. Rajendra Prasad Centre for
Ophthalmic Sciences, All India Institute of Medical
Sciences, New Delhi.
130
Symposium/Seminar/ Workshop/
Course/ Conference
Contact Address
Date & Place
All India. Symposium on Reproductive Bio
logy and General Endocrinology.
November 26-28, 1989;
Baroda
Prof. P.M. Ambedkar, Department of Zoology,
M.S. University of Baroda, Baroda.
Workshop on Recent Advances in Intensive
Care.
November 26-30, 1989;
New Delhi
Dr. H.K. Kaul, Professor & Head, Department of
Anaesthesiology. All India Institute of Medical
Sciences, new Delhi.
International Conference on Structure and
Functions of Biomembranes.
November 28-December 2,1989;
Calcutta
Dr. Parul Chakrabarti, Convenor, Bose Institute,
93/1, APC Road,.Calcutta.
Seminar on Biochemistry and Modern Bio
logy.
December 4-14, 1989;
Lakshadweep
Prof. S.P. Modak, Convenor/Guha Research Con
ference, Department of Zoology, University of
Poona, Pune.
Workshop on Paediatric Urological Re
constructive Surgery.
December 23-25, 1989;
Chandigarh
Dr. S.K. Mitra, Professor & Head, Department of
Paediatric Surgery, Postgraduate Institute of Medi
cal Education and Research, Chandigarh.
Symposia on Cytogenetics; Plant Cell Bio
logy; Mammalian Systems; and Microbial
Systems, and Annual Meeting of the Indian
Society of Cell Biology.
December 27-29, 1989;
Hyderabad
Dr. M.R. Das, Deputy Director, Centre for Cellular
and Molecular Biology, Hyderabad.
XXXIII All India Obstetric and Gynaecologi
cal Congress.
December 28-30, 1989;
Patna
Dr. J. Mishra, Department of Obstetrics and Gynae
cology. Hospital for Women. Patna Medical College.
Patna.
Symposium on Current Advances in Mole
cular Biochemistry: Applications in Health,
Environment, and Agriculture.
December 28-31, 1989;
Lucknow
Dr. G.G. Sanwal, Professor and Head, Department
of Biochemistry, Lucknow University, Lucknow.
Ill International Congress on Traditional
Asian Medicine.
January 4-7, 1990;
Bombay
Dri« K.M. Parikh, Chairman, Organising Committee,
III International Congress on Traditional Asian
Medicine, C/o Zandu Pharmaceutical Works Ltd.,
Dadar, Bombay.
Seminar on Indian Speech, Language and
Hearing Tests—the proposed IS HA battery.
February 8-9, 1990;
New Delhi
Dr. S.K. Kacker, Professor & Head, Department of
Otorhinolaryngology, All India Institute of Medical
Sciences, New Delhi.
National Symposium on Application of Re
combinant DNA Technology in Disease
Diagnosis.
March 23-25, 1989;
Hyderabad
Prof. P.P. Reddy, Director, Institute of Genetics
and Hospital for Genetic Diseases, Osmania Univer
sity, Hyderabad.
COUNCIL’S TRAINING PROGRAMMES
Nutrition
At the National Institute of Nutrition, Hyderabad:
Annual Certificate Course in Nutrition (December
1, 1989 to February 28, 1990).
Occupational Health
At the National Institute of Occupational Health,
Ahmedabad:
Training Course on Disaster Management of
Hazarduous Chemicals in Industry for Industrial
Physicians, Chemists, Safety Officers, Hygienists
(November 6-10, 1989).
Laboratory Animal Technology
At the Laboratory Animal Information Service Centre,
National Institute of Nutrition, Hyderabad:
Training Course for Laboratory Animal Super
visors (September 1 to November 30, 1989).
SOME AVAILABLE ICMR PUBLICATIONS
Price
Rs.
