Chemoprophylaxis vaccination with a Plasmodium liver stage autophagy mutant affords enhanced and long-lasting protection

Genetically attenuated sporozoite vaccines can elicit long-lasting protection against malaria but pose risks of breakthrough infection. Chemoprophylaxis vaccination (CVac) has proven to be the most effective vaccine strategy against malaria. Here, we demonstrate that a liver stage-specific autophagy mutant of Plasmodium berghei (ATG8 overexpressor), when used as a live vaccine under a CVac regimen, provides superior long-lasting protection, in both inbred and outbred mice, as compared to WT-CVac. Uniquely, the protection elicited by this mutant is predominantly dependent on a CD8⁺ T-cell response through an IFN-γ-independent mechanism and is associated with a stable population of antigen-experienced CD8⁺ T cells. Jointly, our findings support the exploitation of liver-stage mutants as vaccines under a CVac protocol. This vaccination strategy is also a powerful model to study the mechanisms of protective immunity and discover new protective antigens.

A single Na+-Pi cotransporter in Toxoplasma plays key roles in phosphate import and control of parasite osmoregulation

Inorganic ions such as phosphate, are essential nutrients required for a broad spectrum of cellular functions and regulation. During infection, pathogens must obtain inorganic phosphate (P_i) from the host. Despite the essentiality of phosphate for all forms of life, how the intracellular parasite Toxoplasma gondii acquires P_i from the host cell is still unknown. In this study, we demonstrated that Toxoplasma actively internalizes exogenous P_i by exploiting a gradient of Na⁺ ions to drive P_i uptake across the plasma membrane. The Na⁺-dependent phosphate transport mechanism is electrogenic and functionally coupled to a cipargarmin sensitive Na⁺-H⁺-ATPase. Toxoplasma expresses one transmembrane P_i transporter harboring PHO4 binding domains that typify the PiT Family. This transporter named TgPiT, localizes to the plasma membrane, the inward buds of the endosomal organelles termed VAC, and many cytoplasmic vesicles. Upon P_i limitation in the medium, TgPiT is more abundant at the plasma membrane. We genetically ablated the PiT gene, and ΔTgPiT parasites are impaired in importing P_i and synthesizing polyphosphates. Interestingly, ΔTgPiT parasites accumulate 4-times more acidocalcisomes, storage organelles for phosphate molecules, as compared to parental parasites. In addition, these mutants have a reduced cell volume, enlarged VAC organelles, defects in calcium storage and a slightly alkaline pH. Overall, these mutants exhibit severe growth defects and have reduced acute virulence in mice. In survival mode, ΔTgPiT parasites upregulate several genes, including those encoding enzymes that cleave or transfer phosphate groups from phosphometabolites, transporters and ions exchangers localized to VAC or acidocalcisomes. Taken together, these findings point to a critical role of TgPiT for P_i supply for Toxoplasma and also for protection against osmotic stresses.

Inorganic phosphate (P_i) is indispensable for the biosynthesis of key cellular components, and is involved in many metabolic and signaling pathways. Transport across the plasma membrane is the first step in the utilization of P_i. The import mechanism of P_i by the intracellular parasite Toxoplasma is unknown. We characterized a transmembrane, high-affinity Na⁺-P_i cotransporter, named TgPiT, expressed by the parasite at the plasma membrane for P_i uptake. Interestingly, TgPiT is also localized to inward buds of the endosomal VAC organelles and some cytoplasmic vesicles. Loss of TgPiT results in a severe reduction in P_i internalization and polyphosphate levels, but stimulation of the biogenesis of phosphate-enriched acidocalcisomes. ΔTgPiT parasites have a shrunken cell body, enlarged VAC organelles, poor release of stored calcium and a mildly alkaline pH, suggesting a role for TgPiT in the maintenance of overall ionic homeostasis. ΔTgPiT parasites are poorly infectious in vitro and in mice. The mutant appears to partially cope with the absence of TgPiT by up-regulating genes coding for ion transporters and enzymes catalyzing phosphate group transfer. Our data highlight a scenario in which the role of TgPiT in P_i and Na⁺ transport is functionally coupled with osmoregulation activities central to sustain Toxoplasma survival.

