ICMR BULLETIN VOL. 24-No.-5-MAY-1994.pdf
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ISSN 0377-4910
)ICMR
Vol. 24, No.5
May, 1994
SUMMARY REPORT OF THE
INTERNATIONAL CONFERENCE ON DENGUE
HAEMORRHAGIC FEVER AND NATIONAL BRAIN
STORMING SESSION ON DENGUE
There is ample evidence that India has experienced
in recent years major epidemics of dengue and dengue
haemorrhagic fever. However, information regarding
these outbreaks has generally not been well documented
or formally presented in the scientific . literature.
Further, indications are that (wide) divergence exists in
local treatment practices of severe dengue infection, and
that local clinicians may not be fully aware of proven
successful procedures for the clinical management of
these patients. Recognising the need for providing more
information on the current status on dengue, and the
need for a coordinated approach to address this
emerging problem, the Indian Council of Medical
Research, in collaboration with the Rockefeller
Foundation, New York, the World Health Organisation,
Headquarters and South East Asia Regional Offices,
and the Department of Biotechnology, New Delhi,
organised an International Conference on Dengue
Haemorrhagic Fever and a National Brain Storming
Session on Dengue. The meeting held between February
7-8, 1994, involved interaction between 144 international
and national scientists and clinicians to share
experiences and formulate a plan of action for India. A
total of 43 papers were presented at the meeting.
Background
Dengue has been known to exist in India for over a
century. Indeed, two strains of dengue 1 virus were first
isolated in India by Sabin in 1954, both from humans
infected in Calcutta. Several references had been made
to "7 day fever" outbreaks near Delhi and Patna during
World War II, and the clinical descriptionrHeave little
doubt that these were outbreaks of dengue. Since 1956,
all 4 dengue serotypes have been isolated from India,
frequently from humans and from vector mosquitoes —
Aedes aegypti and occasionally from Ae. albopictus.
Despite frequent outbreaks of dengue, no report of
haemorrhagic fever associated with dengue was made
until 1963, when outbreaks occurred in Calcutta
followed by Visakhapatnam, and several cities of the
eastern coast of India. The outbreaks appeared to be
associated with both dengue and chikungunya viruses.
In Calcutta, several thousand cases were estimated to
have occurred, and dengue as well as chikungunya
viruses were isolated. The epidemic lasted from 1963 to
1965, and an estimated 100,000 cases of dengue may
have resulted. Dengue haemorrhagic fever (DHF) and
dengue shock syndrome (DSS) were both documented
during the epidemic.
A systematic study of dengue was carried out at
Vellore during 1956 to 1967. Several strains of virus
belonging to all serotypes were isolated from men as well
as mosquitoes. All cases presented with classical clinical
manifestations.
Division of Publication & Information, ICMR, New Delhi - 1 10 029
More recently, serious outbreaks of dengue
occurred in Delhi in 1988, and dengue and DHF was
diagnosed in 30 per cent of the reported cases in Madras
in 1989, including many fatalities ascribed to DHF. A
large outbreak of dengue 3 occurred in Calcutta in 1990,
including cases of DHF, and another outbreak occurred
in Delhi in 1991, but little information is available
regarding the serotypes of dengue involved, or the attack
rates.
Dengue is not a reportable disease in India, and no
active surveillance system exists.
Consequently,
outbreaks of dengue and DHF are not often
documented, and only those which are reported are
likely to be investigated. There is a consensus that the
incidence of dengue and DHF, which was primarily an
urban disease in the 1970s, is now increasingly affecting
the rural population.
Objectives of the Meeting
In view of the current situation regarding dengue in
India, the following objectives were formulated for this
meeting:
I.
To have experts in DHF and DSS meet and
interact with Indian communicable disease epide
miologists, both national and from the states where
DHF has been reported (Tamil Nadu, Gujarat,
Uttar Padesh, Maharashtra, West Bengal and
Andhra Pradesh).
2.
To gather preliminary data on recent occurrences
of DHF/DSS in India.
3.
To meet and interact with key members of the
Indian medical community, especially paediatricians
who have cared for DHF/DSS patients.
4
To disseminate information on case definition and
case management to Indian clinicians.
5.
To discuss and propose recommendations on
various topics, including: (i) Enhanced surveillance
for DHF/DSS in India; (ii) methods of dissemi
nation of technical information on DHF/DSS
throughout the Indian public health and clinical
channels; and (iii) publication of articles on
DHF/DSS in Indian medical journals.
