Squamocolumnar junction visibility, age, and implications for cervical cancer screening programs.

Visual assessment is currently used for primary screening or triage of screen-positive individuals in cervical cancer screening programs. Most guidelines recommend screening and triage up to at least age 65 years old. We examined cervical images from participants in three National Cancer Institute funded cervical cancer screening studies: ALTS (2864 participants recruited between 1996 to 1998) in the United States (US), NHS (7548 in 1993) in Costa Rica, and the Biopsy study (684 between 2009 to 2012) in the US. Specifically, we assessed the visibility of the squamocolumnar junction (SCJ), which is the susceptible zone for precancer/cancer by age, as reported by colposcopist reviewers either at examination or review of cervical images. The visibility of the SCJ declined substantially with age: by the late 40s the majority of people screened had at most partially visible SCJ. On longitudinal analysis, the change in SCJ visibility from visible to not visible was largest for participants from ages 40-44 in ALTS and 50-54 in NHS. Of note, in the Biopsy study, the live colposcopic exam resulted in significantly higher SCJ visibility as compared to review of static images (Weighted kappa 0.27 (95% Confidence Interval: 0.21, 0.33), Asymmetry chi-square P-value<0.001). Lack of SCJ visibility leads to increased difficulty in diagnosis and management of cervical precancers. Therefore, cervical cancer screening programs reliant on visual assessment might consider lowering the upper age limit for screening if there are not adequately trained personnel and equipment to evaluate and manage participants with inadequately visible SCJ.

Treatment of Cervical Precancers is the Major Remaining Challenge in Cervical Screening Research.

Deepening understanding of cervical cancer pathogenesis has yielded one-dose prophylactic human papillomavirus (HPV) vaccines and accurate HPV-based cervical screening tests. Knowing the heterogeneous carcinogenic potential of the individual high-risk HPV types permits prioritization of vaccination and screening strategies. However, "correct" (i.e., safe and effective) treatment of women found to have precancer is still undefined, forcing reliance on one or more rounds of untargeted destructive/excisional treatment. Both over-treatment and under-treatment are common results. Until safe and effective anti-HPV therapies are invented, defining optimal destructive/excisional treatment of precancer remains a fundamental and under-researched challenge, especially in resource-constrained settings. See related article by King et al., p. 681.

Agreement between Xpert and AmpFire tests for high-risk human papillomavirus among HIV-positive women in Rwanda.

Background: High-risk human papillomavirus (hrHPV) may cause more than 99% of cervical cancers worldwide. Little is known about performance differences in tests for hrHPV. Objective: This study analysed agreement for detection of hrHPV between the established, clinically validated Xpert HPV assay and the novel isothermal amplification-based AmpFire HPV genotyping assay. Methods: This study was nested in a larger project on cervical cancer screening among approximately 5000 women living with HIV in Kigali, Rwanda. This sub-study included 298 participants who underwent initial screening for cervical cancer using the Xpert HPV assay and visual inspection with acetic acid in 2017 and tested positive by either or both. Participants were rescreened using colposcopy, and cervical samples were collected between June 2018 and June 2019. Samples were then tested for HPV using the Xpert HPV assay and AmpFire HPV genotyping assay. Agreement between results from both tests was analysed using an exact version of McNemar test and chi-square test. Results: Overall agreement and kappa value for detection of hrHPV by Xpert and AmpFire were 89% and 0.77 (95% confidence interval: 0.70-0.85). AmpFire was marginally more likely to diagnose hrHPV-positive than Xpert (p = 0.05), due primarily to the extra positivity for HPV16 (p < 0.001). Conclusion: Overall, there was good to excellent agreement between the Xpert and AmpFire when testing hrHPV types among women living with HIV. AmpFire was more likely to test extra cases of HPV16, the most carcinogenic HPV type, but the clinical meaning of detecting additional HPV16 infections remains unknown.

Image Quality Classification for Automated Visual Evaluation of Cervical Precancer.

