ICMR BULLETIN VOL. 29-No.-10 & 11-OCTOBER-NOVEMBER-1999.pdf

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ISSN 0377-4910

Vol. 29, No. 10 & 11

October-November, 1999

MULTI DRUG RESISTANT TUBERCULOSIS
Tuberculosis (TB) was declared a global emergency
by the World Health Organisation (WHO) on World TB
■ Day in 1993. This unprecedented declaration was prompted
predominantly by two developments; the resurgence of
TB in the west from the mid 80s, where the disease had
been showing a steady decline from the beginning of the
century1; and a number of outbreaks of multi drug resis­
tant tuberculosis (MDRTB) in the USA and in many other
parts of the world, in the late 1980s and early 1990s. For
much of the developing world, which bears the brunt of
the global TB burden, this declaration by the WHO served
the useful purpose of helping to focus attention on a much
A neglected disease and has helped to draw resources that
were sorely needed.
Multi drug resistant tuberculosis has been a topic of
growing importance in the last decade. It has figured
prominently both in the medical literature and in the lay
press causing great alarm all over the world. It has been
described as the third epidemic, complicating the epi­
demics of human immunodeficiency virus (HIV) and the
reemergence of TB in the West2. The alarm bells were
set ringing by a series of outbreaks of MDRTB in hos­
pitals, prisons and shelters for homeless persons in and
around New York in the early 90s. A majority of the
affected patients were HIV infected and the mortality
was extremely high. Some patients were resistant to six
or seven drugs3'7.

A review by WHO of a series of 63 surveys of drug
resistant TB carried out world-wide between 1985 and
1994 led to the conclusion that the new epidemic may be
global8.. Rates of primary resistance to isoniazid ranged
from 0-17%; to streptomycin, 0-24%; to rifampicin, 0-3%;
and to ethambutol, 0-4%. The rates of acquired resistance
were isoniazid, 4-54%; streptomycin, 0-19%; rifampicin
0-15%; and ethambutol, 0-14%. The highest rates of
MQRTB were from Nepal (48%), Gujarat state (India)
(34%), New York city (USA) (30%), Bolivia (15%) and
South Korea (15%). The WHO and the International Union
Against Tuberculosis and Lung Disease (IUATLD) have
subsequently established a global project of drug resistance
surveillance that is based on standard epidemiological
methods and quality control through an extensive network
of reference laboratories in 35 countries, including India,
during 1994 to 19979. The prevalence of primary multi
drug resistance was 1.4%. Among patients with histories
of treatment for one month or more, the prevalence of
resistance to any of the four first line drugs was 36%,
and the prevalence of multi drug resistance was 13%.
Particularly high prevalence of multi drug resistance was
found in the former Soviet Union, Asia, the Dominican
Republic, and Argentina. The report concludes that
resistance toahti-TB drugs was found in all 35 countries
and regions surveyed, suggesting again that this iso global
problem.

Division of Publication & information, ICMR, New Delhi - 110029

Drug resistance in TB is not a new phenomenon. It
was recognized very soon after the introduction of
effective anti-TB drugs that Mycobacterium tuberculosis
can rapidly become resistant to the drugs used against
it. Resistance to isoniazid and streptomycin was
demonstrated in M. tuberculosis strains from patients
treated in the early years of chemotherapy,0*11. Resistance
could develop to a single drug or to multiple drugs..
However, the definition of multi drug resistance has
undergone a change in perception over the years. In the
pre-rifampicin era the term multi drug resistant
tuberculosis meant disease caused by organisms that
were resistant to at least two of the first line anti-TB
drugs then available, usually to isoniazid and
streptomycin. Today, the term is used to signify disease
due to M. tuberculosis that is resistant to the two most
effective.current anti-TB drugs, isoniazid and rifampicin,
with or without resistance to other drugs’2. The difference
in perception arose because, while previously isoniazid
and streptomycin resistant tuberculosis could still be
effectively treated with the then available drugs,especially
with rifampicin and ethambutol, the outcome of treatment
of isoniazid and rifampicin resistant tuberculosis is not
so favourable.
Types of Drug Resistance

Drug resistance in tuberculosis may be broadly
classified as primary or acquired. When drug resistance
is demonstrated in a pdtient who has not received any
anti-TB treatment in the past, it is termed as primary
resistance. Acquired resistance is that which occurs in a
patient who has received previous treatment. The term
initial resistance is used when one is not sure whether
the resistance is primary or acquired. This is a common
occurrence because TB patients often conceal the history
of previous treatment and sometimes patients are unaware
that they have received any treatment at all. Transient
drug resistance occurs in a patient who is responding to
therapy just before sputum conversion, and usually occurs
in the form of a few colonies, and does not warrant change
of treatment. The level of primary resistance in a
community is considered to reflect the quality ofthe control
measures for tuberculosis in the past, while the level of
acquired resistance is a measure of ongoing TB control
measures13. A study carried out in South Korea illustrates
this point. It showed a decline in primary drug resistance
from 48% in 1980 to 2% in 1990 through improved
programme efficiency. Initial drug resistance decreased
at a lower rate, from 26% in 1965 to 15% in 199014.

106

Causes of Drug Resistance

Drug resistance in tuberculosis may result from the
actions of the physician or the patient. A physician may
contribute to the development of drug resis^nce by the
prescription of an inadequate regimen which may be in
the form of (i) an inappropriate combination of drugs;
(ii) drugs for insufficient duration; and (iii) inadequate
dosage of the drugs.

However, the commonest cause of acquired drug
resistance, is non-adherence to the prescribed therapy
by the patient. In this respect, a patient who takes the
prescribed therapy regularly for sometimes and stops
prematurely is less likely to develop drug resistance
compared to a patient who takes drugs irregularly over
a prolonged period. It is the experience of scientists at
the Tuberculosis Research Centre (TRC), Chennai that
most patients who relapse with tuberculosis after a com­
plete course of treatment for the disease are likely to have
sensitive organisms during their relapse15,16 and can be
retreated with the same regimen that the patient had
responded to earlier.
J
Prevalence of Drug Resistant Tuberculosis in India