6.
To formulate vector control measures.
Summary of Presentations
The meeting was organised into various sessions
which focussed on epidemiology, medical entomology.
60
clinical aspects, immunology of dengue infection and
strategies of dengue control; and a round table
discussion. Following the formal presentations, the
National Brain Storming Session on Dengue was held,
during which the group broke into four sections to
discuss clinical considerations of dengue, surveillance,
medical entomology, and research.
Two general themes dominated the meeting; the
increasing number of dengue outbreaks, and the spread
of the primary vector of dengue, Ae. aegypti.
Outbreaks of dengue fever have been known to
occur in India for more than a century, but it has only
been since the early 1960s that DHF/DSS have been
seen. Over the past decade, a dramatic increase in
number of DHF/DSS cases has occurred, and during
the meeting information was presented on recent
DHF/ DSS outbreaks in nine India states (Maharashtra,
Gujarat, Karnataka, Andaman and Nicobar Islands,
Assam, Nagaland, Haryana, Uttar Pradesh, and Tamil
Nadu). All four serotypes of dengue virus have been
isolated from acutely ill patients in India, and there was
a strong suggestion that dengue was now present in
nearly all states of India, and that the risk of DH F/ DSS
was present and growing. The age of the typical
DHF/DSS patient appears to be increasing, with most
patients being children. Outbreaks are increasing in
frequency and magnitude, but continue to go
unrecognised due to the lack of appropriate diagnostic
facilities in most parts of the country. Dengue and
DHF/DSS are not reportable in India, and when
outbreaks are recognised, it is often based on clinical
presentation alone. Few outbreaks are properly
investigated, and when studied, it is often as
transmission is waning and the epidemic nearly over.
Treatment of the severe forms of dengue, DHFand DSS
is not standardized, and jt is clear that the general Indian
medical community could benefit from provision of
guidelines for the proper management of these disease.
With regard to the status of vectors of dengue,
several species of mosquitoes are present in India that
may transmit dengue, but the principal vector species is
Ae. aegypti. The species has traditionally been
associated with urban centres in India, and is found
virtually throughout the country. During the meeting,
however, new information was presented to indicate
that Ae. aegypti is increasingly abundant in rural
settings, thus placing much more of the country at risk of
dengue and DHF/DSS. Every presentation made that
had data on mosquito densities collected over a period
of years found that Ae. aegypti population densities
were now high, with indications that they were getting
higher. In some areas of India, where human migration
to urban centres has led to over burdened housing, water
supply, and refuse management, concomitant increase
in vector mosquito populations has been especially
dramatic. In spite of recognition of the increasing
densities of vector mosquitoes, no nation-wide campaign
exists for vector control, and when present, vector
control is often limited to emergency measures, with no
sustained programme of control. Thus, it appears that
the conditions are ripe for explosive epidemic dengue
transmission.
(c)
Administration of drugs such as aspirin, ibuprofen,
steroids and heparin should be avoided when
treating dengue fever and DHF/DSS patients.
(d)
Minimum diagnostic facilities for dengue, such as
haemagglutination inhibition tests or ELISAs,
should be available in all medical colleges.
Antigens for this test should be of high quality and
supplied through central source. The National
Institute of Virology (NIV), Pune, should
coordinate and provide quality control for dengue
diagnostic reagents.
(e)
Multicentric research on dengue, DHF/DSS
should be encouraged.
2.
Recommendations from the surveillance group
Recommendations of the Brain Storming Session
1.
Recommendations from the clinical group
(i) An educational campaign should be developed to
raise the level of awareness for dengue and DHF/DSS
among all segments of the Indian population.
(a)
Guidelines encompassing the signs, symptoms and
diagnostic procedures for dengue, DHF/DSS
should be distributed to medical teachers,
practicing clinicians and health care workers.
WHO should be approached to assist in the
development and distribution of these guidelines.
(b) More stress should be placed on providing
information on dengue, DHF/DSS in medical
colleges, in both undergraduate and graduate level
courses.
(c)
(d)
Continuing Medical Education (CME) courses
should be developed and offered to practicing
physicians to update their knowledge of dengue
case management, epidemiology, prevention and
control.
Practicing clinicians should be taught how to
exclude dengue in any febrile patient with flushed
face and without signs or symptoms of upper
respiratory tract infection, and proven no! to have
malaria. Antibio)tic treatment should not be started
unless indicated.