Image quality control is a critical element in the process of data collection and cleaning. Both manual and automated analyses alike are adversely impacted by bad quality data. There are several factors that can degrade image quality and, correspondingly, there are many approaches to mitigate their negative impact. In this paper, we address image quality control toward our goal of improving the performance of automated visual evaluation (AVE) for cervical precancer screening. Specifically, we report efforts made toward classifying images into four quality categories ("unusable", "unsatisfactory", "limited", and "evaluable") and improving the quality classification performance by automatically identifying mislabeled and overly ambiguous images. The proposed new deep learning ensemble framework is an integration of several networks that consists of three main components: cervix detection, mislabel identification, and quality classification. We evaluated our method using a large dataset that comprises 87,420 images obtained from 14,183 patients through several cervical cancer studies conducted by different providers using different imaging devices in different geographic regions worldwide. The proposed ensemble approach achieved higher performance than the baseline approaches.

Redesign of a rapid, low-cost HPV typing assay to support risk-based cervical screening and management.

Accelerated cervical cancer control will require widespread human papillomavirus (HPV) vaccination and screening. For screening, sensitive HPV testing with an option of self-collection is increasingly desirable. HPV typing predicts risk of precancer/cancer, which could be useful in management, but most current typing assays are expensive and/or complicated. An existing 15-type isothermal amplification assay (AmpFire, Atila Biosystems, USA) was redesigned as a 13-type assay (ScreenFire) for public health use. The redesigned assay groups HPV types into four channels with differential cervical cancer risk: (a) HPV16, (b) HPV18/45, (c) HPV31/33/35/52/58 and (d) HPV39/51/56/59/68. Since the assay will be most useful in resource-limited settings, we chose a stratified random sample of 453 provider-collected samples from a population-based screening study in rural Nigeria that had been initially tested with MY09-MY11-based PCR with oligonucleotide hybridization genotyping. Frozen residual specimens were masked and retested at Atila Biosystems. Agreement on positivity between ScreenFire and prior PCR testing was very high for each of the channels. When we simulated intended use, that is, a hierarchical result in order of clinical importance of the type groups (HPV16 > 18/45 > 31/33/35/52/58 > 39/51/56/59/68), the weighted kappa for ScreenFire vs PCR was 0.90 (95% CI: 0.86-0.93). The ScreenFire assay is mobile, relatively simple, rapid (results within 20-60 minutes) and agrees well with reference testing particularly for the HPV types of greatest carcinogenic risk. If confirmed, ScreenFire or similar isothermal amplification assays could be useful as part of risk-based screening and management.

The development of "automated visual evaluation" for cervical cancer screening: The promise and challenges in adapting deep-learning for clinical testing: Interdisciplinary principles of automated visual evaluation in cervical screening.

There is limited access to effective cervical cancer screening programs in many resource-limited settings, resulting in continued high cervical cancer burden. Human papillomavirus (HPV) testing is increasingly recognized to be the preferable primary screening approach if affordable due to superior long-term reassurance when negative and adaptability to self-sampling. Visual inspection with acetic acid (VIA) is an inexpensive but subjective and inaccurate method widely used in resource-limited settings, either for primary screening or for triage of HPV-positive individuals. A deep learning (DL)-based automated visual evaluation (AVE) of cervical images has been developed to help improve the accuracy and reproducibility of VIA as assistive technology. However, like any new clinical technology, rigorous evaluation and proof of clinical effectiveness are required before AVE is implemented widely. In the current article, we outline essential clinical and technical considerations involved in building a validated DL-based AVE tool for broad use as a clinical test.

Multisite Clinical Validation of Isothermal Amplification-Based SARS-CoV-2 Detection Assays Using Different Sampling Strategies.