To have a clear picture of the situation in India it
would be necessary to have epidemiological data cover­
ing all parts of the country over a period of time. How­
ever, this information is not available as it requires re­
peated surveys covering large populations, which is very
expensive and logistically difficult. The data that are
available are localised and from different places and cannot
be compared because of differences in laboratory tech­
niques, criteria for definition of drug resistance and patient
selection. Some of the more reliable data will be reviewed
here.
(i) The Indian Council of Medical Research (ICMR)
conducted drug resistance studies in 1965 to 1967
in 9 cities in different geographical parts of the country.
These were not surveys and did not use statistical
techniques for sampling. The centres were selected
more for logistic considerations than for
epidemiological reasons to represent all parts of the
country. Sputums from patients attending chest
clinics in these nine cities were airlifted to the central
laboratory located at the Tuberculosis Chemotherapy
Centre, Madras (now the TRC, Chennai) where culture
and drug susceptibility tests were carried out. The
first study was on newly diagnosed pulmonary
tuberculosis patients who had not received any

previous treatment, and the second study was on all
patients, new and old. The first study showed that
the level of .primary drug resistance ranged from
11-20% for isoniazid, 8-20% for streptomycin and
4-11% for both drugs17. Overall, 20% of patients had
resistance to one or more drugs ranging from 14-29%
in the nine centres. The second study which reflected
initial drug resistance, showed that 15-69% of patients
exhibited isoniazid resistance, 12-63% streptomycin
resistance and 5-58% double drug resistance18. Overall,
32% had resistance to one or more drugs ranging from
2£-74%. This meant that one ofthree patients attending
a chest clinic was likely to harbour drug resistant
bacilli. The second study also showed that the level
of initial resistance was directly proportional to the
duration of previous treatment, increasing from 22%
in those who had not received any previous treatment
to 76% in those who had previous treatment for more
than 12 months. The wide range in the level of initial
drug resistance between the different centres was due
to the different proportions of patients with previous
treatment for different duration.
(ii) The TRC, Chennai has been conducting controlled
clinical trials in chemotherapy of tuberculosis since
1956. Patients are admitted to these trials on the basis
of positive sputum cultures for ^.tuberculosis. Drug
susceptibility tests are also done on all positive cultures.
Hence drug resistance data are available over a 40 year
period (1956 to 1997) in patients admitted to the clinical
trials. In newly diagnosed patients without prior
treatment, resistance to isoniazid rose from 5 to 13%,
to streptomycin from 3 to 12% and to both drugs from
1-6% in this period19. This increase was fairly rapid
up to about 1976 (3-10%), after which the increase
was more gradual (10-13%) (figure). Rifampicin
resistance in newly diagnosed patients was less than
1% in the period 1985-90 and about 2% in 1990-95.
These figures can be considered to represent primary
resistance fairly precisely because of the rigorous
interrogation methods used. All patients are initially
questioned in detail about previous treatment by doctors,
social workers and nurses. The interrogation is repeated
at the end of one month of treatment and again when
drug susceptibility test results become available in those
with drug resistance. These primaiy drug resistance
figures are not very alarming and do not support the
views expressed in the early years of chemotherapy,
when it was predicted that drug resistance would
increase to such an extent that it would jeopardise the
tuberculosis control programme.

Fig. Drug resistance in newly diagnosed patients with pulmonary
tuberculosis (TRC: 1957-1995)

(iii) Patients attending any treatment service, however,
are a mix of new and previously treated patients. The
initial drug resistance data are of more value for
treatment planners. While the data from TRC are from
a research institute, where patients are selected for
prospective good compliance with treatment drug,
resistance figures from the Institute of Thoracic
Medicine, Chennai are more interesting. This institute
caters to a large, outpatient population and has a
monthly attendance of about 150 patients of
tuberculosis, old and new. Initial drug resistance to
any drug in this centre has increased from 31% in
1988 to 37% in 1994 and this increase applies to all
drugs, vz±. streptomycin, isoniazid, rifampicin and
ethambutol (personal communication). These data
appear to suggest that drug resistance is on the increase.

In
(iv)

a comprehensive review of the drug resistance
scenario in India, it was reported that the overall pri­
mary resistance to isoniazid ranged from 6-13%, ex­
cept among the rural population of Kolar, Karnataka,
with a figure of 27%, to streptomycin from 1-6%
and to rifampicin from 0-2%. Acquired resistance
ranged from 35-67% for isoniazid, 26-27% for strep­
tomycin and 3-37% for rifampicin. Overall, the com­
bined resistance to rifampicin and isoniazid was low
and ranged from 0-6%18. In a study from Gujarat
*
it
was observed that in patients with treatment failure
and relapse resistance to rifampicin increased from
3% in 1980 to 37% in 1986, and to isoniazid, from
35 to 56% over the same period20.

(v) Data are also available on drug resistance from
the TB control programme. The TRC was given
the responsibility for implementing short course
107

chemotherapy in the District Tuberculosis Programme
in 18 districts all over India in the mid 1980s. Dur­
ing this period drug resistance surveys were carried
out in three districts, North Arcot in Tamil Nadu,
Raichur in Karnataka and in Pondicherry Union
Territory. Initial drug resistance in these districts was
found to be 26% (MDRTB 2%), 35% (MDRTB 8%)
and 14% (MDRTB 1%)21 respectively. These figures
demonstrate the wide variation in drug resistance
figures in different parts of the country. Pondicherry
Union Territory is a much smaller area compared to
the other two districts and has a more efficiently
functioning TB control programme, and these prob­
ably are the reasons for the lower level of drug resis­
tance in this centre.

Mechanism of Drug Resistance
Drug resistance in M.tuberculosis occurs by random,
single step, spontaneous mutation at a low but predict­
able frequency, in large bacterial populations. There is
no convincing evidence for the role of plasmids or
transposons as in other bacterial pathogens. It has been
estimated that the probability of incidence of drug resis­
tant mutants in a population of M.tuberculosis is depicted
by the formula P=l-(l-r)n, where P is the probability of
incidence of drug resistant cases, r is the probability of
incidence of drug resistant mutants and n is the number
of bacilli in the lesion22. The value of r for rifampicin is
,
**
10
that for isoniazid, streptomycin, kanamycin, ethambutol and para-aminosalicylic (PAS) acid is 10
* 6. Thus,
for isoniazid and streptomycin, there is likely to be one
resistant bacillus in a population of one million sensitive
bacilli. The corresponding figure for rifampicin is one in
one hundred million. The probability of resistance occur­
ring to two drugs at the same time, is the product of the
probabilities of drug resistance to a single drug. For ex­
ample, the probability of resistance developing to both
isoniazid and rifampicin in the same bacillus is l:!06x
1:108 ie 1:1014. Therefore, in a medium sized cavity of
2.5 cm diameter, as might be seen in a patient with open
pulmonary tuberculosis, which is estimated to contain about
107-109 bacilli, there are likely to be a few bacilli resistant
to isoniazid, a few bacilli resistant to rifampicin but none
resistant to both drugs. This illustrates a very funda­
mental principle that multi drug resistant tuberculosis
is an iatrogenic problem.
Genetic Basis of Drug Resistance

While, it was generally known that resistance in
M. tuberculosis occurs due to spontaneous mutation, the
exact genetic basis of this mutation has been discovered
108

only recently. In the last seven years, there have been
many dramatic discoveries in molecular biology which
have greatly increased the understanding of the mecha­
nism of drug resistance. The most important of these was
by Ying Zhang ofthe Royal Postgraduate Medical School,
London. In 1992 he and his colleagues were able to trans­
form an isoniazid resistant strain of M. smegmatis by
repeated splicing of DNA segments from M. tuberculo­
sis, till the strain was rendered completely isoniazid sen­
sitive23. The segment of DNA which was responsible for
restoring drug sensitivity was also able to restore
catalase-peroxidase activity. This segment has been
identified as the katG gene which encodes for catalaseperoxidase activity. It is well known that many strains of
M. tuberculosis resistant to isoniazid show reduced cata­
lase-peroxidase activity.

