Current practices in family planning: a population based study

Background: To study the knowledge, current practices of family planning methods and acceptance post motivation.Methods: Cross-sectional study conducted at family planning OPD of AIIMS, New Delhi, India. A total of 1516 couples who came for MTP at any gestation couple were enquired about knowledge, currently used contraceptive method and reason for abortion. Couple was counseled and allowed to choose contraceptive method using cafeteria approach. Mean values of continuous data were tested using t-test/ANOVA. Categorial data were compared using chi-square/ Fischers exact test.Results: Mean±SD age of the women was 28.89±5.21 years with 9.98±4.56 weeks POG. Around 81% of women had one or more living children with 62.67% women with at least one abortion previously. Majority used male condoms (42.10%) followed by natural method (21.01%), Cu-T (3.80%), OCPs (1.65%), injectable (0.30%), I-pill (0.24%). Awareness was maximum for male condoms, Cu-T, OCPs, female sterilization (100%) and least for female condoms (20%) and LNG-IUS (8.46%). Contraceptive failure (68.90%), congenital abnormality in the fetus (22.40%), maternal disease (5.90%), rape (1.60%), completed family (0.80%) and not using any method (0.30%) were the reasons of abortion. Majority of abortions were in first trimester (70%). Post-motivation around 69.30% of the couples accepted some form of contraception. Female sterilization (32.50%) method accepted by the couples as compares to temporary methods (36.70%) such as Cu-T, OCPs, Injectables etc.Conclusions: Despite of awareness the family planning programme is unsuccessful largely due to inappropriate attitude. Behavioral modification and communication goes a long way to slove the problem.

Enhanced efficacy of sequential administration of Albendazole for the clearance of Wuchereria bancrofti infection: Double blind RCT

Till today, there is no effective treatment protocol for the complete clearance of Wuchereria bancrofti (W.b) infection that causes secondary lymphoedema. In a double blind randomized control trial (RCT), 146 asymptomatic W. b infected individuals were randomly assigned to one of the four regimens for 12 days, DEC 300 mg + Doxycycline 100 mg coadministration or DEC 300 mg + Albendazole 400 mg co-administration or DEC 300 mg + Albendazole 400 mg sequential administration or control regimen DEC 300 mg and were followed up at 13, 26 and 52 weeks post-treatment for the clearance of infection. At intake, there was no significant variation in mf counts (F(3,137)=0.044; P=0.988) and antigen levels (F(3,137)=1.433; P=0.236) between the regimens. Primary outcome analysis showed that DEC + Albendazole sequential administration has an enhanced efficacy over DEC + Albendazole co-administration (80.6 Vs 64.7%), and this regimen is significantly different when compared to DEC + doxycycline co-administration and control (P<0.05), in clearing microfilaria in 13 weeks. Secondary outcome analysis showed that, all the trial regimens were comparable to control regimen in clearing antigen (F(3, 109)=0.405; P=0.750). Therefore, DEC + Albendazole sequential administration appears to be a better option for rapid clearance of W. b microfilariae in 13 weeks time. (Clinical trials.gov identifier – NCT02005653)

Response of malaria vectors to conventional insecticides in the southern districts of Odisha State, India.

Background & objectives: Updating information on response (susceptible / resistant status) of vectors to the insecticides in use is essential to formulate and introduce appropriate resistance management strategy. Therefore, a study was undertaken in the 10 southern districts of Odisha State, which are endemic for Plasmodium falciparum malaria, to determine the insecticide susceptibility/ resistance status of Anopheles fluviatilis and An. culicifacies, the vectors of malaria. Methods: Mosquitoes were collected during September 2010 - February 2012 from 60 randomly selected villages in the 10 districts and blood-fed females were exposed to the diagnostic dosage of DDT (4.0%), malathion (5.0%) and deltamethrin (0.05%) for one hour. Mortality was recorded at 24 h after the exposure. The test mortality was corrected to the control mortality. Results: An. fluviatilis was susceptible to the three insecticides tested while, An. culicifacies was resistant to DDT and malathion in all the 10 districts except in two, where its response against malathion was under ‘verification required’ category. Against deltamethrin, An. culicifacies was susceptible in two districts; while in the other eight districts its response was under ‘verification required’ category. Interpretation & conclusions: Since An. fluviatilis the vector species primarily associated with transmission of malaria, was still susceptible to DDT, indoor residual spraying with DDT could be continued in the 10 districts. Also, in view of the large scale implementation of long lasting insecticidal nets and the signs of development of resistance in An. culicifacies to deltamethrin, response of the vectors to synthetic pyrethroids needs to be periodically monitored.

