Implementation of the Treat All Policy Among Persons with HIV Infection Enrolled in Care But Not on Antiretroviral Therapy - India, May 2017-June 2018.

Since September 2015, the World Health Organization has recommended antiretroviral therapy (ART) for all persons with human immunodeficiency virus (HIV) infection, regardless of clinical stage or CD4 count (1). This Treat All policy was based on evidence that ART initiation early in HIV infection as opposed to waiting for the CD4 count to decline to certain levels (e.g., <500 cells/mm3, per previous guidelines), was associated with reduced morbidity, mortality, and HIV transmission (2-4). Further, approximately half of persons enrolled in non-ART care that included monitoring for HIV disease progression (i.e., in pre-ART care) were lost to follow-up before becoming ART-eligible (5). India, the country with the third largest number of persons with HIV infection in the world (2.1 million), adopted the Treat All policy on April 28, 2017. This report describes implementation of Treat All during May 2017-June 2018, by India's National AIDS Control Organization (NACO) and partners, by facilitating ART initiation among persons previously in pre-ART care at 46 ART centers supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR)* in six districts in the states of Maharashtra and Andhra Pradesh. Partners supported these 46 ART centers in identifying and attempting to contact persons who were enrolled in pre-ART care during January 2014-April 2017, and educating those reached about Treat All. ART center-based records were used to monitor implementation indicators, including ART initiation. A total of 9,898 (39.6%) of 25,007 persons previously enrolled in pre-ART care initiated ART; among these 9,898 persons, 6,315 (63.8%) initiated ART after being reached during May 2017-June 2018, including 1,635 (16.5%) who had been lost to follow-up before ART initiation. NACO scaled up efforts nationwide to build ART centers' capacity to implement Treat All. Active tracking and tracing of persons with HIV infection enrolled in care but not on ART, combined with education about the benefits of early HIV treatment, can facilitate ART initiation.

Fertility suppression in male albino rats by administration of methanolic extract of Opuntia dillenii.

To control growing world population, there is a need for male contraceptive methods that are comparable to female contraceptives, but due to lack of knowledge or investigation, no sufficient safe and effective contraceptives were developed till now. In the present investigation, the effect of 100% methanol extract of Opuntia dillenii phylloclade on reproduction in male rats was studied. A first group (I) received vehicle alone to serve as control. The second group (II) was further divided into treated and recovery groups, and the plant extract at 50 mg kg body weight(-1) was administered orally for 30 days. Biochemical, haematological and histopathological analyses were carried out to reveal the effects on reproductive organs in the male rats. The weights of reproductive organs were recorded. It was found that the number of fertile males, number of inseminated females, number of litters delivered and testosterone levels were reduced significantly. Epididymal sperm count and motility were also significantly decreased. Biochemical parameters support the antifertility activity of O. dillenii i.e. decreases in protein, glycogen content and elevation in cholesterol level. Testes and sperm morphology were altered significantly. Haematological parameters have not shown any significant changes. It is concluded that 100% methanol extract of O. dillenii possesses antifertility effects on male reproduction without change in general physiology.

Diversification of T cell responses to carboxy-terminal determinants within the 65-kD heat-shock protein is involved in regulation of autoimmune arthritis.

The T cell response to the 65-kD mycobacterial heat-shock protein (Bhsp65) has been implicated in the pathogenesis of autoimmune arthritis. Adjuvant arthritis (AA) induced in the Lewis rat (RT-1(l)) by injection of Mycobacterium tuberculosis serves as an experimental model for human rheumatoid arthritis (RA). However, the immunological basis of regulation of acute AA, or of susceptibility/resistance to AA is not known. We have defined the specificity of the proliferative T cell responses to Bhsp65 during the course of AA in the Lewis rat. During the early phase of the disease (6-9 d after onset of AA), Lewis rats raised T cell responses to many determinants within Bhsp65, spread throughout the molecule. Importantly, in the late phase of the disease (8-10 wk after onset of AA), there was evidence for diversification of the T cell responses toward Bhsp65 carboxy-terminal determinants (BCTD) (namely, 417-431, 441-455, 465-479, 513-527, and 521-535). Moreover, arthritic rats in the late phase of AA also raised vigorous T cell responses to those carboxy-terminal determinants within self(rat) hsp65 (Rhsp65) that correspond in position to the above BCTD. These results suggest that the observed diversification is possibly triggered in vivo by induction of self(Rhsp65)-reactive T cells. Interestingly, another strain of rat, the Wistar Kyoto (WKY/NHsd) rat (RT-1(l)), with the same major histocompatibility complex class II molecules as the Lewis rat, was found to be resistant to AA. In WKY rats, vigorous responses to the BCTD, to which the Lewis rat responded only in the late phase of AA, were observed very early, 10 d after injection of M. tuberculosis, Strikingly, pretreatment with the peptides comprising the set of BCTD, but not its amino-terminal determinants, provided significant protection to naive Lewis rats from subsequent induction of AA. Thus, T cell responses to the BCTD are involved in regulating inflammatory arthritis in the Lewis rat and in conferring resistance to AA in the WKY rat. These results have important implications in understanding the pathogenesis of RA and in devising new immunotherapeutic strategies for this disease.