However, not all resistant strains of M. tuberculosis
are catalase-peroxidase deficient. Some strains are
catalase-peroxidase positive. Thus, other mechanisms in
drug resistance are also possible. Subsequently a muta­
tion was discovered in the inhA gene, which is required
for the synthesis of mycolic acid, an essential compo­
nent of the bacterial cell wall, and which may tie a target
of activity for isoniazid in some resistant strains of
M. tuberculosis.
In the last few years, there has been considerable
progress in our understanding of the mechanisms of
action and resistance to anti-tuberculosis agents. To date,
there is information about 11 genes involved in resis­
tance to all major anti-TB drugs in M.tuberculosis.
Mutations in katG, inhA and ahpC genes are found in
upto 90% of isoniazid resistant strains, rifampicin
resistance is associated (> 96%) with rpoB mutations,
pyrazinamide resistance with pncA mutations (72-97%),
ethambutol resistance with-mutations in embB (47-65%),
streptomycin resistances with rrs or rpsL mutations (70%)
and fluoroquinolone resistances with gyrA substitu­
tions (75-94%). Additional genes and mechanisms may
play a role, particularly in association with lower levels
of resistance24.
Transmissibility
Drug resistant strains of M. tuberculosis show reduced
catalase-peroxidase activity, demonstrate reduced viru­
lence in guineapigs and grow poorly in artificial media.
So for many years, drug resistant M.tuberculosis was
considered to be less infectious than drug susceptible
strains. Therefore, drug resistant tuberculosis was con­
sidered to be a problem for
the
*
individual but not for the

community. However, there is now evidence to show that
drug resistant bacilli are as infectious as drug susceptible
ones and are capable, to causing severe disease25. This
view has been reinforced recently in the outbreaks of multi
drug resistant tuberculosis in the USA, where studies have
shown that contacts of patients with multi drug resistant
tuberculosis were at equal risk of getting infected com­
pared to contacts of those with drug susceptible tu­
berculosis.
Detection of Drug Resistance
One of the major handicaps in the management of
drug resistant tuberculosis is the diagnosis. Traditional
methods which include culture of the organism, identifi­
cation of the cultured bacilli and drug susceptibility tests
require at least 10 to 12 weeks. This leads to undue delay
in the initiation of appropriate treatment and during this
time the patient continues to transmit drug resistant
infection in the community. There is thus a need for more
rapid methods of detection of drug resistance. In this
respect, some recent developments are of very great
relevance.

(i) The BACTEC method is an automated radiometric
technique, which depends on the detection of radiolabelled CO2as a measure of growth index for grow­
ing microorganisms. Using this system it is pos­
sible to provide drug susceptibility results for
M.tuberculosis in three weeks26'27. A comparison
with conventional procedures for it’s ability to de­
tect drug resistant strains shows excellent correlation28.
ii) The luciferase phage system in which mycobacteria
are infected with a phage carrying the enzyme
luciferase, which is responsible for the glow of the
firefly. When the infected M.tuberculosis carrying
the enzyme is grown in culture containing the drug,
to which the substrate luciferin is added, light is
produced if the M. tuberculosis strain is resistant to
the drug in the medium. If the strain is sensitive to
the drug, it is killed and there is no luciferase in the
system and no light is produced. Thus drug resistant
strains produce light and drug susceptible strains do
not29-30. The test is both highly sensitive and specific.

iii) Polymerase chain reaction (PCR) single stranded
conformation polymorphism has made possible the
rapid identification of rifampicin resistant
M.tuberculosis3'^2., Results are available within 24
hours. The analogous setting for isoniazid resistance
is less favourable, since more than one gene
*
may be
involved in isoniazid resistance.

Restriction fragment length, polymorphism (RFLP)
using insertion element IS986-/IS6110 based DNA
probe has been used with success in epidemiological
studies in MDRTB outbreaks33.

iv) Slide culture sensitivity systems which can provide
results in seven days show great promise34. They need
to be evaluated further in clinical settings in devel­
oping countries.

Using these methods the time spent from receipt of
specimens to the reporting of results has been cut down
to two to three weeks. However, there are clearly prob­
lems in trying to apply.these new techniques in develop­
ing countries, the constraints being technological and
financial. For the time being they will remain predomi­
nantly as research tools35.
HIV and Tuberculosis

It is estimated that globally more than four million
people are co-infected with HIV and TB. The HTV epi­
demic has had a very dramatic impact on the global epi­
demiology of tuberculosis in the recent past. It has been
one of the major reasons for the sharp increase in the
number’of tuberculosis cases observed in the West from
the mid*1 980s, after years Of declining case rates’. The
epidemic has also caused a great increase in the number
of cases of pulmonary and extra-pulmonary tuberculosis
in many countries in the African continent. It is widely
forecast that Asia, and South-East Asia in particular, would
be the next area where the adverse impact of the HIV
epidemic on the tuberculosis situation would be felt.
Tuberculosis has been shown to occur much earlier
in the clinical course of HIV disease compared to other
opportunistic infections. It has been estimated that only
10% of immunocompetent persons infected with tuber­
culosis run fhe risk of developing clinical disease during
their lifetime, 5% in the first five years and 5% during
the rest of their lifetime. HIV infection greatly acceler­
ates this risk. The risk of developing clinical tuberculo­
sis in a TB infected persons who is also infected with
HIV is 8% per year. The HIV infected person who devel­
ops TB is likely to do so in a relatively short time after
infection with TB36.