Survival of diurnally sub periodic Wuchereria bancrofti in Downsiomyia nivea (Diptera: Culicidae): a density dependent factor from Andaman & Nicobar Islands.

Background & objectives: In India, diurnally sub periodic Wuchereria bancrofti transmitted by Downsiomyia nivea is prevalent only in the Nicobar district of Andaman and Nicobar Islands. The ongoing LF elimination programme aims at transmission interruption by bringing down the microfilarie (mf) load in the community, which has implication on the parasite load in mosquito vector. Therefore, understanding density dependent constraints on transmission assumes significance from control perspective. The present study was undertaken in Teressa Island to understand the density dependent parasite mortality and survival probability of the parasite Do. nivea. Methods: The entomological data collected from Teressa Island, endemic for the diurnally sub periodic form of W. bancrofti were used to examine the parasite loss and its survival up to infectivity. Patterns of parasite distribution in Do. nivea were examined. Results: Distribution patterns of microfilariae were found to be over dispersed in Do. nivea. The later stages of the parasite in the vector were randomly distributed. Distribution pattern of various filarial larval stages suggested that the loss of parasites occurred as development progressed and was maximal between the first and second stages. Further, both the prevalence of infection and the degree of parasite aggregation in the vector population have fallen significantly with development of parasite stage. Interpretation & conclusions: Results indicate the operation of parasite density dependent mortality of vectors or parasite loss or combination of both. The present study with Aedes transmitted filariasis conducted before launching LF elimination programme in the study area indicates a comparable level of parasite regulation in the vector which has similar implications on the transmission threshold. Thus, the consideration of Aedes with Culex in deriving the critical level of antigen positive for making decisions on cessation of mass drug administration (MDA) can be justified. However, with MDA aiming at reducing parasite load in the community, the operation of density dependent factor in the transmission becomes less pronounced in the subsequent rounds of MDA.

Seasonal prevalence & resting behaviour of Anopheles minimus Theobald & An. fluviatilis James (Diptera: Culicidae) in east-central India.

Background & objectives: Anopheles minimus has recently been reported to have re-appeared in Keonjhar district of Orissa after a period of about 45 years of launching the malaria eradication programme. An. minimus and An. fluviatilis were the incriminated major malaria vectors in the district, endemic for falciparum malaria. The information on seasonal prevalence and resting behaviour of the vectors is crucial for implementing appropriate malaria control measures. Therefore, a study was undertaken on seasonal prevalence and resting behaviour of An. minimus and An. fluviatilis in this district. Methods: Seven randomly selected villages of Keonjhar district, Orissa, were studied during August 2005 to November 2007. Daytime resting collections indoors and outdoors were made covering three seasons of the year. The Anopheles mosquitoes obtained from different habitats were identified. Collections were maintained separately according to different sites as well as heights of the walls in human dwellings. Results: Among the indoor collections, the densities of An. minimus and An. fluviatilis were higher in human dwellings than cattle sheds. An. fluviatilis was the predominant (41.5%) species followed by An. minimus (26.3%) in human dwellings. The density of both the vector species in human dwellings peaked during rainy and winter seasons followed by summer. Walls were the most preferred site by these vectors for resting and the maximum number was collected at a height of 3 to 4 ft. Interpretation & conclusions: The resting behaviour of the vector species increases their contact with the sprayed walls and therefore, a quality residual spraying of human dwellings focusing indoor walls could interrupt the malaria transmission in this area.