Isothermal amplification-based tests have been introduced as rapid, low-cost, and simple alternatives to real-time reverse transcriptase PCR (RT-PCR) tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection. The clinical performance of two isothermal amplification-based tests (Atila Biosystems iAMP coronavirus disease of 2019 [COVID-19] detection test and OptiGene COVID-19 direct plus RT-loop-mediated isothermal amplification [LAMP] test) was compared with that of clinical RT-PCR assays using different sampling strategies. A total of 1,378 participants were tested across 4 study sites. Compared with standard of care RT-PCR testing, the overall sensitivity and specificity of the Atila iAMP test for detection of SARS-CoV-2 were 76.2% and 94.9%, respectively, and increased to 88.8% and 89.5%, respectively, after exclusion of an outlier study site. Sensitivity varied based on the anatomic site from which the sample was collected. Sensitivity for nasopharyngeal sampling was 65.4% (range across study sites, 52.8% to 79.8%), for midturbinate was 88.2%, for saliva was 55.1% (range across study sites, 42.9% to 77.8%), and for anterior nares was 66.7% (range across study sites, 63.6% to 76.5%). The specificity for these anatomic collection sites ranged from 96.7% to 100%. Sensitivity improved in symptomatic patients (overall, 82.7%) and those with a higher viral load (overall, 92.4% for cycle threshold [CT] of ≤25). Sensitivity and specificity of the OptiGene direct plus RT-LAMP test, which was conducted at a single study site, were 25.5% and 100%, respectively. The Atila iAMP COVID test with midturbinate sampling is a rapid, low-cost assay for detecting SARS-CoV-2, especially in symptomatic patients and those with a high viral load, and could be used to reduce the risk of SARS-CoV-2 transmission in clinical settings. Variation of performance between study sites highlights the need for site-specific clinical validation of these assays before clinical adoption. IMPORTANCE Numerous SARS-CoV-2 detection assays have been developed and introduced into the market under emergency use authorizations (EUAs). EUAs are granted primarily based on small studies of analytic sensitivity and specificity with limited clinical validations. A thorough clinical performance evaluation of SARS-CoV-2 assays is important to understand the strengths, limitations, and specific applications of these assays. In this first large-scale multicentric study, we evaluated the clinical performance and operational characteristics of two isothermal amplification-based SARS-CoV-2 tests, namely, (i) iAMP COVID-19 detection test (Atila BioSystems, USA) and (ii) COVID-19 direct plus RT-LAMP test (OptiGene Ltd., UK), compared with those of clinical RT-PCR tests using different sampling strategies (i.e., nasopharyngeal, self-sampled anterior nares, self-sampled midturbinate, and saliva). An important specific use for these isothermal amplification-based, rapid, low-cost, and easy-to-perform SARS-CoV-2 assays is to allow for a safer return to preventive clinical encounters, such as cancer screening, particularly in low- and middle-income countries that have low SARS-CoV-2 vaccination rates.

Multi-site clinical validation of Isothermal Amplification based SARS-COV-2 detection assays using different sampling strategies.

BACKGROUND: Isothermal amplification-based tests were developed as rapid, low-cost, and simple alternatives to real-time reverse transcriptase-polymerase chain reaction (RT-PCR) tests for SARS-COV-2 detection. METHODS: Clinical performance of two isothermal amplification-based tests (Atila Biosystems iAMP COVID-19 detection test and OptiGene COVID-19 Direct Plus RT-LAMP test) was compared to clinical RT-PCR assays using different sampling strategies. A total of 1378 participants were tested across four study sites. RESULTS: Compared to standard of care RT-PCR testing, the overall sensitivity and specificity of the Atila iAMP test for detection of SARS-CoV-2 were 76.2% and 94.9%, respectively, and increased to 88.8% and 89.5%, respectively, after exclusion of an outlier study site. Sensitivity varied based on the anatomic collected site. Sensitivity for nasopharyngeal was 65.4% (range across study sites:52.8%-79.8%), mid-turbinate 88.2%, saliva 55.1% (range across study sites:42.9%-77.8%) and anterior nares 66.7% (range across study sites:63.6%-76.5%). The specificity for these anatomic collection sites ranged from 96.7% to 100%. Sensitivity improved in symptomatic patients (overall 82.7%) and those with a higher viral load (overall 92.4% for ct≤25). Sensitivity and specificity of the OptiGene Direct Plus RT-LAMP test, conducted at a single study-site, were 25.5% and 100%, respectively. CONCLUSIONS: The Atila iAMP COVID test with mid-turbinate sampling is a rapid, low-cost assay for detecting SARS-COV-2, especially in symptomatic patients and those with a high viral load, and could be used to reduce the risk of SARS-COV-2 transmission in clinical settings. Variation of performance between study sites highlights the need for site-specific clinical validation of these assays before clinical adoption.