Determinants of Malaria Protective Immunity in Mice Immunized with Live Sporozoites during Trimethoprim-Sulfamethoxazole Prophylaxis

HIV and malaria geographically overlap. Trimethoprim–sulfamethoxazole (TMP-SMX) is a drug widely used in HIV-exposed uninfected and infected children in malaria-endemic areas, and is known to have antimalarial effects. Further study in terms of antimalarial impact and effect on development of malaria-specific immunity is therefore essential. Using rodent malaria models, we previously showed that repeated Plasmodium exposure during TMP-SMX administration, or chemoprophylaxis vaccination (CVac), induces CD8 T-cell–dependent preerythrocytic immunity. However, humoral immune responses have been shown to be important in models of preerythrocytic immunity. Herein, we demonstrate that antibody-mediated responses contribute to protective immunity induced by CVac immune sera using TMP-SMX in models of homologous, but not heterologous, parasite species. Clinical studies must account for potential anti-Plasmodium antibody induced during TMP-SMX prophylaxis.

Correction: Identification of Novel Pre-Erythrocytic Malaria Antigen Candidates for Combination Vaccines with Circumsporozoite Protein

[This corrects the article DOI: 10.1371/journal.pone.0159449.].

Trimethoprim-Sulfamethoxazole Prophylaxis During Live Malaria Sporozoite Immunization Induces Long-Lived, Homologous, and Heterologous Protective Immunity Against Sporozoite Challenge

Trimethoprim-sulfamethoxazole (TMP-SMX) is widely used in malaria-endemic areas in human immunodeficiency virus (HIV)-infected children and HIV-uninfected, HIV-exposed children as opportunistic infection prophylaxis. Despite the known effects that TMP-SMX has in reducing clinical malaria, its impact on development of malaria-specific immunity in these children remains poorly understood. Using rodent malaria models, we previously showed that TMP-SMX, at prophylactic doses, can arrest liver stage development of malaria parasites and speculated that TMP-SMX prophylaxis during repeated malaria exposures would induce protective long-lived sterile immunity targeting pre-erythrocytic stage parasites in mice. Using the same models, we now demonstrate that repeated exposures to malaria parasites during TMP-SMX administration induces stage-specific and long-lived pre-erythrocytic protective anti-malarial immunity, mediated primarily by CD8⁺ T-cells. Given the HIV infection and malaria coepidemic in sub-Saharan Africa, clinical studies aimed at determining the optimum duration of TMP-SMX prophylaxis in HIV-infected or HIV-exposed children must account for the potential anti-infection immunity effect of TMP-SMX prophylaxis.

Right atrial mural thrombi: An autopsy study of an under-diagnosed complication at an unusual site

Background:

Right atrial mural thrombi (RAMT) are often seen in association with cardiac diseases or foreign bodies. Unusual locations at the flutter isthmus and the atrial appendage prompted us to evaluate our 2-year autopsy data on such thrombi.

Materials and Methods:

In the 2-year retrospective autopsy, the clinical and autopsy records of patients with RAMT were reviewed, with particular reference to the presence of central venous catheter (CVC), its site of insertion, its type, material and size, its duration of placement, and the drugs infused through the catheter.

Results:

Of the 940 autopsies performed in 2 years, RAMT was seen in 24 hearts and was related to an insertion of a CVC in 23 patients (95.8%). The risk and/or associated factors for this complication were tunneled and polyethylene catheters, Intensive Care Unit admission, infused drugs, underlying cardiac diseases, and pregnancy. A noteworthy feature was the location of the thrombi in the flutter isthmus in 16 hearts (66.7%) and atrial appendage in another six hearts. Localized endocarditis/myocarditis and pulmonary thromboembolism were observed in six and four patients, respectively.