Effect of a single dose of diethylcarbamazine, albendazole or both on the clearance of Wuchereria bancrofti microfilariae and antigenaemia among microfilaria carriers: A randomized trial.

Background. Lymphatic filariasis is a major vector-borne parasitic disease. The global programme to eliminate lymphatic filariasis was launched in 1997 and currently over 570 million people are covered under it in 48 countries. Mass annual single-dose drug administration of diethylcarbamazine (DEC), co-administrated with albendazole for 5–6 years and mass distribution of diethylcarbamazine-fortified salt are the two strategies for elimination of filariasis. Methods. Asymptomatic volunteers residing in Puducherry, India were screened for microfilaria (mf) by examining nocturnal thick blood smears. Those testing positive were randomly assigned to receive a single dose of DEC (6 mg/kg body weight) or albendazole 400 mg or both. Participants were hospitalized for 5 days. Membrane filtration count was used to assess microfilaraemia and ELISA (Og4C3) assay to measure circulating filarial antigens (CFA). Measurements were done before treatment and at 1, 2 and 3 years post-treatment. Viability of the adult worms was assessed by looking for the filarial dance sign (FDS) using ultrasound examination of the scrotum in men with hydrocele. Results. Fifty-four microfilaraemic individuals were studied. The mf prevalence started decreasing only by day 180 posttreatment in the DEC group but much earlier in the other two groups (day 30 in the albendazole and day 90 in the DEC with albendazole group). The decrease in mf was marginal (17.6%, 26.3% and 27.8%, respectively) by the end of year 1 posttreatment, but significant (96.7%, 78.6% and 93.3%, respectively) by the end of year 2 post-treatment (p<0.05). By the end of year 3, the level decreased to 80% in the DEC, 90% in the albendazole and to 100% in the DEC and albendazole groups. However, the mf intensity decreased © The National Medical Journal of India 2010 Vector Control Research Centre, Department of Health Research (ICMR), Indira Nagar, Puducherry 605006, India S. L. HOTI, S. P. PANI, P. VANAMAIL, K. ATHISAYA MARY, L. K. DAS, P. K. DAS Correspondence to S. L. HOTI; slhoti@yahoo.com significantly (by 39%; p<0.05) by day 7 post-treatment in both the DEC and DEC with albendazole groups, but only by day 30 in the albendazole group. In all the drug groups, the prevalence as well as intensity of CFA returned to pretreatment levels by the end of year 3 post-treatment. Conclusion. Annual single-dose administration of all the 3 drug regimens significantly reduced antigenaemia levels. There were no significant differences in the efficacy and overall pattern of CFA clearance between the 3 drug regimens.

Tolerability and efficacy of a three-age class dosage schedule of Diethylcarbamazine citrate (DEC) in the treatment of microfilaria carriers of Wuchereria bancrofti and its implications in mass drug administration (MDA) strategy for elimination of lymphatic filariasis (LF).