It has also been shown that if the relative risk (RR)
of developing clinical tuberculosis in a PPD positive
individual is one, when there is no other underlying risk
factor, the RR is 113 for someone who is also infected
with HIV and 170 if he/she has.AIDS. This means that
an HIV infected person has 113 times greater risk and
109

an AIDS patient has 170 times greater risk of develop­
ing tuberculosis compared to someone who is immuno­
competent.
Most of the outbreaks of multi drug resistant tuber­
culosis in the USA in the first half of the 1990s were in
HIV infected patients. These outbreaks were characterised
by extremely high mortality rates. The HIV epidemic is
expected to cause an increase in the number of cases of
drug resistant tuberculosis for the following reasons:
(i) increase in the number of cases of tuberculosis will
give rise to an increase in the number of cases with pri­
mary drug resistance; (ii) overloading of the tuberculo­
sis treatment services because of the expected increase
in the number of cases will give rise to more cases with
acquired dnig resistance; and (iii) immunocompromised
status of HIV patients may lead to decreased efficacy of
anti-tuberculosis treatment regimens, and thereby increas­
ing the chance of acquired drug resistance12.

two months followed by isoniazid and rifampicin for the
next four months cures 94-97% of patients with resistance
to isoniazid or streptomycin or to both drugs39. Studies at
the TRC have shown that in patients with resistance to
streptomycin, isoniazid, or both drugs, only 2, 8 and 17%
respectively failed to respond when treated with appropriate
regimens. When resistance is demonstrated to both
isoniazid and rifampicin (MDRTB), however, the outlook
is very different. Of 38 patients, 35 failed to respond40.

The management of MDRTB is a challenging prob­
lem. The treatment is less effective, more toxic and much
more expensive compared to the treatment of drug sus­
ceptible tuberculosis. Certain guidelines have to be borne
in mind when confronted with suspected drug resistance.
The first and foremost of these is to obtain from the patient
an exhaustive and detailed history of previous treatment
|
for tuberculosis. The importance of this step cannot be
over emphasised. Details such as the names of drugs, the
dosage, when taken for what duration and with what
Management
regularity are all important. All available prescriptions
Multi drug resistant tuberculosis is an iatrogenic
have to be perused. Patients often do not know what drugs
problem. Therefore the prevention of the emergence of
they had been prescribed. So indirect questions might be
drug resistance is of paramount importance. The best
necessary, such as did the patient take any capsules which
strategy to prevent the emergence of drug resistance is to
made the urine red, any medicines that caused joint pains
prescribe standardised and well tested regimens in the
etc. Patients should be prescribed at least three drugs which
proper dosage for the proper duration, and to ensure that
the patient has not received in the past, or to which the
the patient completes the full course of treatment till he
bacilli are demonstrated to be susceptible by laboratory
or she is cured. The tendency is often to blame the pa­
tests. Treatment should be supervised as far as possible,
tient for the development of drug resistance due to poor
at least in the initial stages, or till the sputum becomes
adherence to treatment. But it is a fact that physicians
negative. Studies have shown that even in developed
often contribute to this problem by prescribing inappro­
countries, there is much variation in the results from
priate combination of drugs with inadequate dosage. A
different laboratories which perform drug susceptibility
study on the prescribing practices of private practitio­
tests for M. tuberculosis. Of more than 80 strains typed
ners by the Foundation for Research in Community Health
as resistant to streptomycin, isoniazid or PAS at the
(FRCH), showed that, in Mumbai, 100 practitioners pre­
peripheral laboratory, only 27-49% of the strains were
scribed a total of 80 different regimens and in Pune, 113
confirmed to be resistant when retested at the reference
practitioners prescribed 90 different regimens for the treat­
laboratory41. Incorrect results of susceptibility test can
ment of tuberculosis37. This problem of poor prescrip­
lead to unnecessary changes of drugs, decreasing the
tion is not confined to the developing countries. A study
chances of cure. Judicious clinical judgement often ob­
in the USA that evaluated the prescribing practices of
viates the need for drug susceptibility testing. In the clinical
physicians in New Jersey showed that 36% of 1,230
trials at TRC 88-92% of patients with sputum positive
patients were not initially treated with four or more drugs
pulmonary tuberculosis treated with short course chemo­
and a substantial proportion of physicians did not ini­
therapy became culture negative by two months, and
tially treat their TB patients according to the recommen­
90-96% by three months of treatment42'44. A general rule,
dations of the Centres for Disease Control/American
therefore, would be to suspect drug resistance in a pa­
Thoracic Society38
tient who continues to remain sputum smear positive after
four months of regular treatment with an established short
It has been well established that the currently advocated
course chemotherapy regimen. Ifdrug susceptibility testing
short Course regimen of six months for the treatment of
is considered essential, it should be done in a laboratory
pulmonary tuberculosis, with isoniazid, rifampicin,
with established credentials..
pyrazinamide and ethambutol or streptomycin for the first
110

One important dictum in the management of
tuberculosis is never to substitute a single drug to a regimen
that appears to be failing as this may lead to the sequential
development of resistance to the drug that are being
introduced. Two or. more new drugs should always be
introduced. Since most drugs used in the treatment of
MDRTB have adverse effects, toxicity has to be carefully
monitored. Sometimes drugs may need to be withdrawn
either temporarily or permanently and alternate drug
substituted. Often adverse reactions can be managed with
symptomatic treatment. The patient needs constant
encouragement and motivation to cope with adverse
reactions to drugs and to complete the full course of
treatment. Ideally this should be done in hospital and it
is a good policy to hospitalise patients, at least initially,
to facilitate close monitoring, both for toxicity and for
treatment compliance. Members of the patients family
should be encouraged to participate in the patients’s
management by providing emotional and psychological
support.
The outcome of treatment of multi drug resistant
tuberculosis is not very favourable. In a retrospective
analysis of 171 immunocompetent patients treated over
a ten year period (1973-83) at the National Jewish
Hospital in Denver the overall favourable outcome was
only a little over 50%45. All patients were treated with
individually tailored regimens in which they received
at lest 3 or 4 drugs which they had not received previously,
or to which they were known to be susceptible. Of the
134 patients evaluated for efficacy, 65% became culture
negative and 35% failed to respond. Of those who became
culture negative, 14% eventually relapsed giving an
overall favourable outcome in 56% of patients. Of the
patients who failed, 46% died of tuberculosis.
In the Cape Province- of South Africa the 5 year
outcome of240 MDRTB patients was death in 48%, cure
in 33%, 15% were respiratory disabled and 13% were
still bacteriology positive46.

However, not all the reports are so grim. In a retro­
spective analysis reported from South Korea, of 107
patients with MDRTB treated with at least four drugs to
which hey had not been exposed to before, or to which
they were known to be susceptible, in 63 patients with
sufficient follow up data, 52 (82.5%) responded to che­
motherapy. There was no subsequent relapse among the
patients who responded, and there were no tuberculosis
related deaths. The authors conclude that, MDR pulmo­
nary tuberculosis responds relatively well to carefully
selected regimens. However, the mean period of follow
up was only 17 months47.