Conclusions:

This autopsy study, which has a high incidence of catheter-related RAMT, does not reflect the true incidence but reiterates the importance of guided insertion of central venous and prompt recognition of thrombus formation.

Identification of Novel Pre-Erythrocytic Malaria Antigen Candidates for Combination Vaccines with Circumsporozoite Protein

Malaria vaccine development has been hampered by the limited availability of antigens identified through conventional discovery approaches, and improvements are needed to enhance the efficacy of the leading vaccine candidate RTS,S that targets the circumsporozoite protein (CSP) of the infective sporozoite. Here we report a transcriptome-based approach to identify novel pre-erythrocytic vaccine antigens that could potentially be used in combination with CSP. We hypothesized that stage-specific upregulated genes would enrich for protective vaccine targets, and used tiling microarray to identify P. falciparum genes transcribed at higher levels during liver stage versus sporozoite or blood stages of development. We prepared DNA vaccines for 21 genes using the predicted orthologues in P. yoelii and P. berghei and tested their efficacy using different delivery methods against pre-erythrocytic malaria in rodent models. In our primary screen using P. yoelii in BALB/c mice, we found that 16 antigens significantly reduced liver stage parasite burden. In our confirmatory screen using P. berghei in C57Bl/6 mice, we confirmed 6 antigens that were protective in both models. Two antigens, when combined with CSP, provided significantly greater protection than CSP alone in both models. Based on the observations reported here, transcriptional patterns of Plasmodium genes can be useful in identifying novel pre-erythrocytic antigens that induce protective immunity alone or in combination with CSP.

Structural and functional characterization of recombinant napin-like protein of Momordica charantia expressed in methylotrophic yeast Pichia pastoris

Napin and napin-like proteins belong to the 2S albumin seed storage family of proteins and have been shown to display a variety of biological activities. However, due to a high degree of polymorphism, purification of a single napin or napin-like protein exhibiting biological activity is extremely difficult. In the present study, we have produced the napin-like protein of Momordica charantia using the methylotrophic Pichia pastoris expression system. The recombinant napin-like protein (rMcnapin) secreted in the extracellular culture supernatant was enriched by ammonium sulfate precipitation, and purified using size exclusion chromatography at a yield of ∼290 mg/L of culture. Secondary structure analysis of the purified rMcnapin revealed it to be predominantly α-helical with minimal β strand content. CD spectroscopic and fluorescence spectroscopic analyses revealed the rMcnapin to be stable at a wide range of temperatures and pH. The rMcnapin exhibited antifungal activity against Trichoderma viride with an IC50 of ∼3.7 μg/ml and trypsin inhibitor activity with an IC50 of 4.2 μM. Thus, large amounts of homogenous preparations of the biologically active rMcnapin could be obtained at shake flask level, which is otherwise difficult from its natural source.

Elastic liposome-mediated transdermal immunization enhanced the immunogenicity of P. falciparum surface antigen, MSP-119

Transdermal immunization results in poor immunogenicity, which can be attributed to poor permeability of antigens through the skin. Therefore, elastic liposome, ultradeformable lipid vesicles, may overcome the challenges faced during transdermal immunization. This versatile carrier proves better vehicle for transcutaneous delivery of protein, peptide and nucleic acid antigens. The present results are suggestive of improved immunogenicity of carboxyl-terminal 19 kDa fragment of merozoite surface protein-1 (PfMSP-119) of Plasmodium falciparum when administered subcutaneously through elastic liposomes. The prepared elastic liposomes were characterized with respect to vesicles shape and surface morphology, size and size distribution, entrapment efficiency, elasticity, stability and in vitro release. Humoral and cell-mediated immune (CMI) response elicited by topically applied PfMSP-119-loaded elastic liposomes, intramuscularly administered alum-adsorbed PfMSP-119 solution, and topically applied PfMSP-119-loaded conventional liposomes were compared and normalized with vehicle control. Results suggest greater transcutaneous immunization via elastic liposomes, and induced robust and perdurable IgG-specific antibody and cytophilic isotype responses. We report to have achieved sizeable CMI activating factor (IFNγ), a crucial player in conferring resistance to asexual blood stage malaria, responses with elastic liposomes when compared with other formulations. The fluorescence microscopy and histopathology results are suggestive of prominent skin permeation and biodistribution, and demonstrate efficient delivery of malaria antigen via elastic liposomes to immunocompetent Langerhans cells (LC) and lymphatics. In conclusion, elastic liposomal formulation provided greater entrapment efficiency, enhanced penetration and heightened and long-lasting immune response. Moreover, effective immunoadjuvant property of this carrier justifies its potential for improved vaccine delivery, and opens new avenues to explore further on the development of malaria vaccine.