(ii)
Treatment of dengue and DHF/DSS
(a)
Torniquet tests should be done on all patients
suspected to have dengue fever, DHF/ DSS.
(b) A flow chart to guide in the treatment of patients
with DHF/DSS should be made available to -11
hospitals and primary health centres.
(i) Dengue haemorrhagic fever and dengue- shock
syndrome should be reportable diseases.
(a)
WHO case definitions should be used.
(b)
Existing reporting networks ie for poliomyelitis
should be used whenever possible.
(c)
Each state should define its own areas of
surveillance.
(d)
The National Institute of Communicable Diseases
(NICD), Delhi, should present a coordinated
reporting system to national authorities.
(ii) Each otate should have laboratory diagnostic
capabilities for dengue, DHF/DSS.
(a)
The NIV should serve as a national reference centre
to assist with technical problems and to maintain
quality assurance and proficiency testing of local
testing of the peripheral groups.
(b)
Other laboratories should be used as surveillance
centres.
(c)
The IgM capture ELISA is the test of choice for
routine diagnosis of dengue, DHF/DSS.
(d)
WHO should be requested to assist with the initial
acquisition of reagents and for training.
(iii) Entomological surveillance should be initiated
and linked with vector control efforts.
(a)
Entomological surveillance data (ie malaria
control, Ae. aegypti, others) should be shared at
the district level.
61
(b)
National summaries could be collated, distributed
and stored at the Vector Control Research Centre,
Pondicherry.
(iv) Outbreak investigations should be linked to
surveillance activities.
(a)
(b)
NICD should.prepare guidelines for surveillance
and outbreak investigations.
States should organise their own investigation
teams.
(v) A training component should be included in all
surveillance activities.
3.
Recommendations from the epidemiology and
research group
(i) Improve Indian research capacity: Apart from
improving funding of research in the area through
various funding agencies, there is an urgent need |o
develop and standardize research tests and reagents, and
this in turn requires the training of scientists and
designation and strengthening of present training
centres. The WHO Collaborating Centre at the NIV can
assist in standardizing research test systems in India with
those of the international community.
(ii) Collaborative research should be stressed: Research
test protocols and reagents can best be developed
through high quality research projects that have reagent
production and training as defined components. Such
collaboration could be especially rewarding in the area
of biotechnology, where modern techniques could be
focussed on reagent production.
(iii) Clinical research should be linked with virological
laboratory support through a multicentric approach.
(iv) Epidemiological research should focus on deve
lopment of several sites where prospective epidemiologi
cal studies on DHF/DSS may be undertaken. Both
clinical and epidemiological studies will generate
research specimens that will require characterization
and contribute to virological, immunological and
pathogenesis research.
(v) Basic research on pathogenesis should be supported
to contribute to human clinical pathogenesis studies.
(vi) To strengthen the prevention and control
strategies of dengue, reports on the clinical burden of
DHF/DSS should be plublished in the media.
(vii) To assist clinicians and public health workers,
video films would be prepared highlighting the clinical
features of dengue, DHF/DSS, treatment and vector
control strategies.
4.
Recommendations from the vector control group
(i) A nation-wide vector surveillance system based on
existing institutions should be established to map and
publish the present distribution of Ae. aegypti, and be
used to restrict its spread to new areas.
(ii) The ecological factors that encourage the increase
or decrease of vector population densities should be
investigated.
(iii) An institute or agency should be designated to
maintain database of Ae. aegypti, including distribution,
population densities, insecticide resistance and vector
incrimination information.
(iv) To ensure uniform reporting and utilization of
information collected, standardized reporting of vector
levels and indices should be used.
This report has been prepared by Dr. Kalyan Banerjee,
Director, National Institute of Virology, Pune.
ABSTRACTS
Some Research Projects Completed Recently
Susceptibility of vectors of Japanese encephalitis in
Karnataka to insecticides.
The study was carried out to test the susceptibility
of Japanese encephalitis (JE) vectors of Karnataka to
synthetic pyrethroids, organophosphate and organochlorine insecticides.