The water-deficit stress- and red-rot-related genes in sugarcane.

Sugarcane is an important international commodity as a valuable agricultural crop especially in developing countries. Sequencing was carried out to generate >35,000 expressed sequence tags (ESTs) from healthy as well as red-rot-infected tissue of Indian subtropical variety of sugarcane. Subsequent clustering with existing sugarcane ESTs in public databases identified 4,087 clusters, including 85 clusters that preferentially express upon Colletotrichum falcatum (red-rot) infection, which were previously unreported. Real-time reverse transcription-PCR profiling of selected EST clusters identified several sugarcane clusters that show differential expression in response to biotic and abiotic stress conditions. Twenty-five stress-related clusters showed >2-fold relative expression during water-deficit stress in sugarcane. Similarly, EST clusters could be identified, which exhibit association with red-rot disease when assessed in red-rot-susceptible and red-rot-resistant varieties of sugarcane. Such EST clusters are good candidates for in-depth analysis to elucidate stress-responsive pathways in sugarcane and facilitate genetic manipulation to tailor this crop for tolerance to various stresses.

Mitochondria, molecular chaperone proteins and the in vivo assembly of microtubules.

Two proteins, P1 and P2, which are specifically altered in mammalian cell mutants resistant to antimitotic drugs, have been identified as the homologs of two members of the class of proteins known as molecular chaperones. P1 is localized in mitochondria and P2-related proteins are involved in the translocation of proteins to mitochondria. To account for these and a number of other observations, a new model for in vivo microtubule assembly is proposed.

The origin of the eukaryotic cell.

Molecular sequence data are beginning to provide important insights into the evolutionary origin of eukaryotic cells. Global phylogenies of numerous protein sequences indicate that the eukaryotic cell nucleus is a chimera, which has received major contributions from both a Gram-negative eubacterium and an archaebacterium. Recent studies also indicate that the formation of the nuclear envelope and the endoplasmic reticulum was accompanied by duplication of genes for the molecular chaperone proteins (e.g. hsp70, hsp90), which facilitate protein transport across membranes. Based on these observations, it is suggested that the ancestral eukaryotic cell arose by a unique endosymbiotic event involving engulfment of an eocyte archaebacterium by a Gram-negative eubacterial host.

Mitochondrial-matrix proteins at unexpected locations: are they exported?

Many proteins that were originally characterized on the basis of non-mitochondrial functions have unexpectedly been shown to be identical to mitochondrial-matrix proteins. Most of these proteins are encoded by single nuclear genes and are initially targeted to the mitochondrial matrix. We suggest that mitochondria, as organelles of bacterial origin, possess specific mechanisms for export of proteins to other compartments.

Protein phylogenies and signature sequences: A reappraisal of evolutionary relationships among archaebacteria, eubacteria, and eukaryotes.