ZIPCO, a putative metal ion transporter, is crucial for Plasmodium liver-stage development

The malaria parasite, Plasmodium, requires iron for growth, but how it imports iron remains unknown. We characterize here a protein that belongs to the ZIP (Zrt-, Irt-like Protein) family of metal ion transport proteins and have named ZIP domain-containing protein (ZIPCO). Inactivation of the ZIPCO-encoding gene in Plasmodium berghei, while not affecting the parasite's ability to multiply in mouse blood and to infect mosquitoes, greatly impairs its capacity to develop inside hepatocytes. Iron/zinc supplementation and depletion experiments suggest that ZIPCO is required for parasite utilization of iron and possibly zinc, consistent with its predicted function as a metal transporter. This is the first report of a ZIP protein having a crucial role in Plasmodium liver-stage development, as well as the first metal ion transporter identified in Plasmodium pre-erythrocytic stages. Because of the drastic dependence on iron of Plasmodium growth, ZIPCO and related proteins might constitute attractive drug targets to fight against malaria.

Chloroquine neither eliminates liver stage parasites nor delays their development in a murine Chemoprophylaxis Vaccination model

Chemoprophylaxis Vaccination (CVac) confers long lasting sterile protection against homologous parasite strains in humans, and involves inoculation of infectious sporozoites (SPZ) under drug cover. CVac using the drug chloroquine (CQ) induces pre-erythrocytic immunity in humans that includes antibody to SPZ and T-cell responses to liver stage (LS) parasites. The mechanism by which CVac with CQ induces strong protective immunity is not understood as untreated infections do not confer protection. CQ kills blood stage parasites, but its effect on LS parasites is poorly studied. Here we hypothesized that CQ may prolong or perturb LS development of Plasmodium, as a potential explanation for enhanced pre-erythrocytic immune responses. Balb/c mice with or without CQ prophylaxis were infected with sporozoite forms of a luciferase-expressing rodent parasite, Plasmodium yoelii-Luc (Py-Luc). Mice that received primaquine, a drug that kills LS parasites, served as a positive control of drug effect. Parasite burden in liver was measured both by bioluminescence and by qRT-PCR quantification of parasite transcript. Time to appearance of parasites in the blood was monitored by microscopic analysis of Giemsa-stained thick and thin blood smears. The parasite load in livers of CQ-treated and untreated mice did not significantly differ at any of the time points studied. Parasites appeared in the blood smears of both CQ-treated and untreated mice 3 days after infection. Taken together, our findings confirm that CQ neither eliminates LS parasites nor delays their development. Further investigations into the mechanism of CQ-induced protection after CVac are required, and may give insights relevant to drug and vaccine development.