62
Both adult and larval population of Culex
tritaeniorhynchus, Cx. gelidus and Cx. fuscocephala,
from Mysore and Mandya districts of Karnataka were
tested for their susceptibility to insecticies. Adult
susceptibility tests were conducted with propoxur
(0.1%), DDT (4%), malathion (5%), deltamethrin
(0.025%) and cyfluthrin (0.05%). Deltamethrin was
foynd to be the most effective adulticide as it produced
100 per cent mortality in 15 min. DDT required 120 min
to kill over 90 per cent mosquitoes compared to 30 min
by malathion and cyfluthrin. Cx. tritaeniorhynchus was
found to be more tolerant compared to the other two
species.
The larval tests revealed differential tolerance of
the vectors with regard the LCso values of insecticides
tested. LCso values for cypermethrin,' deltamethrin,
fenthion, fenitrothion, temephos and malathion against
larvae of Cx. tritaeniorhynchus were 0.000254,
0.000424, 0.039472, 0.075500, 0.025930 and 0.061908
respectively, compared to 0.000063,0.000063,0.002343,
0.011647, 0.001868 and 0.044426 respectively against
larvae of Cx. fuscocephala. Results revealed high
tolerance against insecticides in Cx. tritaeniorhynchus
during larval stage also.
Experiments conducted to compare the effects of
continuous and intermittent exposures with cypermethrin showed that multipulse exposure of two, 1 h
duration exposures with a6h insecticide free period was
more effective compared to continuous 2 h exposure in
all 3 vector species tested.
V.A. Vijayan
Department of Studies in Zoology
University of Mysore
Mysore
Publications:
Vijayan, V.A., Revanna, M.A., Vasudeva, K.S., Pushpalatha, N.
and Poornima. Comparative susceptibility of two Japanese
encephalitis vectors from Mysore to six insecticides. Indian J Med
Res 97; 215, 1933.
Metabolic fate of membrane proteins in rat brain during
chronic ethanol treeatment.
The study was carried out on Wister strain albino
rats of both sexes (age 30 ± 2 days) to identify the
changes in morphological, macromolecular and mem
brane architectural properties of neurons and astrocytes
and to ascertain specific cell type vulnerability in brain
following chronic in vivo ethanol treatment. Rats in the
experimental group were given ethanol (5% V/V) as
their only oral fluid upto the third month of age.
Control animals were given only tap water. Another set
of control animals were also maintained on tap water
containing isocaloric sucrose substituted for ethanol.
Ethanol treated rats did not show any overt
63
pathological or behavioural symptoms, excepting that
their sleeping time was slightly increased and the
animals were flaccid. Ethanol consumption induced a 9
per cent decrease in the body weight of rats, however, it
did not cause much variation in the pattern of food
intake.
Scanning electron microscopy revealed no change
in the appearance of neurons from control and ethanol
treated rats. However, astrocytes from ethanol treated
rats displayed a characteristic smoothening of cell
surface and lacked protruding elements which were seen
on the surface of astrocytes from normal rats.
There was a decrease in DNA, RNA and protein
contents in both neurons and astrocytes from ethanol
fed rats, but the changes in RNA and protein were more
conspicuous than those in DNA. Protein synthesis as
determined by incorporation of 3H-leucine was
markedly diminished in both neurons and astrocytes.
The enolase activity (cell specific marker) in the
neuronal fraction from ethanol treated rat brain did not
show any change but glutathione synthetase activity in
the astrocytes was decreased by 35 per cent compared to
normal rats. There were alterations in membrane
protein composition and many of the membrane
proteins disappeared in both neurons and astrocytes.
Very few proteins seemed to have been synthesized after
chronic ethanol exposure. N-terminal glycoproteins
showed an increase in astrocyte cell membrane.
Studies using monoclonal antibody for neurofilamental protien-160 and polyclonal antibody for glial
fibrillary acidic protein as well as identification of
changes in these proteins revealed no significant effect
of ethanol treatment suggesting that ethanol was
probably not acting on the cytoskeletal elements at the
concentration used in the study. The changes that were
observed in the membrane fraction of astrocytes and
neurons following chronic ethanol exposure might be
relevant to the chemical basis of alterations in specific
neuronal circuits during memory formations.
Mohan C. Vemuri
School of Life Sciences
University of Hyderabad
Hyderabad.
Publications:
1.
Prakash Babu, P. and Vemuri, M.C. Liver plasma membrane
proteins in chronic ethanol intoxication. Biochem Int 20:517,
1990.
2.
Prakash Babu, P., Nagaraju, N. and Vemuri, M.C.
Differences in plasma membrane proteins of chronic alcoholic
rat brain. Mem Biochem 9: 227, 1991.