The presence of shared conserved insertion or deletions (indels) in protein sequences is a special type of signature sequence that shows considerable promise for phylogenetic inference. An alternative model of microbial evolution based on the use of indels of conserved proteins and the morphological features of prokaryotic organisms is proposed. In this model, extant archaebacteria and gram-positive bacteria, which have a simple, single-layered cell wall structure, are termed monoderm prokaryotes. They are believed to be descended from the most primitive organisms. Evidence from indels supports the view that the archaebacteria probably evolved from gram-positive bacteria, and I suggest that this evolution occurred in response to antibiotic selection pressures. Evidence is presented that diderm prokaryotes (i.e., gram-negative bacteria), which have a bilayered cell wall, are derived from monoderm prokaryotes. Signature sequences in different proteins provide a means to define a number of different taxa within prokaryotes (namely, low G+C and high G+C gram-positive, Deinococcus-Thermus, cyanobacteria, chlamydia-cytophaga related, and two different groups of Proteobacteria) and to indicate how they evolved from a common ancestor. Based on phylogenetic information from indels in different protein sequences, it is hypothesized that all eukaryotes, including amitochondriate and aplastidic organisms, received major gene contributions from both an archaebacterium and a gram-negative eubacterium. In this model, the ancestral eukaryotic cell is a chimera that resulted from a unique fusion event between the two separate groups of prokaryotes followed by integration of their genomes.

In vitro and in vivo antidiabetic activity of isolated fraction of Prosopis cineraria against streptozotocin-induced experimental diabetes: A mechanistic study.

A rapidly increasing incidence of Diabetes mellitus throughout the world is a major concern in both developed and developing countries and the drawbacks associated with currently available treatments led to switching researcher's attention towards naturopathy. Since ancient time, herbal plants have been traditionally used for the treatment of diabetes as they consider to be less toxic and free from side effects than synthetic ones. In our previous studies, we had isolated two new compounds (Methyl 5-tridecyloctadec-4-enoate and Nonacosan-8-one), together with three known compounds (Lupeol, ß-sitosterol and Stigmasterol) from chloroform fraction of stem bark of P. cineraria (CfPc). The present study aimed to determine the in vivo and in vivo antidiabetic activity of CfPc in streptozotocin induced experimental diabetes and also evaluated their possible mode of action. CfPc was orally administrated to STZ (55 mg/kg b.wt) induced diabetic rats at the doses of 50 and 100 mg/kg b.wt for 21 days. Treatment of CfPc significantly (p < 0.05) lowered the level of blood glucose, glycosylated hemoglobin and also restored body weight, liver glycogen content and serum insulin level in diabetic rats in a dose-dependent manner. A significant (p < 0.05) reduction in serum lipid profile markers and elevation in HDL-C after treatment with CfPc, also signifying the protective effects of CfPc in diabetes-associated complications. In addition, CfPc also promoted a significant inhibition of α-amylase enzyme activity with an IC50 value of 40.29 µg/ml. Results indicate that CfPc possess a potential in vitro and in vivo antidiabetic activity and this effect could be due to multitarget mode of action that includes antihyperglycemic, postprandial hypoglycemic, hypolipidemic and insulin secretory actions. Therefore, it could be used as a safer complementary drug in the management of diabetes and associated complications.

Tuberculosis infection control measures at health care facilities offering HIV and tuberculosis services in India: A baseline assessment.

BACKGROUND: Tuberculosis (TB) is one of world's oldest infectious disease and ranks alongside HIV as leading infectious killer. Tuberculosis infection control especially in HIV and TB care facilities has warranted attention after the recent health care-associated outbreaks in South Africa. The aim of this study was to describe the tuberculosis infection control measures implemented by HIV and TB care facilities in five high HIV burden provinces in India. METHODS: Baseline assessment of 30 high burden Antiretroviral centers and TB facilities was conducted during Oct 2015-Dec 2015 by AIC trained staff using a structured format. RESULTS: Thirty HIV and TB care facilities in five high HIV burden provinces were enrolled. Facility infrastructure and airborne infection control practices were highly varied between facilities. TB screening and fast tracking at ART centers is happening at majority of centers however inadequate TB infection control training, poor compliance to administrative and personal protective measures and lack of mechanism for health care workers surveillance need attention. CONCLUSIONS: Local specific TB infection control interventions to be designed and implemented at HIV and TB care facilities including implementation of administrative, environmental and use of personal protective equipment's with the training of staff members. Health care workers surveillance needs to be prioritized considering the rising instances of tuberculosis among Health care workers.

Phylogenetic analysis of 70 kD heat shock protein sequences suggests a chimeric origin for the eukaryotic cell nucleus.