Neither the HIV protease inhibitor lopinavir-ritonavir nor the antimicrobial trimethoprim-sulfamethoxazole prevent malaria relapse in plasmodium cynomolgi-infected non-human primates

Plasmodium vivax malaria causes significant morbidity and mortality worldwide, and only one drug is in clinical use that can kill the hypnozoites that cause P. vivax relapses. HIV and P. vivax malaria geographically overlap in many areas of the world, including South America and Asia. Despite the increasing body of knowledge regarding HIV protease inhibitors (HIV PIs) on P. falciparum malaria, there are no data regarding the effects of these treatments on P. vivax's hypnozoite form and clinical relapses of malaria. We have previously shown that the HIV protease inhibitor lopinavir-ritonavir (LPV-RTV) and the antibiotic trimethoprim sulfamethoxazole (TMP-SMX) inhibit Plasmodium actively dividing liver stages in rodent malarias and in vitro in P. falciparum, but effect against Plasmodium dormant hypnozoite forms remains untested. Separately, although other antifolates have been tested against hypnozoites, the antibiotic trimethoprim sulfamethoxazole, commonly used in HIV infection and exposure management, has not been evaluated for hypnozoite-killing activity. Since Plasmodium cynomolgi is an established animal model for the study of liver stages of malaria as a surrogate for P. vivax infection, we investigated the antimalarial activity of these drugs on Plasmodium cynomolgi relapsing malaria in rhesus macaques. Herein, we demonstrate that neither TMP-SMX nor LPV-RTV kills hypnozoite parasite liver stage forms at the doses tested. Because HIV and malaria geographically overlap, and more patients are being managed for HIV infection and exposure, understanding HIV drug impact on malaria infection is important.

Development of novel carrier(s) mediated tuberculosis vaccine: more than a tour de force

Despite worldwide availability of the vaccines against most of the infectious diseases, BCG and various programs such as Directly Observed Treatment Short course (DOTS) to prevent tuberculosis still remains one of the most deadly forms of the disease affecting millions of people globally. The evolution of multi drug resistant strains (MDR) has increased the complexity further. Although currently available marketed BCG vaccine has shown sufficient protection against childhood tuberculosis, it has failed to prevent the most common form of disease i.e., pulmonary tuberculosis in adults. However, various vaccine candidates have already entered phase I clinical trials and have shown promising outcomes. The most prominent amongst them is the heterologous prime-boost approach, which shows a great promise towards designing and development of a new efficacious tuberculosis vaccine. It has also been shown that the use of various viral and non-viral vectors as carriers for the potential vaccine candidates will further boost their effect on subsequent immunization. In this review, we briefly summarize the potential of a few novel nano-carriers for developing effective vaccination strategies against tuberculosis.

Pre-erythrocytic malaria vaccines: identifying the targets

Pre-erythrocytic malaria vaccines target Plasmodium during its sporozoite and liver stages, and can prevent progression to blood-stage disease, which causes a million deaths each year. Whole organism sporozoite vaccines induce sterile immunity in animals and humans and guide subunit vaccine development. A recombinant protein-in-adjuvant pre-erythrocytic vaccine called RTS,S reduces clinical malaria without preventing infection in field studies and additional antigens may be required to achieve sterile immunity. Although few vaccine antigens have progressed to human testing, new insights into parasite biology, expression profiles and immunobiology have offered new targets for intervention. Future advances require human trials of additional antigens, as well as platforms to induce the durable antibody and cellular responses including CD8(+) T cells that contribute to sterile protection.

Vaccination Strategies against Malaria: novel carrier(s) more than a tour de force

The introduction of vaccine technology has facilitated an unprecedented multi-antigen approach to develop an effective vaccine against complex systemic inflammatory pathogens such as Plasmodium spp. that cause severe malaria. The capacity of multi subunit DNA vaccine encoding different stage Plasmodium antigens to induce CD8(+) cytotoxic T lymphocytes and interferon-γ responses in mice, monkeys and humans has been observed. Moreover, genetic vaccination may be capable of eliciting both cell mediated and humoral immune responses. The cytotoxic T cell responses are categorically needed against intracellular hepatic stage and humoral response with antibodies targeted against antigens from all stages of malaria parasite life cycle. Therefore, the key to success for any DNA based vaccine is to design a vector able to serve as a safe and efficient delivery system. This has encouraged the development of non-viral DNA-mediated gene transfer techniques such as liposome, virosomes, microsphere and nanoparticles. Efficient and relatively safe DNA transfection using lipoplexes makes them an appealing alternative to be explored for gene delivery. Also, liposome-entrapped DNA has been shown to enhance the potency of DNA vaccines, possibly by facilitating uptake of the plasmid by antigen-presenting cells (APC). Another recent technology using cationic lipids has been deployed and has generated substantial interest in this approach to gene transfer. In this review we discussed various aspects that could be decisive in the formulation of efficient and stable carrier system(s) for the development of malaria vaccine.