A six-age class dosage schedule of Diethylcarbamazine (DEC) of 50mg (1-2 years), 100mg (3-4 years), 150mg (5-8 years), 200mg (9-11 years), 250mg (12-14 years) and 300mg for above 14 years is being adopted for annual single dose MDA for LF elimination treat Wuchereria bancrofti microfilaria carriers. In order to increase the community compliance as well as to make the distribution easier during MDA, a revised 3 age class dosage schedule of 100mg (2-4 years), 200mg (5-14 years) and 300mg for above 14 years was evaluated for its tolerability and efficacy. By this change, it was observed that the 4-8 years age class is receiving 50 mg higher and 11-14 years age class is receiving 50mg lesser dose compared to the earlier class schedule. Therefore, the safety aspect in the age class of 4-8 years and efficacy component in the age class of 11-14 years were assessed. Apparently "healthy" asymptomatic microfilaraemic volunteers between the age class of 4-8 and 11-14 years were recruited for the study. The incidence of side reaction in the 4-8 years age class was 50.0% with 150mg dose and 66.7% with 200mg (P>0.05). No life threatening adverse reactions was observed in any dosage schedule. Fever, headache and myalgia, the predominant adverse reactions were mild and similar in both schedules. The mean intensity of the three major specific adverse reactions (fever, headache and myalgia) also did not differ significantly (P>0.05). For the purpose of LF elimination, efficacy in terms of reduction in mean microfilaria load is important. In the 11-14 year age class considerable reduction in the geometric mean density (GMD) was observed by day 90 and 180 post-therapy in both groups (250mg group and 200mg group) compared to pre-therapy level. By day 360 post-therapy, the difference was statistically not significant (P>0.05) (reduction of 72.2% in 250mg and 69.6% reduction in 200mg). The reductions in GMD were statistically significant when compared to pre-therapy levels in both the old (250mg) and new (200mg) doses. Thus, three- age class dosage schedule is as safe and efficacious as the six- age class schedule.

Tolerability and efficacy of single dose diethylcarbamazine (DEC) alone or co-administration with Ivermectin in the clearance of Wuchereria bancrofti microfilaraemia in Pondicherry, South India.

The tolerability and efficacy of single dose DEC (12mg/kg body weight) or co-administration of DEC (6mg/kg body weight) with Ivermectin (200 or 400 mcg/kg of body weight) was studied in 60 asymptomatic W. bancrofti microfilariae (Mf) carriers following a double blind randomized design. The drugs were tolerated well. The incidence of adverse reactions of DEC (85.0%), DEC + Ivermectin 200mcg (95.0%) and DEC + Ivermectin 400mcg (100%) did not vary significantly (P>0.05). The mean score of adverse reaction intensity due to DEC + Ivermectin 200mcg (1.41) was significantly higher compared to DEC (0.61) (P<0.05). However, there was no significant difference between and DEC +Ivermectin 400mcg (0.89) and DEC + Ivermectin 200mcg (1.41) and DEC + Ivermectin 400mcg and DEC. The major adverse reactions were fever, headache and myalgia in all groups. The incidence and intensity of the adverse reactions were maximum between 24 to 48 hours of post therapy. The haematological and biochemical parameters did not vary significantly between pre and 7-day post therapy values in any of the study groups (P>0.05). Efficacy was measured in terms of proportion of cases clearing microfilaraemia completely and reduction in geometric mean parasite density in comparison to pre therapy levels. At the end of one year, DEC with Ivermectin 400mcg group showed significantly higher efficacy in complete clearance of Mf (94.4%) than that of DEC with Ivermectin 200mcg (60.0%) or DEC alone (52.6%) (P<0.05). However, no significant difference was observed in reduction of geometric mean Mf density (99.9%, 99.7%, 99.5% respectively). In all the groups, the tolerability and efficacy of the drugs were independent of host age and gender.

Comparison of an immunochromatographic card test with night blood smear examination for detection of Wuchereria bancrofti microfilaria carriers.

BACKGROUND: At present, two diagnostic tests--Og4C3 ELISA and an immunochromatographic card test (ICT)--are available to detect circulating filarial antigens of Wuchereria bancrofti in serum/whole blood samples collected during the day. We aimed to assess the sensitivity of the new format card test 'NOW ICT Filariasis' in detecting microfilaria carriers of W. bancrofti in comparison with conventional microscopic techniques and Og4C3 ELISA. METHODS: A total of 200 persons were selected from two villages following a quota sampling design (100 in each village). The required number of houses was selected using a systematic sampling procedure with a random start of the first household. Blood samples were taken from all the available persons in each selected house until the quota of 100 was reached. The new format ICT test, Og4C3 ELISA and night blood smear examination for microfilaria were carried out following standard procedures. RESULTS: The sensitivity of the new format ICT test was 100% among microfilaria carriers (detected by both early and late readings). The kappa statistic measure of agreement between the two readings of all the samples (n =200) tested was 0.811 (p<0.05). The new format test also reported 25% of microfilaria-negative individuals as being positive for circulating filarial antigens. However, the diagnostic lines were not stable beyond 10 minutes (particularly in the case of amicrofilaraemic persons). Though there was an overall agreement between the results of ICT and Og4C3 tests (kappa =0.612; p< 0.05), the sensitivity of the Og4C3 test was lower than that of ICT. CONCLUSION: The new format ICT test is highly sensitive in detecting microfilaria carriers in endemic communities. Improvement in the format to provide stable diagnostic lines, specificity of the format and cost of the test kit are to be considered before its large-scale use.