Growth & Physical Development of Indian Infants and Children (1972), Reprinted 1989
10.00
Studies on Weaning & Supplementary Foods (1974), Reprinted 1984
6.00
Studies on Pre-School Children (1974), Reprinted 1984
6.00
A Manual of Nutrition (1973), Second Edition 1974, Reprinted 1984
2.50
Lqw Cost Nutritious Supplements (1972), Second Edition 1975, Reprinted 1977
1.50
Menus for Low Cost Balanced Diets and School Lunch Programmes Suitable for South India
(1959), Third Edition 1977, Reprinted 1984
2.00
Menus for Low Cost Balanced Diets and School Lunch Programmes Suitable for North India
(1959), Third Edition 1977, Reprinted 1984
2.00
Some Common Indian Recipes and their Nutritive Value (1964), Fourth Edition 1977,
Reprinted 1984, by Swaran Pasricha and L.M. Rebello
6.00
Nutrition for Mother & Child (1962), Third Edition 1978, Reprinted 1983, by P.S. Venkatachalam
and L.M. Rebello
5.00
Japanese Encephalitis in India (Revised Edition 1980)
5.00
Some Therapeutic Diets (1969), Fourth Edition 1981, Reprinted 1983, Revised 1988,
by Swaran Pasricha
2.00
Recommended Dietary Intakes for Indians (1981), Reprinted 1984
4.60
Lathyrism: A Preventable Paralysis (Revised Edition 1983)
1.50
A Manual of Laboratory Techniques (1983), Edited by N. Raghuramulu, K. Madhavan Nair
and S. Kalyanasundaram
30.00
Fruits (1983), by Indira Gopalan and M. Mohan Ram
2.50
Count What You Eat (1989), by Swaran Pasricha
4.50
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
Unpriced Publications
(for limited distribution)
Collaborative Study on Short-term Sequelae of Induced Abortion (1981)
Proceedings of the Indo-UK Workshop on-Leishmaniasis. (1983)
Peoples of India—Some Genetic Aspects (1983)
Management of Acute Diarrhoea (1985)
Plague Conquest and Eradication in India (1987) by S.C. Seal
Laboratory Manual for the Diagnosis of Haemophiloid Disorders (1989),
by Manorama Bhargava and Dinesh Jain
These publications are available on prepayment of cost by cheque or postal order (bank and postal charges will be extra) drawn 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.4508, Ansari Nagar,
New Delhi-110029.
132
INDIAN COUNCIL OF MEDICAL RESEARCH
International Research Fellowships of National Institutes of Health(USA)
Applications (on prescribed form) are invited from candidates for award of
International Research Fellowships of the National Institutes of Health, USA for specialised
training in that country.
ELIGIBILITY REQUIREMENTS
To be eligible for an International Research Fellowship, an applicant must:
1.
hold an earned doctoral degree (PhD, MD, DO, DDS, DVM, OD, DPM, SeD, EngD,
Dr PH. or DNS) or the equivalent in a health science field at the time of submission of
an application to the Nominating Committee;
2.
have earned the doctoral degree within 10 years of the application receipt date (should
have received their doctoral degree on August 1, 1980 or thereafter);
3.
have demonstrated the ability to engage in independent basic or clinical research;
4.
submit a research proposal in an area of one of the biomedical or behavioural sciences;
5.
have a sponsor in the United States at a nonprofit institution who has agreed to accept
the applicant for research on the applicant’s proposed project;
6.
have assurance from a nonprofit institution in the home country that there is a position
to which the applicant can return after completion of the fellowship;
7.
be proficient in spoken and written English;
8.
should not have been in the United States on J-1 visa for more than two months if they
apply for a two year fellowship or for more than 14 months if they apply for a one year
fellowship;
9.
not be a US citizen or a permanent US resident.
Application forms and details of the. fellowship can be obtained before February 20,
1990 from the Director-General, Indian Council of Medical Research (Room No.406), Post
Box No.4508, Ansari Nagar, New Delhi 110029. The last date for receipt of completed
application form by ICMR is March 5, 1990. Application forms received after the closing
date will not be considered.
133
ANNOUNCEMENT
IC MR has set up an External Quality Assurance Facility for scientific
investigators working in the area of Reproduction Biology as regards FSH, LH,
Prolactin, Estradiol, Progesterone and Testosterone. Those who are desirous of
availing this facility may contact Dr. S.R. Mokkapati, Senior Research Officer,
ICMR, Ansari Nagar, New Delhi-110029/Prof. D.K. Hazra, Incharge, EQA
Scheme, Nuclear Medicine & RIA Unit, Postgraduate Department of Medicine,
S.N. Medical College, Agra.
EDITORIAL BOARD
Chairman
Dr. A.S. Paintal
Director-General
Chief, Publications
Dr. G.V. Satyavati
Members
Dr. Usha K. Luthra
Dr. Badri N. Saxena
Dr. S.P. Tripathy
Editor
Dr. N. Medappa
Printed and Published by Shri G.P. Kulshreshth for the Indian Council of Medical Research New Delhi
at the ICMR Offset Press, New Delhi
R.N. 21813/71
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