Evaluation of anti-apoptotic activity of different dietary antioxidants in renal cell carcinoma against hydrogen peroxide

OBJECTIVE

To evaluate the anti-apoptotic and radical scavenging activities of dietary phenolics, namely ascorbic acid,α-tocopherol acetate, citric acid, salicylic acid, and estimate H2O2-induced apoptosis in renal cell carcinoma cells.

METHODS

The intracellular antioxidant potency of antioxidants was investigated. H2O2-induced apoptosis in RCC-26 was assayed with the following parameters: cell viability (% apoptosis), nucleosomal damage and DNA fragmentation, bcl-2 levels and flow cytometery analysis (ROS production evaluation).

RESULTS

The anticancer properties of antioxidants such as ascorbic acid, α-tocopherol acetate, citric acid, salicylic acid with perdurable responses were investigated. It was observed that these antioxidants had protective effect (anti-apoptotic activity) against hydrogen peroxide (H2O2) in renal cell carcinoma (RCC-26) cell line.

CONCLUSIONS

This study reveals and proves the anticancer properties. However, in cancer cell lines anti-apoptotic activity can indirectly reflect the cancer promoter activity through radicals scavenging, and significantly protect nucleus and bcl-2.

In vitro refolded napin-like protein of Momordica charantia expressed in Escherichia coli displays properties of native napin

Napins belong to the family of 2S albumin seed storage proteins and are shown to possess antifungal activity. Napins, in general, consist of two subunits (derived from single precursor) linked by disulphide bridges. Usually, reducing environment of the E. coli cytosol is not conducive for proper folding of heterodimeric proteins containing disulphide bridges. Present investigation reports for the first time expression of napin-like protein of Momordica charantia (rMcnapin) in E. coli and its in vitro refolding to produce biologically active protein. Full-length cDNA encoding napin-like protein (2S albumin) was isolated from M. charantia seeds by immunoscreening a cDNA expression library. The cDNA consisted of an open reading frame encoding a protein of 140 amino acid residues. The 36 amino acids at the N-terminus represent the signal and propeptide. The region encoding small and large chains of the M. charantia napin is separated by a linker of 8 amino acid residues. The region encoding napin (along with the linker) was PCR amplified, cloned into pQE-30 expression vector and expressed in E. coli. rMcnapin expressed as inclusion bodies was solubilized and purified by Ni2+-NTA affinity chromatography. The denatured and reduced rMcnapin was refolded by rapid dilution in an alkaline buffer containing glycerol and redox couple (GSH and GSSG). Refolded His-rMcnapin displayed similar spectroscopic properties as that of mature napin-like protein of M. charantia with 48.7% alpha-helical content. In addition, it also exhibited antifungal activity against T. hamatum with IC50 of 3 microg/ml. Refolded His-rMcnapin exhibited approximately 90% antifungal activity when compared with that of mature napin-like protein of M. charantia. Thus, a heterologous expression system and in vitro refolding conditions to obtain biologically active napin-like protein of M. charantia were established.

Socio-clinical profile of rabis cases in anti-rabies clinic, M. K. C. G. Medical College, Orissa

A hospital based study was conducted in the anti-rabies clinic of a medical college of Orissa during April 1988 to May 2002. Of 24 clinically diagnosed and reported rabies cases during the four years study period, 62.5% were children below 15 years of age, 67% were males, 87.5% were victims of stray dogs, 79% had not taken any anti-rabies treatment though all had undergone treatment by traditional systems of medicine.