Network Visualization and Pyramidal Feature Comparison for Ablative Treatability Classification Using Digitized Cervix Images.

Uterine cervical cancer is a leading cause of women's mortality worldwide. Cervical tissue ablation is an effective surgical excision of high grade lesions that are determined to be precancerous. Our prior work on the Automated Visual Examination (AVE) method demonstrated a highly effective technique to analyze digital images of the cervix for identifying precancer. Next step would be to determine if she is treatable using ablation. However, not all women are eligible for the therapy due to cervical characteristics. We present a machine learning algorithm that uses a deep learning object detection architecture to determine if a cervix is eligible for ablative treatment based on visual characteristics presented in the image. The algorithm builds on the well-known RetinaNet architecture to derive a simpler and novel architecture in which the last convolutional layer is constructed by upsampling and concatenating specific RetinaNet pretrained layers, followed by an output module consisting of a Global Average Pooling (GAP) layer and a fully connected layer. To explain the recommendation of the deep learning algorithm and determine if it is consistent with lesion presentation on the cervical anatomy, we visualize classification results using two techniques: our (i) Class-selective Relevance Map (CRM), which has been reported earlier, and (ii) Class Activation Map (CAM). The class prediction heatmaps are evaluated by a gynecologic oncologist with more than 20 years of experience. Based on our observation and the expert's opinion, the customized architecture not only outperforms the baseline RetinaNet network in treatability classification, but also provides insights about the features and regions considered significant by the network toward explaining reasons for treatment recommendation. Furthermore, by investigating the heatmaps on Gaussian-blurred images that serve as surrogates for out-of-focus cervical pictures we demonstrate the effect of image quality degradation on cervical treatability classification and underscoring the need for using images with good visual quality.

A proposed new generation of evidence-based microsimulation models to inform global control of cervical cancer.

Health decision models are the only available tools designed to consider the lifetime natural history of human papillomavirus (HPV) infection and pathogenesis of cervical cancer, and the estimated long-term impact of preventive interventions. Yet health decision modeling results are often considered a lesser form of scientific evidence due to the inherent needs to rely on imperfect data and make numerous assumptions and extrapolations regarding complex processes. We propose a new health decision modeling framework that de-emphasizes cytologic-colposcopic-histologic diagnoses due to their subjectivity and lack of reproducibility, relying instead on HPV type and duration of infection as the major determinants of subsequent transition probabilities. We posit that the new model health states (normal, carcinogenic HPV infection, precancer, cancer) and corollary transitions are universal, but that the probabilities of transitioning between states may vary by population. Evidence for this variability in host response to HPV infections can be inferred from HPV prevalence patterns in different regions across the lifespan, and might be linked to different average population levels of immunologic control of HPV infections. By prioritizing direct estimation of model transition probabilities from longitudinal data (and limiting reliance on model-fitting techniques that may propagate error when applied to multiple transitions), we aim to reduce the number of assumptions for greater transparency and reliability. We propose this new microsimulation model for critique and discussion, hoping to contribute to models that maximally inform efficient strategies towards global cervical cancer elimination.

Role of demographic and clinical factors in survival of HIV patients on antiretroviral therapy.

Our retrospective cohort study assesses the survival probability and identifies the demographic and clinical predictors of mortality in HIV patients taking antiretroviral therapy using an antiretroviral therapy centre data in Western India. Secondary data on 7532 registered HIV-infected individuals between September 2006 and January 2013 were analysed. The probability of survival at 75 months was 84.9%. Significant indicators of poor chances of survival were greater age, lower occupation class, lower CD4 count, poor functional status; higher stage of disease, lower weight, the presence and type of opportunistic infections, co-trimoxazole therapy and poor adherence to antiretroviral therapy. We thus find that, in addition to pre-ART, antiretroviral therapy clinical status and treatment adherence, socioeconomic status plays an important influence on ultimate survival of HIV patients on antiretroviral therapy.

A Deep Clustering Method For Analyzing Uterine Cervix Images Across Imaging Devices.