Metabolism of lipids and glycoconjugates in alcohol
treated animals.
The study was carried out on Sprague-Dawley
strain male albino rats to ascertain the effect of different
concentrations of ethanol on the metabolism of lipids
and glycoconjugates, effect of paracetamol on normal
and alcohol treated rats as also the protective effect of
testosterone and N-acetyl-D-cysteine on the alcohol
and paracetamol treated rats. Comparative studies of
the hepatotoxic effects of alcohc! and paracetamol as
also histopathological study of the changes in the liver
tissue of the alcohol and paracetamol treated rats were
also undertaken.
'Serum glutamate oxalacetate transaminase (SGOT),
serum glutamate pyruvate transaminase (SGPT) and
serum acid and alkaline phosphatases activities
increased after alcohol and paracetamol treatment.
SGOT, SGPT, alkaline phosphatase and acid phos
phatase activities were further increased when para
cetamol was administered to the alcohol treated rats.
Liver and kidney alcohol dehydrogenase (ADH)
activities decreased in alcohol and paracetamol treated
rats. This was further decreased after paracetamol
administration in alcohol fed rats. Changes were also
observed in the levels of liver GOT and GPT as also in
the metabolism of lipids, lipid peroxidase and
glycoconjugates in the liver and brain. As a result the
level of malondialdehyde increased in the liver and
brain of both alcohol and paracetamol treated rats.
Alcohol administration also increased the deposition of
glycolipids in the brain. Alterations in the metabolism
of lipids, lipid peroxides and glycoconjugates were also
observed in extraneural and extrahepatic tissues (eg
heart, kidney and aorta).
Testosterone and N-acetyl-D-cysteine offered
some protection against the toxic effects of alcohol and
pracetamol singly or together. This protective effect was
evident from the decrease in SGOT, SGPT and serum
acid and alkaline phosphatase activities as also
reduction in the levels of triglycerides, peroxidation
products, serum lipid and glycolipids.
Hepatic histopathology of alcohol and paraceta
mol treated rats showed changes in the form of high
degree of nuclear disintegration, chromatolysis, cyto
plasmic and hydropic vacuolation as also necrosis,
necrobiosis and central venous dilation. Liver cells of
rats treated with alcohol alone showed appearance of
binucleate cells, hyaline bodies, necrobiosis, portal
inflammation and kupffer cell hyperplasia. Admini
stration with only paracetamol produced nuclear
disintegration, chromatolysis and necrosis. These A
changes confirmed the hepatotoxic effect of alcohol and
paracetamol. Paracetamol produced synergistic effect
when administered to alcohol fed rats.
D.S. Jaya
Venugopal P. Menon
Department of Biochemistry
University of Kerala
Thiruvananthapuram.
Publications:
Jaya, D.S., Augustine, J. and Menon. V.P. Role of lipid peroxides,
glutathione and antiperoxidative enzymes in the alcohol and drug
toxicity./hd知)J Exp Biol 30: 453, 1993.
ICMR NEWS
The following meetings of various technical
groups/committees of the Council were held:
EG on Neem Oil for
Contraception
April 19, 1994*
Meetings of Task Forces (TFs)/Expert Groups
(EGs)/Scientific Working Groups (SWGs)/Project
Advisory Committees (PACs)/Scientific Advisory
Committees (SACs) held at New Delhi:
SWG on Cardiovascular
Diseases
April 27, 2994
Inter-Departmental
meeting of TF on Product
Development for Indigenization
of Copper T 200 B Materials.
64
April 18, 1994
PAC on Long-term
Epidemiological Study on Gas
Exposed Victims at Bhopoal
May 3, 1994
SAC of the Bhopal Gas
Disaster Research Centre,
Bhopal
May 3, 1994
PAC on Coronary Heart
Diseases
May 10, 1994
Research Centre, Madras, participated in the joint
meeting of the Steering Committees on Immunology
(IMMYC) and Chemotherapy (THEMYC) of Myco
bacterial Diseases and also in the third meeting of the
Steering Committee on the Chemotherapy of Myco
bacterial Diseases (THEMYC) at Geneva (April 27-30,
1994).