Equine rabies immunoglobulin: a study on its clinical safety

To confirm and assess the clinical safety of equine rabies immunoglobulin (ERIG) administered locally for postexposure prophylaxis against rabies since human rabies immunoglobulin is too expensive to be affordable by most patients, a study was carried out among 3723 patients who attended the antirabies clinic, department of community medicine, MKCG Medical College Hospital, an urban tertiary hospital between September 1, 2003 and March 31, 2004. They were advised ERIG, 1621 patients were of high risk due to the nature of the bites or animal, but only 286 patients of them who could afford the treatment received it. Side-effects were monitored during the follow-up visits on days 3,7,14,30,60 and 90. Statistical analysis was done by using simple proportions and chi-square test. Of the 286 cases receiving antirabies treatment, 214 patients had dog bites and in 100 cases the animal showed abnormal behaviour. Pain (n=237) was the most common side-effect and in 18 patients fever was the systemic side-effect. No anaphylaxis was noted in the study. On day 90 none of the patients had developed rabies. So it can be concluded that ERIG is safe for passive immunisation against rabies.

Leprosy elimination campaigns in Orissa

Four Modified Leprosy Elimination Campaigns (MLECs) were conducted in Orissa by March 2003. Their impact on various leprosy indicators was analyzed. More than 70% of the people of the State were examined during these campaigns. The suspect rate decreased from 1.44% to 0.37% towards the fourth MLEC. About 15% of the suspects were clinically confirmed to be having leprosy. The total number of new cases detected during the MLEC years was on the decrease. A marked fall in new case-detection rate was observed during inter-MLEC years. This has resulted in fluctuation in the prevalence rate during the MLEC years, but the overall PR/10,000 population decreased from 12.18 in 1996-97 to 7.3 in March 2003. More than 40% of the total new cases and about 45% of total new child cases for the corresponding year were detected during the MLECs, and the proportion of total new case-detection was as high as 60.8% during the first MLEC. The proportion of female cases detected during succeeding MLECs improved and an almost equal number of female cases were detected during MLECs III and IV. Considering the present leprosy situation in Orissa and the effectiveness of MLECs in case-detection, it was recommended that such campaigns should be undertaken in select high prevalent blocks of the State at regular intervals, along with the strengthening of the integration of NLEP activities into primary health care activities.

Perspectives of leprosy patients on MDT services after integration of NLEP functions into primary health care

Sixty-five leprosy patients residing in rural Digapahandi block of Ganjam district were studied during July-August 2001 in order to ascertain their perspectives regarding different MDT services after NLEP functions were integrated into primary health care (PHC) in Orissa after September 1999. They included 43.08% multibacillary (MB) cases and 61.92% paucibacillary (PB) cases. Assessment was done by personal interviews of adult patients and the parents of child cases after verification of their treatment cards at the sub-centre. Patient's knowledge regarding the availability of MDT services under PHC services and utilization of these services were highlighted. Influence of different socio-demographic factors was also studied. Basing on the study results, recommendations were made for sustained NLEP functions through PHC in order to improve the utilization of MDT services, which will help in the elimination of leprosy.

An interventional strategy to strengthen integration of NLEP into primary health care

The Government of Orissa implemented the Revised Operational Strategy in September 1999 to integrate the NLEP functions into primary health care activities. An interventional strategy, in the form of consensus on job responsibilities and capacity-building through training of PHC staff, was developed and adopted in a rural block under the Department of Community Medicine to strengthen the integration process. The impact was studied six months after the intervention by comparing it with the leprosy situation in the pre-intervention period. Data were collected by verification of registers at the block PHC and sub-centre levels. Analysis was done using different leprosy indices, such as new case-detection rate (NCDR), child rate, deformity rate, profile of leprosy cases and patient compliance, etc. This integrated approach was found to be more community-oriented and effective in early case-detection in children and women. It also helped in providing continuous MDT services because of the involvement of primary health care functionaries in the post-intervention period.