BACKGROUND: The evolutionary relationships between archaebacteria, eubacteria and eukaryotic cells are of central importance in biology. The current view is that each of these three groups of organisms constitutes a monophyletic domain, and that eukaryotic cells have evolved fom an archaebacterial ancestor. Recent studies on a number of highly conserved protein sequences do not, however, support this view and raise important questions concerning the evolutionary relationships between all extant organisms, particularly regarding the origin of eukaryotic cells. RESULTS: We have used sequences of 70 kD heat shock protein (hsp70)--the most conserved protein found to date in all species--to examine the evolutionary relationship between various species. We have obtained two new archaebacterial hsp70 sequences from the species, Thermoplasma acidophilum and Halobacterium cutirubrum. A global comparison of hsp70 sequences, including our two new sequences, shows that all known archaebacterial homologs share a number of sequence signatures with the Gram-positive group of bacteria that are not found in any other prokaryotic or eukaryotic species. In contrast, the eukaryotic homologs are shown to share a number of unique sequence features with the Gram-negative bacteria that are not present in any archaebacteria. Detailed phylogenetic analyses of hsp70 sequences strongly support a specific evolutionary relationship between archaebacteria and Gram-positive bacteria on the one hand, and Gram-negative bacteria and eukaryotes on the other. The phylogenetic analyses also indicate a polyphyletic branching of archaebacteria within the Gram-positive species. The possibility that the observed relationships are due to horizontal gene transfers can be excluded on the basis of sequence characteristics of different groups of homologs. CONCLUSIONS: Our results do not support the view that archaebacteria constitute a monophyletic domain, but instead suggest a close evolutionary linkage between archaebacteria and Gram-positive bacteria. Furthermore, in contrast to the presently accepted view, eukaryotic hsp70s show a close and specific relationship to those from Gram-negative species. To explain the phylogenies based on different gene sequences, a chimeric model for the origin of the eukaryotic cell nucleus involving fusion between an archaebacterium and a Gram-negative eubacterium is proposed. Several predictions from the chimeric model are discussed.

Griseofulvin resistance mutation of Chinese hamster ovary cells that affects the apparent molecular weight of a congruent to 200,000-dalton protein.

A single-step griseofulvin-resistant mutant (GrsR-4) of CHO cells which exhibit very specific cross-resistance towards certain microtubule inhibitors showed the absence of a protein of molecular weight congruent to 200,000 (designated P5) and the concomitant presence of a new protein spot, M5, of lower molecular weight (Mr congruent to 180,000) which is not present in other cell lines. Peptide mapping studies showed that proteins P5 and M5 are related to each other and that M5 may be missing a peptide fragment present in P5. In GrsR-4 X GrsS cell hybrids, both P5 and M5 were present in equal amounts, which provided evidence against post-translation mechanisms in the origin of M5 and indicated that the GrsR-4 mutant most likely contains a nonsense mutation in the structural gene for protein P5, which causes its premature termination and leads to the formation of M5. Our studies also showed that in different Chinese hamster cell lines the two alleles of the protein P5 are nonidentical and make protein products which differ from each other in isoelectric points. It is suggested that protein P5 and its isoelectric variant P6 may constitute microtubule-associated proteins.

Formycin B-resistant mutants of Chinese hamster ovary cells: novel genetic and biochemical phenotype affecting adenosine kinase.

Stable mutants which are approximately three- and eightfold resistant to the pyrazolopyrimidine nucleosides formycin A and formycin B (FomR) have been selected in a single step from mutagenized Chinese hamster ovary cells. In cell extracts, the two FomR mutants which were examined were both found to contain no measurable activity of the enzyme adenosine kinase (AK). However, cross-resistance studies with other adenosine analogs such as toyocamycin and tubercidin show that these mutants are distinct from toyocamycin or tubercidin resistant (Toyr) mutants which also contain no measurable AK activity in cell extracts. Studies on the uptake and incorporation of [3H]adenosine and [3H]tubercidin by various mutants and parental cell lines show that unlike the Toyr mutants, which are severely deficient in the phosphorylation of these compounds, the FomR mutants possess nearly normal capacity to phosphorylate these compounds and incorporate them into cellular macromolecules. These results suggest that the FomR mutants contain normal levels of AK activity in vivo. In cell hybrids formed between FomR X FomS cells and FomR X Toyr cells, the formycin-resistant phenotype of both of the FomR mutants behaved codominantly. However, the extracts from these hybrid cells contained either congruent to 50% (FomR X FomS) or no measurable (FomR X Toyr) AK activity, indicating that the lesion in these mutants neither suppresses the wild-type AK activity nor complements the AK deficiency of the Toyr mutants. The presence of AK activity in the FomR mutants in vivo, but not in their cell extracts, along with the codominant behavior of the mutants in hybrids, indicates that the lesions in the FomR mutant are of a novel nature. It is suggested that the genetic lesion in these mutants affects AK activity indirectly and that it may involve an essential cellular function which exists in a complex form with AK. Some implications of these results regarding the mechanism of action of formycin B are discussed.