Participation of ICMR Scientists in Scientific Events:
Dr. Kalyan Banerjee, Director, Nation?! Institute
of Virology, Pune, participated in a WHO meeting on
Emerging Diseases at Geneva (April 25-26, 1994). •
Dr. C.P. Puri, Dy. Director, Institute for Research
in Reproduction, Bombay, participated in the Steering
Committee meeting of the Task Force on Post
ovulatory Methods for Fertility Regulation, as also in
the Scientific Group meeting on Medical Methods for
Inducing Abortion at Geneva (April 20-22 and 25-27,
1994 respectively).
Dr. Puri delivered a lecture on Antiovulatory
Activity of RU 486 and related Substance at the Institute
of Hormone and Fertility Research at Hamburg (May 2,
1994).
Dr. M.D. Gupte, Dy. Director (Senior Grade),
CJIL Field Unit at Avadi, Madras and Dr. T. Shanta
Devi, Dy. Director (Senior Grade), Tuberculosis
Dr. G.V. Satyavati, Director-General (Designate),
participated in the meeting of the Task Force on
Biotechnology of Medicinal and Aromatic Plants at the
Department of Biotechnology, New Delhi (May 9,
1994).
Appointments:
Dr. V.K. Srivastava took over as Director of the
Councirs Regional Medical Research Centre, Dibrugarh
w.e.f. April 28, 1994.
Workshops:
Workshops were organized for the staff of the
Human Reproduction Research Centres on "Improving
Health Education, Counselling and Technical Skills in
Delivery of Contraceptives through Cafeteria Approach*'
at Guwahati nd Belgaum on April 21-22 and 24-25,1994
respectively.
COUNCIL'S TRAINING PROGRAMMES FOR 1994-95
Virology
...
At the National Institute of Virology, Pune:
Diploma in
May!995).
...
Medical - Virology (June
1994-
)Reproductive Biology
At the Institutefor Research in Reproduction, Bombay:
Workshop on Gynaecologic Cytology and Immuno
cytochemistry (September 26-October 1, 1994).
...
Occupational Health
At the National Institute of Occupational Health. •
Ahmedabad:
...
Orientation Course on Occupational Health for
Industrial Medical Officers (September 19-24,
杪 94).
...
Training Course on Air Pollution Monitoring and
Risk Assessment (October 19-25, 1994).
...
Training Course in Pesticide Residue Analysis
(December 5-9, 1994).
Endocrinology
At the National Institute of Nutrition, Hyderabad:
..
Annual Training Course on Endocrinological
Techniques and their Applications (August 1September 16, 1994).
Nutrition
Medical Entomology
At the Vector Control Research Centre, Pondicherry:
...
M.Sc.in Medical Entomology (from August 1994:
for 2 years).
...
Short-term Course on Malaria, Filariasis and
Urban Vector Control for in-service candidates
(June 1994).
the National Institute of Nutrition, Hyderabad:
...
M.Sc.in Applied Nutrition (June 1J994-February
28, 1995).
Annual Training Course in Nutrition (December 1,
1994-February 28, 1995).
65
Laboratory Animal Technology
Haematology
At the Laboratory Animal Information Service Centre,
National Institute of Nutrition, Hyderabad:
At the Institute of ImmunohaemMolofiy, Bombar;
Training Course for Laboratory Animal Techni
cians (June 15-July 31, 1994).
*
"J
•/
...
Training Course in Blood Grjpup Serology and
Blood Bank Methodology for Technicians (August
9-September 8, 1994).
...
Training Course in Blood Group Serology and
Blood Bank Methodology for Medical Officers
(August 9-October 7, 1994).
Training Course for Laboratory Animal Super
visors (September 12- December 10, 1994).
INDIAN COUNCIL OF MEDICAL RESEARCH
The following areas have been identified for research in tuberculosis and other
chest diseases::
•
Pharmacokinetics of antitubercular drugs in the young and elderly.
•
Operational research studies in tuberculosis.
•
Studies to evolve epidemiological tools/indicators.
•
Diagnostic criteria for tuberculosis of organs other than the lungs.
•
Bacteriology of community acquired pneumonia.
•
Nontubercular chest diseases.
•
Use of bronchoalveolar lavage in the diagnosis of obscure pulmonary pathology.
Editorial Board
Chairman
Dr. S.P. Tripathy
Director-General
Members
Dr. Badri N. Saxena
Dr. C.R. Ramachandran
Chief, Publication & Information
Dr. G.V. Satyavati
Editor
Dr. N. Medappa
Printed and Published by Shri J.N. Mathur for the Indian Council of Medical Research
New Delhi at the ICMR Offset Press, New Delhi
R.N. 21813/71
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