Micro-spatial variation in filarial disease and risk of developing disease associated with microfilaremia in urban situation.

Clinical and parasitological surveys were carried out concurrently during 1986 in Pondicherry. The analyses showed that there was no significant micro-spatial variation in prevalence of total diseases (acute and chronic) and the manifestations such as hydrocele and lymphedema in the different zones and stations of Pondicherry urban area, a stable endemic area. Analyses on different filariometric indices in different stations showed a significant correlation between disease and mf prevalence (r = 0.4106; p = 0.037). The prevalence of disease and hydrocele in microfilaremic individuals (9.4% and 20.0% respectively) was higher compared to that observed in amicrofilaremic persons (6.4% and 11.2% respectively). The relative risk (RR) of parasite carriers developing disease (any manifestations) was marginally higher compared to amicrofilaremic persons (1.18). However, the RR of developing hydrocele manifestation due to microfilaremia was much greater (1.5) compared to amicrofilaremic persons. The attributable risk (AR) due to microfilaremia for developing hydrocele was 0.05. This suggests that although the risk is high in mf carriers, there might be alternate ways of developing disease without the infected person becoming microfilaremic. The limitations of point prevalence data on understanding complex dynamics of infection and disease are discussed.

Cumulative exposure and its relationship with chronic filarial disease in bancroftian filariasis.

Several hypotheses have been put forth about the factors influencing the dynamics of infection and disease in lymphatic filariasis. However, appropriate validation of these hypotheses by real situation analyses of epidemiological data is lacking. The present analyses examine the relationship between cumulative exposure to infection and prevalence of disease by utilizing the existing entomological and clinical data collected between 1981 and 1986 in Pondicherry, South India, endemic for bancroftian filariasis. While there was a significant negative association when the cumulative exposure was correlated with total prevalence of disease (r = 0.70, p = 0.024) as well as hydrocele alone (r = 0.74, p = 0.014), a significant positive association was found with prevalence of lymphedema (r = 0.72, p = 0.018). These results suggest that hydrocele development follows early after exposure, but prolonged exposure could result either in development of lymphedema or immune tolerance resulting in microfilaremia. These could also suggest that the pathomechanisms in development of hydrocele and lymphedema could follow different pathways. Implications of the present findings are discussed in light of the various hypotheses put forward by earlier studies.

Biting periodicity index of Culex quinquefasciatus & its relationship with microfilaria periodicity in Pondicherry.

The biting periodicity index of the bancroftian filariasis vector, C. quinquefasciatus, was calculated on the basis of a large longitudinal data base and compared with the periodicity index of microfilariae of Wuchereria bancrofti. The biting periodicity index of the vector population was 29.78 and found to be close to the periodicity index of the microfilariae. The peak biting activity of the vector and peak appearance of microfilariae in the peripheral blood occurred at about 01.00 h, which accounts for the optimum infection of the vector population. The early night biting density of the vector population showed a highly significant (P less than 0.0005) linear relationship with all night biting density.

Influence of diethylcarbamazine on the patent period of infection in periodic Brugia malayi.