Primary structure of a human mitochondrial protein homologous to the bacterial and plant chaperonins and to the 65-kilodalton mycobacterial antigen.

The complete cDNA for a human mitochondrial protein designated P1, which was previously identified as a microtubule-related protein, has been cloned and sequenced. The deduced amino acid sequence of P1 shows strong homology (40 to 50% identical residues and an additional 20% conservative replacements) to the 65-kilodalton major antigen of mycobacteria, to the GroEL protein of Escherichia coli, and to the ribulose 1,5-bisphosphate carboxylase-oxygenase (rubisco) subunit binding protein of plant chloroplasts. Similar to the case with the latter two proteins, which have been shown to act as chaperonins in the posttranslational assembly of oligomeric protein structures, it is suggested that P1 may play a similar role in mammalian cells. The observed high degree of homology between human P1 and mycobacterial antigen also suggests the possible involvement of this protein in certain autoimmune diseases.

Identification of a protein altered in mutants resistant to microtubule inhibitors as a member of the major heat shock protein (hsp70) family.

A major cellular protein (P2; approximately 70 kilodaltons) which is altered in Chinese hamster ovary (CHO) cell mutants resistant to the microtubule inhibitors colchicine and podophyllotoxin has been shown to correspond to the constitutive form of the 70-kilodalton heat shock protein (hsc70). The inference that P2 and hsc70 are the same protein is based on the following observations: (i) migration of P2 in two-dimensional polyacrylamide gels in the same position as that reported for hsc70; (ii) cross-reactivity of a monoclonal antibody which reacts with both the constitutive and induced forms of hsp70 with the P2 spot from wild-type CHO cells and with both P2 and a mutant form of P2 in a CHO cell mutant; (iii) specific reactivity of a polyclonal antibody to P2 with both the constitutive and heat-induced forms of hsp70 in human cells; (iv) identical immunofluorescent staining of dot/patchlike structures with both P2 and hsp70 antibodies in human and CHO cells; and (v) a cDNA clone for hsc70 has been isolated and sequenced from wild-type CHO cells. The in vitro transcription and translation product of this cDNA has been shown to comigrate with the P2 protein spot in two-dimensional gels, indicating their identity. The fact that there is an alteration in hsc70 in mutants resistant to antimitotic drugs suggests a role for this protein in the in vivo assembly and function of microtubules.

Evaluation of contraceptive activity of methanol extract of Dendrophthoe falcata stem in male albino rats.

The present study was undertaken to evaluate the contraceptive efficacy of methanol extract of Dendrophthoe falcata Ettingsh (family-Loranthaceae), stem in male albino rats as reported in folk remedies. Adult proven fertile male rats were gavaged methanol extract of D. falcata stem at 50, 100 and 200mg/rat/day for 60 days. The activity was compared with standard drug, i.e. Lonidamine. On day 61 the animals were autopsied and the testes, epididymides, seminal vesicle and ventral prostate were dissected out and weighed. Sperm motility and density and serum testosterone level were assessed. The sperm motility and density were significantly reduced. The histoarchitecture of testes revealed degenerative changes in the seminiferous tubules, arrest of spermatogenesis at the stage of round spermatid. Serum testosterone levels were decreased significantly in all treatment groups. It is concluded that D. falcata methanol stem extract showed a significant effect on fertility in male rats as reported in folk remedies.

Species-specific differences in toxicity of antimitotic agents toward cultured mammalian cells.