Experience of scientists of TRC, Chennai with
MDRTB has been equally discouraging. In about 170
patients with MDRTB over a 12 year period (1986-1997)
all but two of whom were HIV negative, only one third
had a favourable outcome, and one third died. These
patients were treated with regimens which included at
least three or four of the following drugs: ethionamide,
ethambutol, pyrazinamide, cycloserine, streptomycin or
kanamycin, PAS, thioacetazone and high dose isoniazid
(600 mg) with 10 mg of pyridoxine. More than one fourth
of the patients defaulted mainly due to adverse reactions
to the drugs, most commonly to ethionamide. In the last
five years ofloxacin has been used at TRC for the treat­
ment of these patients and the results appear to be prom­
ising, but a longer period is necessary before coming to
conclusions. The fluroquinolones have marked anti my­
cobacterial activity
*
and are being increasingly used to
treat MDRTB. However, this class of drugs is also widely
prescribed for a variety of respiratory and other infec­
tions. Caution has to be exercised as indiscriminate use
will lead to the development of resistance to this class of
drugs also. A report from New York indicates that this
may be happening48.
The value of the older drugs in the treatment of
MDRTB today has to be emphasised. Many young pa­
tients with MDRTB have not received PAS or
thioacetazone in the past and these can be used with success
in such patients. So also the value of high dose isoniazid
(600 mg), in patients with documented isoniazid resis­
tance. Experience of scientists at TRC has shown that
patients with MDRTB who have remained sputum posi­
tive for many years while on treatment with other drugs
have converted to sputum negativity when changed to
600 mg of isoniazid and PAS as a last resort.
The duration of therapy for MDRTB has not been
clearly established. The duration that has been recoipmended in the USA is for 18-24 months at least, or for
24 months after sputum culture converts to negative35.
At the TRC treatment is continued, for at least 12 months
after sputum cultures become negative.

While the outcome for patients with MDRTB is not
very favourable in immunocompetent patients, the re­
sponse in HIV positive patients is even bleaker. In the
outbreaks of MDRTB in and around New York city,
between 1988 and 1992, predominantly in HIV infected
individuals, mortality was in the order of 80% and the
mean duration from diagnosis to death was 4-16 weeks.
In a study of 173 patients hospitalized from 1983 to
1993 with MDRTB, of whom 52% were known to be
111

HIV infected, HIV positive MDRTB patients had sig­
nificantly more pulmonary and constitutional symptoms,
more extrapulmonary disease, and fewer cavitary lesions
on chest radiographs. Fifty five per cent of the patients
in the cohort died; mortality was significantly greater
for HIV positive than HIV negative (72 versus 20%) pa­
tients. The median duration of survival of MDRTB pa­
tients was 22 to 1 month. In HIV positive patients, only
appropriate therapy was associated with prolonged sur­
vival49.

In the recent past there have been a number of re­
ports of the value of amoxycillin-clavunalic acid combi­
nation50, interferon-y via aerosol51, rifabutin52 and recom­
binant human interleukin 253 in the management of
MDRTB. However, these are in small numbers of pa­
tients, and need to be evaluated in larger number of patients
in well designed clinical trials.

is being gradually implemented in India is based on this
principle. It has been shown that the administration of
therapy under direct supervision will play a crucial role
in helping to achieve significant reduction in the frequency
of multi drug, resistance56.

There is an urgent need for research to develop drugs
with anti-mycobacterial activities. Prospective controlled
trials to assess the efficacy of treatment regimens for
MDRTB are also required. At the beginning of the new
millennium the threat of MDRTB looms large over us,
and great resolve and commitment are needed to face
this challenge.

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MDRTB is an emerging problem that many people
fear would take us back into the past, to the era when
tuberculosis was considered untreatable. Though there is
as yet no firm evidence to indicate that MDRTB is
increasing in India, it would be prudent to consider that
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potent anti-TB drugs are often available over the counter
without a valid prescription. Since MDRTB is a preventable
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This article has been contributed by Dr. M.S. Jawahar, Dy.
Director, Tuberculosis Research Centre, Chennai.

ICMR AWARDS & PRIZES 1996
The Indian Council of Medical Research has awarded the following prizes and awards to various Indian scien­
tists for their outstanding research work in various fields of biomedical sciences.

Basanti Devi Amir Chand Prize, 1997
Dr. Kamala Krishnaswamy
Director
National Institute of Nutrition.
Hyderabad

Diet and cancer

and
Dr. M.Gourie-Devi
Director and Vice-Chancellor
National Institute of Mental Health &
Neurosciences
Bangalore

114

Neuroepidemiology

Dr.P.N.Raju Oration Award for Research in Orthopaedics, 1996
Dr.O.N.Nagi
Professor and Head
Department of Orthopaedics
Postgraduate Institute of
Medical Education and Research
Chandigarh

Bone grafting - New techniques

Sandoz Oration Award for Research in Cancer, 1996

Dr.B.B.YeoIe
Deputy Director
Bombay Cancer Registry
Indian Cancer Society
Mumbai

Cancer epidemiology

and
Dr.Ranju Ralhan
Additional Professor
Department of Biochemistry
All India Institute of Medical Sciences
New Delhi

Tumour suppressor genes

Dr.Y.S.Narayana Rao Oration Award for Research in Microbiology, 1996
Dr. Gita Satpathy
Additional Professor (Microbiology)
Dr.Rajendra Prasad Centre for
Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi

Chlamydial infections

Dr. Kamala Menon Medical Research Award for Research in Internal Medicine, 1996
Dr.Dipika Mohanty
Director
Institute of Immunohaematology
Mumbai

Molecular basis, diagnosis,
pathophysiology, and management
of bleeding disorders

Kshanika Oration Award for Women Scientists, 1996
Dr. Asha Mathur
Professor and Head
Department of Microbiology
K.G.Medical College
Lucknow

Role of chemotactic cytokine in JE
virus infection

115

Dr.M.K.Seshadri Prize for Practice of Community Medicine, 1996
Dr.Umesh Kapil .
Additional Professor
Human Nutrition Unit
All India Institute of Medical Sciences
New Delhi

Community medicine and maternal
and child health

JALMA Trust Fund Oration Award for Research in Leprosy, 1996

Dr.N.K.Mehra
Professor and Head
Department of Histocompatibility and Immunogenetics
All India Institute of Medical Sciences
New Delhi

Molecular basis of susceptibility to
leprosy : HLA studies

ICMR Prize for Biomedical Research for Scientists belonging to Underprivileged Communities, 1996

Dr.R.K.Kale
Associate Professor
School of Life Sciences
Jawaharlal Nehru University
New Delhi

Radiation/Cancer biology

ICMR Prize for Biomedical Research in Underdeveloped Areas, 1996
Dr. Neeru Singh
Deputy Director
Malaria Research Centre Field Station, Mandla
Medical College Campus
Jabalpur

Malaria

BGRC Silver JubileeOration Award for Research in Haematolgoy/ Immunohaematolgoy, 1996
Dr.Roshan Colah
Assistant Director
Institute of Immunohaematology
Mumbai