The patent period of infection which reflects the fecundic life span of the adult female worm was estimated for periodic B. malayi in south India by using immigration death model. Longitudinal data on natural loss of infection or that due to different degrees of DEC pressure in a cohort population of microfilaria carriers after a three years period, were used for the estimations. The patent period of infection was estimated to be 3.45 yr under natural conditions (without DEC therapy), which was reduced to 1.67 yr following one full course of selective therapy (6 mg/kg body wt/day for 12 days). When selective therapy was supplemented with four rounds of biannual single-dose mass DEC therapy (6 mg/kg body wt) the patent period was further reduced to 1.34 yr. The proportion loss of infection was relatively higher in microfilaria carriers who discontinued DEC selective therapy, when compared to natural loss. The percentage reduction in the mean microfilaria count was observed to decrease with increasing DEC pressure. Neither sex nor the age of the host was found to influence the fecundic life span or the survival of female adult worm.

Estimation of fecundic life span of Wuchereria bancrofti from longitudinal study of human infection in an endemic area of Pondicherry (south India).

The fecundic life span of adult female W. bancrofti was estimated by longitudinal study of microfilaraemia in a cohort of population (7,525) in Pondicherry. The estimation was based on a deterministic model, using the rate of loss in infection. The life span of the parasite was 10.2 yr without chemotherapy, while it was reduced to 5.3 yr following diethyl-carbamazine therapy. The analysis of mean microfilarial counts in microfilaraemic persons without chemotherapy indicates that the rate of production of microfilaria by the adult female is stable at least for a period of five years.

A mathematical analysis of various factors involved in transmission of bancroftian filariasis in Pondicherry.

The variation of clumping factor in microfilaraemia among different age groups was observed in Pondicherry for 1981 and 1986. The clumping factor was minimum in the age group 0-5 yr and it was maximum in 16-20 yr group in 1981 and 21-25 yr in 1986. The variation in clumping factor resembled the changes in microfilaria (mf) rate. Multiple linear regression analysis showed that the multiple correlation between mf rate and the other parameters i.e., median microfilarial density (MFD50), clumping factor in human population, and, infection rate and infectivity rate in vector population was highly significant. The relationship between filariometric indices in human host and vector population may provide the basis on which a mathematical model on transmission of filariasis could be developed.

A simple deterministic model for host-parasite relationship in Wuchereria bancrofti infection & its relevance to parasite regulation in human host.

A deterministic immigration-death model, which reflects the population dynamics of W. bancrofti in human host has been applied to study the relationship between vector and human infections. Application of the model showed that the rate of acquisition and loss of human infection were approximately equal (L = 0.130 and M = 0.129). The relationship of infective resting density (IRD) in vector population with maximum intensity (Imax) of infections and microfilaria prevalence (MFP) in human population were examined by using the least squares polynomial regressions. The fifth order polynomial regressions were found to be adequate to describe the observed pattern (Imax vs IRD: R2 = 0.8464, P = 0.0015; MFP vs IRD: R2 = 0.7246, P = 0.019). The observed relationships indicated that at an infective resting density of 0.26 per man hour or above, the density-dependent factors start regulating the human infections, which showed a declining trend, following this level.

Prevalence of bancroftian filariasis & its control by single course of diethyl carbamazine in a rural area in Tamil Nadu.

The prevalence of microfilaraemia, clinical spectrum of bancroftian filariasis and vector potential were studied in Vettavalam village in North Arcot district of Tamil Nadu. The effectiveness of selective therapy with diethyl carbamazine (DEC) in controlling filariasis in rural areas was also evaluated. The prevalence of microfilaraemia (mf rate) and disease (disease rate) was found to be 11.7 and 11.09 per cent respectively. Hydrocele was the dominant clinical sign in males and lymphoedema in females. The density of the vector Culex quinquefasciatus was 25.44 females/man-hour, and the infection and infectivity rates were 18.16 and 1.09 per cent respectively. All mf carriers detected after the mass blood survey were given a single course of DEC at the dosage of 6 mg/kg of body wt/day for 12 days. Only 61.6 per cent of them took the full course of DEC treatment. DEC therapy brought down the mf rate from 11.7 to 5.84 per cent after one month. In the absence of further treatment, there was no significant change in mf prevalence after one year.