Toxicities of various microtubule inhibitors, namely, colchicine, podophyllotoxin, maytansine, vinblastine, nocodazole, griseofulvin, and steganacine, toward numerous independently established cell lines from three different species, namely, human, mouse, and Chinese hamster, were examined. Some of these inhibitors (namely, colchicine, vinblastine, taxol, and maytansine) were found to exhibit large (between tenfold and fiftyfold) differences in their toxic and antimitotic concentrations toward various cell lines and these differences appeared to be species related inasmuch as all cell lines from a particular species showed similar sensitivities toward these inhibitors. Of the three species examined, cells of human origin exhibited maximum sensitivity toward these inhibitors while Chinese hamster cells were found to be most resistant. The reduced cellular transport of [3H]colchicine and [3H]vinblastine in Chinese hamster cells as compared to the cellular transport in human cells and the equivalent binding of [3H]colchicine and [3H]vinblastine to microtubule proteins in cell extracts from both these lines provided strong evidence that the observed differences in toxicity to these inhibitors were most likely caused by differences in the cellular transport of these drugs. In contrast to the toxicities of the above compounds, the toxicities of other microtubule inhibitors such as podophyllotoxin, steganacine, griseofulvin, and nocodazole were found to be very similar for cells from all three species, indicating that the cellular transport of these 2 groups of microtubule inhibitors differed in some important respect. Some implications of the observed species-specific differences in drug toxicity to clinical studies are discussed.

4'-Demethylepipodophyllotoxin-beta-D-glucoside: a new podophyllotoxin derivative with VM-26-like and VP-16-213-like activities.

Mutants of Chinese hamster ovary (CHO) cells independently selected for resistance to the anticancer drug 4'-demethylepipodophyllotoxin thenylidene-beta-D-glucoside (VM-26) and the microtubule inhibitor podophyllotoxin exhibit mutually an exclusive cross-resistance pattern toward various podophyllotoxin derivatives that possess either VM-26-like or podophyllotoxin-like activities, respectively. The cross-resistance studies with these mutants have led to the identification of a new podophyllotoxin derivative, 4'-demethylepipodophyllotoxin-beta-D-glucoside (compound No. 13), which possesses VM-26-like and 4'-demethylepipodophyllotoxin ethylidene-beta-D-glucoside (VP-16-213)-like activity. This inference is strongly supported by our observation that, like VM-26 and VP-16-213, compound No. 13 showed no antimitotic activity (as seen by the effect on the mitotic index) but was highly active in inducing DNA strand breaks, sister chromatid exchanges, and mutations at the hypoxanthine-guanine phosphoribosyl transferase and adenosine kinase loci in CHO cells. On the basis of structure-activity data of various podophyllotoxin derivatives, three structural features have been identified that appear essential for VM-26-like activity. These are: 1) the presence of an hydroxyl group at the 4'-carbon, 2) an epi-configuration at the C-4 position, and 3) the presence of a glycoside moiety on the hydroxyl group at the C-4 position. In addition, the nature of the glycoside substituents at the C-4 position greatly affects the relative VM-26-like activity of various compounds.

Mother and child service coverage: reproductive and child health programme in Alwar district, Rajasthan state.

Present study was conducted to assess the child immunization coverage and availability of safe motherhood intervention services for expecting mothers under RCH programme in Alwar district. WHO-30 cluster sampling method was used and 26 rural and 4 urban clusters were surveyed. Fully immunized children were more in urban areas (82.1%) as compared to rural (45.1%) areas. The immunization coverage was more or less similar in both sexes. BCG and Measles coverage was also higher i.e. 89.3% and 85.7% in urban areas than 69.61%, and 52.2% in rural respectively. High drop out rate was found for DPT (25.3%) and OPV (23.2%) in rural areas as compare to urban (7.70/ each). Failure of immunization in rural areas was mainly due to unawareness of need for immunization (35.4%), mother too busy in 16.8%, place and time not known in 9.7%, place for immunization too far 8.8% and 7.1% each for unaware of need to return for subsequent doses, fear of side reactions and vaccinator absent. TT immunization coverage was mainly through Government source and two third of the mothers were immunized in both urban and rural areas. 71.4% of urban and 36.1% of the rural mothers received ANC >=3. However the iron folic acid supplementation was similar in urban and rural areas. Place of delivery was mainly hospital in urban areas (71.4%) and were home (61.7%) in rural areas. Hospital staff (Govt. or pvt.) conducted 82.1% of the deliveries in urban areas as compared to 58.5% in rural. The ANM/ Health staff (56.4%) and family members (27.0%) were main source of information for mother for the need of mother and child immunization.