Molecular genetics and prevention of
major haemoglobinopathies in India

and
Dr.K.Madhavan Nair
Senior Research officer
National Institute of Nutrition
Hyderabad

Nutritional haematology

M.O.T.Iyengar Memorial Award for Research in Malaria, Filariasis, Plague or Medical Entomology, 19%

Dr.T.Adak
Assistant Director
Malaria Research Centre
Delhi
116

Diagnostic tools for identification
of malaria vectors

d

Prof. B.K.Aikat Oration Award for Research in Tropical Diseases, 1996

Molecular parasitology of
leishmaniasis

Dr.Neeloo Singh
Scientist
Division of Biochemistry
Central Drug Research Institute
Lucknow

Amrut Mody Unichem Prize for Research in Neurology, 1996
Cranio-vertebral and spinal stability

Dr.Atul Goel
Associate Professor
Department of Neurosurgery
Seth G.S.Medical College
Mumbai

Amrut Mody Unichem Prize for Research in Chest Diseases, 1996

Dr.S.K.Sharma
Professor
Department of Medicine
All India Institute of Medical Sciences
New Delhi

Granulomatous lung disorders

Lala Ram Chand Kandhari Award for Research in Dermatology and Sexually Transmitted Diseases, 1996

Clinical, immunological and therapeutic
studies on alopecia areata

Dr.V.K.Sharma
Additional Professor
Departmentof Dermatology
Postgraduate Institute of
Medical Education and Research
Chandigarh

Prof. Surindar Mohan Marwah Award for Research in Geriatrics, 1996

Biochemical and molecular basis of
aging,

Dr.Kalluri Subba Rao
Professor and Head
Department of Biochemistry
University of Hyderabad
Hyderabad

AWARDS/PRIZES FOR YOUNG SCIENTISTS

Shakuntala Amir Chand Prizes, 1996
Dr.Sunil Pradhan
Associate Professor
Department of Neurology
Sanjay Gandhi Postgraduate Institute of
Medical Sciences
Lucknow

Clinical neurophysiology

117

Dr.Vedantam Rajshekar
Professor of Neurosurgery
Department of Neurological Sciences
Christian Medical College
Vellore

Computerised tomographic stereotactic
surgery

Dr.Ashim Ghatak
Scientist E-l
Division of Clinical and Experimental Medicine
Central Drug Research Institute
Lucklnow

Cardiovascular medicine

Dr.Poonam Kakkar
Scientist E-l
Ecotoxicology Section
Industrial Toxicology Research Centre
Lucknow

Studies on oxidative stress

Raja Ravi Sher Singh of Kalsia Memorial Award for Research in Cancer, 1996

Dr.B.M.Biswal
Senior Research Associate
Department of Radiation Oncology
Institute Rotary Cancer Hospital
All India Institute of Medical Sciences
New Delhi

Clinical research in cancer

Tilak Venkoba Rao Award for Research in Psychological Medicine, 1996

Dr.R.K.Chaddha
Associate Professor
Institute of Human Behaviour and Allied Sciences
Delhi

Somatisation in psychiatry

DR.T.Ra mac hand ra Rao Award for Research in Medical Entomolgoy, 1996
Dr.B.N.Nagpal
Senior Research Officer
Malaria Research Centre
Delhi

Anophelines in India

Dr. Dharamvir Datta Memorial Oration Award for Research in Liver Diseases, 1996
Dr.R.K.Dhiman
Assistant Professor
Department of Hepatology
Postgraduate Institute of .
Medical Education and Research
Chandigarh

118

Endoscopic ultrasonography in
portal hypertension

Prof. B.C. Srivastava Foundation Award for Research in Community Medicine, 1996

Sociocultural and epidemiological
aspects of opium use

Dr.K.K.Ganguly
Senior Research Officer
ICMR Headquarters
New Delhi

Major General Saheb Singh Sokhey Award for Research in Communicable Diseases, 1996

Dr.Samiran Panda
5/3, Snuff Mill Street
Belghoria
Calcutta

Clinical epidemiology.of HTV
disease in Manipur

DR.H.B.Dingley Memorial Award for Research in Paediatrics, 1996

Dr.Shally Awasthi
Associate Professor
A Department of Paediatrics
K.G.Medical College
Lucknow

Effect of air pollution on respiratory
disease in preschool children

ICMR NEWS
The following meetings of various technical groups/
committees of the Council were held:
Meetings of the Scientific Advisory Committees (SACs)
of the ICMR Institutes/Centres:

SAC of the Institute of
Immunohaematology,
Mumbai
SAC of the Vector Control
Research Centre, Pondicherry
W

October 6-7, 1999

October 25, 1999

SAC of the National Institute November 14-15, 1999
of Virology, Pune
SAC of the Malaria Research
Centre, Delhi

November 26, 1999

Meetings of the Scientific Advisory Group (SAG)/Task
Forces (TFs)ZExpert Groups (EGs)/Project Review
Committees (PRCs)ZProject Advisory Committee
(PAC):

TF on New Initiatives in
Genome Research

September 25, 1999
(at New Delhi)

EG on Copper IUDs

September 27,1999
(at Mumbai)

PAC on Clinical Trials with
ICRC Vaccine for Leprosy

October 5,1999
(at New Delhi)

ICMR’s Ethical Committee
on Human Research

October 9,1999
(at New Delhi)

TF on Pancreatic Diseases

October 9,1999
(at Chandigarh)

EG on Hypertension amongst
Youth

October 18, 1999
(at New Delhi)

PRC on Cardiovascular Diseases,
Ophthalmology and Anaesthesia

October 21,1999
(at Ne(v Delhi)

TF on Human Genetics

October 22, 1999
(at New Delhi)

PRC on Gastroenterology,
Experimental Medicine, Urology,
Oral Health and Oncology

October 25, 1999
(at New Delhi)

PRC on Biochemistry and
Cellular and Molecular Biology

November 8, 1999
(at New Delhi)

TF on Childhood Asthma

November 12, 1999
(at Chandigarh)

Expert Committee on
Handigodu Disease
SAG of the Division of
Reproductive Health and
Nutrition

EG on BCG Vaccine

November 15-17, 1999
(at Sagar Taluk of Shimoga
District in Karnataka)
November 18-19, 1999
(at New Delhi)
November 27, 1999
(at New Delhi)
119

Participation of ICMR Scientists in Scientific Events:

Conference on Insecticide Treated Nets at Dar es Salaam
(October 11-14, 1999).

Dr. Veena Shatrugna, Asstt. Director, National Insti­
tute of Nutrition (NIN), Hyderabad, participated in the
second International Congress on Women, Work and Health
at Rio de Janeiro. (September 19-22, 1999).

Dr. B.N. Nagpal, Sr. Research Officer, MRC, Delhi,
participated in a workshop on How to Grow and Use Neem
at Mbita Point, Kenya (October 14-19, 1999).

Dr. N. Raghuramulu, Dy. Director (Sr. Grade), NIN,
Hyderabad, participated in the International Conference
on Chemistry and Biology of Vitamin D Analogs at Rhode
Island, USA (September 26-28, 1999).

Dr. Lal it Kant, Sr. Dy. Director-General and Dr. Mukesh
Kumar, Sr. Research Officer, visited Vietnam under the
Indo-Vietnam Joint Committee Programme on Science and
Technology for Joint Collaboration on Medical Research
(October 13-20, 1999).

Dr. J.M. Deshpande, Director, Enterovirus Research
Centre, Mumbai, participated in the fifth meeting of the
WHO Global Polio Laboratory Network at Geneva (Sep­
tember 29 - October 1, 1999).
Dr. C.N. Paramasivan, Dy. Director (Sr. Grade),
Tuberculosis Research Centre, Chennai, participated in
TB Laboratories Modular Course at Addis Ababa (October
2-17, 1999).

Dr. Vas Dev, Sr. Research Officer and Officer-inCharge, Malaria Research Centre (MRC) Field Station,
Sonapur, participated in the second International

Dr. Neeru Singh, Dy. Director and Officer-ih-Charge,
MRC Field Station, Mandla, participated in the WHO In­
tercountry Consultations on Adverse Effects of Develop­
mental Projects on Mosquito-borne Diseases at Bangkok
(October 18-22, 1999). She also participated in the WHO
Informal Consultation on Malaria Diagnostics at Geneva
(October 25-27, 1999).
Dr. U. Sengupta, Director, Central JALMA Institute
for Leprosy, Agra and Dr. M.D. Gupte, Director, Institute
of Epidemiology, Chennai, participated in a workshop on
Future of Leprosy Research in the Post-genome Era at
Bethesda (November 21-22, 1999).

ICMR AIDED SYMPOSIA/SEMINARSAVORKSHOPS/COURSES/CONFERENCES
Symposium/Seminar/Workshop/
Course/Conference

Date & Place

Contact Address

I Conference of the Council of Behavioural Scientists

October 2-3, 1999;
(at Agra)

Dr. S. Qamra, Organising Secretary of the Con­
ference, Central JALMA Institute for Leprosy,
Agra-282001.

National Symposium and Update on Problem Areas
in Diagnostic Oncopathology

October 8-10,1999;
(at Sevagram)

Dr. N. Gangane, Organising Secretary of the Sym­
posium, Department of Pathology, Mahatma
Gandhi Institute of Medical Sciences, Seyagram,
Wardha-442102.

IV Postgradute Course on Endocrine Surgery and
International Workshop on Endocrine Telesurgery

October 25-29,1999;
(at Lucknow)

Dr. S.K. Mishra, Course Convener, Department
of Endocrine Surgery, Sanjay Gandhi Post­
graduate Institute of Medical Sciences,
Lucknow-226014.

India Consensus Development Workshop on Standards of
Care in HIV Disease

October 28-30,1999;
(at Chennai)

Dr. Suniti Solomon, Organising Secretary of the
Workshop, YRG Care, T.Nagar, Chennai-600017.

International Workshop on Challenges to Scientists to
Preserve.the Mother Earth in the Next Millennium

October 28-30,1999;
(at Pondicherry)

Prof. T.R.C. Sinha, General Secretary, National
Environmental Science Academy, 206, Rajtower-I, Alakananda Community Centre, New
Delhi-110019.

X Ail India Congress of Cytolgoy and Genetics

October 29-31, 1999;
(at Kalyani)

Prof. G.K. Manna, Secretary Convener, AICCG,
B-10/250, Kalyani-741235. ‘

November 12-14,1999;
(at New Delhi)

Dr. Nita Saxena, Prof, and Head, Department of
Cardiac Anaesthesia, Cardiothoracic Centre,
All India Institute of Medical Sciences, New
Delhi-110029.

III National Conference of the Indian Association of
Cardiovascular and Thoracic Anaesthesiologists

120

Symposium/Seminar/Workshop/
Course/Conference

Date & Place

Contact Address

XIX Annual Convention of Neonatology Forum

November 18-19,1999;
(at Bangalore)

Dr. P.P. Maiya, Organising Secretary of the Con­
vention, Agadi Hospital, Bangalore-560027.

Symposium on Microbial Infections of the Central
Nervous System

November 20, 1999;
(at Chandigarh)

Dr. Nancy Malla, Organising Secretary, XXIII
National Congress of LAMM, DepartmentofPara­
sitology, Postgraduate Institute of Medical Edu­
cation and Research, Chandigarh-160012.

XXXII Annual Meeting of Nutrition Society of India

November 25-26,1999;
(at Coimbatore)

Dr. Usha Chandrasekhar, Convener and
Organising Secretary of the Meeting,
Avinashilingam Institute for Home Science
and Higher Education for Women, Coimbatore641043.

National Conference on Challenges in HIV/AIDS in the
Next Millennium

November 25-27,1999:
(at New Delhi)

Dr. Ashutosh Biswas, Organising Secretary,
Department of Medicine, All India Institute of
Medical Sciences, New Delhi-110029.

National Symposium on Advances and Applications of
Animal Sciences for Human Welfare and I Zoological
Congress of Eastern India

November 25-28,1999;
(at Darjeeling)

Dr. J. Pal, Head, Department of Zoology, Univer­
sity ofNorth Bengal, Siliguri, Darjeeling-734430.

International Conference on Man, Environment and
Nature

November 26-28, 1999;
(at Calcutta)

Prof. Sunirmal Chanda, Convener of the Con­
ference, Centre for Study of Man and Environ­
ment, Parivesh Kendra, CK-11, Sector-2, Salt Lake
City, Calcutta-700091.

XXIII All India Cell Biplogy Conference

November 27-29, 1999;
(at Hyderabad)

Dr. Lalji Sngh, Convener of XXIII AICBC,
Centre for Cellular and Molecular Biology,
Hyderabad-500007.

XXIV National Conference and International CME of
Indian Society of Blood Transfusion and Immunohaematolgoy

November 27-30, 1999;
(at Lucknow)

Dr. N. Chaudhury, Organising Secretary, ISBTI
1999, Department of Transfusion Medicine,'
Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Lucknow-226014.

International Symposium on Chemotherapy: Problem
and Perspectives in 21st Century

November 28-29, 1999;
(at Lucknow)

Dr. R.C. Saxena, Head, Department of Pharma­
cology, K.G. Medical College, Lucknow-226003.

XI Annual Conference of the Physiological Society of
India

November 28-30,1999;
(at Delhi)

Prof. M. Fahim, Head, Department of Physio­
logy, Vallabhbhai Patel Chest Institute,
Delhi-110007.

International Congress on Frontiers in Pharmacology and
Therapeutics in 21st Century

December 1-4, 1999;
(at New Delhi)

Prof. S.K. Gupta, Secretary General of ICPT-21,
Department of Pharmacology, All India Institute
of Medical Sciences, New Delhi-110029.

Symposia on (i) Impact of Statistics in Biomedical Research;
and (ii) Recent Advances in Statistical Methods and
Challenges for the New Millennium

Decemocr 2-4,1999;
(at Bangalore)

Dr. D.K. Subbakrishna, Organising Secretary of
the Annual Conference of ISMS, Department of
Biostatistics, National Institute of Mental Health
and Neurosciences, Bangalore-560029.

Workshop on the Role of Nitric Oxide Gas in the Treatment
of High Altitude Pulmonary Edema and Adult Respiration
Distress Syndrome

December 4,1999;
(at Pune)

Dr. W. Selvamurthy, Director, Pefence Institute
of Physiology and Allied Sciences, Delhi-110054.

Indo-European Seminar-cum-Workshop on Advances
in Human Cytogenetics

December 6-9,1999;
(at Lucknow)

Dr. SIS. Agarwal, Head, Department of Medi­
cal Genetics, Sanjay Gandhi Postgraduate Insti­
tute of Medical.Sciences, Lucknow-226014.

XXXI Annual Conference of the Society of Nuclear
Medicine

December 8-11, 1999;
(at Madurai)

Dr. Y.N.I. Anand, Organising Secretary of the
Conference, Department of Imaging Science,
Meenakshi Mission Hospital and Research
Centre, Madurai-625107.

121

Symposium/Seminar/Workshop/
Coil rse/Con feren ce

Contact Address

Date & Place

International Symposium on Cancer Control in Developing
Countries

December 10, 1999;
(at Calcutta)

Dr. Urmi Sen, Organising Secretary of the Sympo­
sium, Chittaranjan National Cancer Institute,
Calcutta-700026.

XV Asia Pacific Cancer Conference

December 12-15,1999;
(at Chennai)

Dr. T. Raj k urn ar, Secretary General, The XV
APCC Secretariat, Cancer Institute (WIA),
Chennai-600036.

II International Conference on Contaminants in the Soil
Environment in Australasia - Pacific Region

December 12-17, 1999:
(at New Delhi)

Dr. Rajendra Prasad, Organising Secretary of the
Conference, Council of Scientific and Industrial
Research, Rafi Marg, New Delhi-110001.

International Conference on Medical Diagnostic Techniques
and Procedures

December 15-17, 1999;
(at Chennai)

Dr. Megha Singh, Organising Secretary,
ICMDTP, Department of Applied Mechanics,
Indian Institute of Technology, Chennai-600036.

III International Symposium on Cognition, Education and
Mental Health

December 16-19, 1999;
(at Varanasi)

Dr. C.B. Dwivedi, Organising Secretary of the
Symposium, Department of Psychology, Banaras
Hindu University, Varanasi-221005.
A

LXVIII Annual Meeting of Society of Biological Chemists
(India) and Symposium on Current Trends in Biology

December 27-29,1999;
(at Bangalore)

Dr. Sandhya S. Visweswariah, Organising Sec­
retary, 68th SBC(I) Meeting, Indian Institute of
Science, Bangalore-560012.

XVIII National Symposium on Reproductive Biology
and Comparative Endocrinology

December 27-29, 1999;
(at Chennai)

Dr. R. Moses Inbaraj, Organising Secretary, 18th
SRBCE, Department of Zoology, Madras Christ­
ian College, Chennai-600059.

XLIII All India Congress of Obstetrics and Gynaecology

December 27-30, 1999;
(at Lucknow)

Dr. Vinita Das, Organising Secretary of the Con­
gress, Department of Obstetrics and Gynaecology,
K.G. Medical College, Lucknow-226003.

LXXXVII Session of the Indian Science Congress

January 3-7,2000;
(at Pune)

Dr. Bhushan, Patwrdhan, Local Organising Sec­
retary, Indian Science Congress-2000, University
of Pune, Pune-411007.

Workshop on Gene Amplification Techniques in Disease
Diagnosis and National Conference of Laboratory Medicine

January 21-25,2000;
(at New Delhi)

Dr. Sarman Singh, Organising Secretary of the
Conference, Department of Laboratory Medicine,
All India Institute of Medical Sciences, New
Delhi-110029.

V World Conference on Injury Prevention and Control

March 5-8, 2000;
(at New Delhi)

Prof. Dinesh Mohan, Secretary General
(FIWOCO), Transportation Research and Injury
Prevention Programme, Indian Institute of
Technology, New Delhi-110016.______________

COUNCIL’S TRAINING PROGRAMMES FOR 1999-2000
Reproductive Biology

Biomedical Statistics

At the Institutefor Research in Reproduction, Mumbai:

At the National Institute ofEpidemiology, Chennai:

•

Training Course on Cytological Detection of Repro. ductive Tract Infections (December 13-17, 1999).

Nutrition
At the National Institute of Nutrition, Hyderabad:
• Postgraduate Certificate Course in Nutrition (Decem­
ber 1,1999-February 28,2000).
122

•

Training Course in Field Epidemiology (November,
1999).

Haematology

At the Institute of Immunohaematology, Mumbai:
•

Training Course in Advanced Haematology and
Immuno-haematology (October 11-29,1999).

|

W

Japanese Encephalitis in India (Revised Edition 1980)

3x00

Some Therapeutic Diets (Fifth Edition 1996) by Swar&n Pasricha

100

Nutrient Requirements and Recommended Dietan
*
Allowances for Indians (1990, Reprinted 1998)

16.00

Fruits (Second Edition 1996) by Indira Gopalan and NL Mohan Ram

-OAH'

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 Vol2 (1987)

13&00

Diet and Diabetes (Second Edition 1993, Reprinted 1998) by T,C, Raghuram.Sw aran Pasricha
and R.D. Sharma

20.00

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

Dietary Guidelines for Indians (1998)

10.00

(filcfitl

3TCH

3TTKT7

3ft

*
ufift

1974,

(1997)

1990)

6.00
9.00

* 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
chargeswill 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).

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about the activities of ICMR.
The welcome section gives general information like address and phone numbers of
Chiefs of Divisions in the ICMR Hqs., Profile of the Director General, Highlights of
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EDITORIAL BOARD
Chairman
Dr. N.K. Ganguly
Director-General

Members
Dr. Padam Singh
Dr. Lalit Kant
Dr. Bela Shah
Sh. N.C. Saxena
Dr. V. Muthuswamy

Editor
Dr. N. Medappa

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