Visual inspection of the cervix with acetic acid (VIA), though error prone, has long been used for screening women and to guide management for cervical cancer. The automated visual evaluation (AVE) technique, in which deep learning is used to predict precancer based on a digital image of the acetowhitened cervix, has demonstrated its promise as a low-cost method to improve on human performance. However, there are several challenges in moving AVE beyond proof-of-concept and deploying it as a practical adjunct tool in visual screening. One of them is making AVE robust across images captured using different devices. We propose a new deep learning based clustering approach to investigate whether the images taken by three different devices (a common smartphone, a custom smartphone-based handheld device for cervical imaging, and a clinical colposcope equipped with SLR digital camera-based imaging capability) can be well distinguished from each other with respect to the visual appearance/content within their cervix regions. We argue that disparity in visual appearance of a cervix across devices could be a significant confounding factor in training and generalizing AVE performance. Our method consists of four components: cervix region detection, feature extraction, feature encoding, and clustering. Multiple experiments are conducted to demonstrate the effectiveness of each component and compare alternative methods in each component. Our proposed method achieves high clustering accuracy (97%) and significantly outperforms several representative deep clustering methods on our dataset. The high clustering performance indicates the images taken from these three devices are different with respect to visual appearance. Our results and analysis establish a need for developing a method that minimizes such variance among the images acquired from different devices. It also recognizes the need for large number of training images from different sources for robust device-independent AVE performance worldwide.

Design and feasibility of a novel program of cervical screening in Nigeria: self-sampled HPV testing paired with visual triage.

BACKGROUND: Accelerated global control of cervical cancer would require primary prevention with human papillomavirus (HPV) vaccination in addition to novel screening program strategies that are simple, inexpensive, and effective. We present the feasibility and outcome of a community-based HPV self-sampled screening program. METHODS: In Ile Ife, Nigeria, 9406 women aged 30-49 years collected vaginal self-samples, which were tested for HPV in the local study laboratory using Hybrid Capture-2 (HC2) (Qiagen). HPV-positive women were referred to the colposcopy clinic. Gynecologist colposcopic impression dictated immediate management; biopsies were taken when definite acetowhitening was present to produce a histopathologic reference standard of precancer (and to determine final clinical management). Retrospective linkage to the medical records identified 442 of 9406 women living with HIV (WLWH). RESULTS: With self-sampling, it was possible to screen more than 100 women per day per clinic. Following an audio-visual presentation and in-person instructions, overall acceptability of self-sampling was very high (81.2% women preferring self-sampling over clinician collection). HPV positivity was found in 17.3% of women. Intensive follow-up contributed to 85.9% attendance at the colposcopy clinic. Of those referred, 8.2% were initially treated with thermal ablation and 5.6% with large loop excision of transformation zone (LLETZ). Full visibility of the squamocolumnar junction, necessary for optimal visual triage and ablation, declined from 68.5% at age 30 to 35.4% at age 49. CIN2+ and CIN3+ (CIN- Cervical intraepithelial neoplasia), including five cancers, were identified by histology in 5.9 and 3.2% of the HPV-positive women, respectively (0.9 and 0.5% of the total screening population), leading to additional treatment as indicated. The prevalences of HPV infection and CIN2+ were substantially higher (40.5 and 2.5%, respectively) among WLWH. Colposcopic impression led to over- and under-treatment compared to the histopathology reference standard. CONCLUSION: A cervical cancer screening program using self-sampled HPV testing, with colposcopic immediate management of women positive for HPV, proved feasible in Nigeria. Based on the collected specimens and images, we are now evaluating the use of a combination of partial HPV typing and automated visual evaluation (AVE) of cervical images to improve the accuracy of the screening program.

Designing low-cost, accurate cervical screening strategies that take into account COVID-19: a role for self-sampled HPV typing2.

BACKGROUND: We propose an economical cervical screening research and implementation strategy designed to take into account the typically slow natural history of cervical cancer and the severe but hopefully temporary impact of COVID-19. The commentary introduces the practical validation of some critical components of the strategy, described in three manuscripts detailing recent project results in Asia and Africa.The main phases of a cervical screening program are 1) primary screening of women in the general population, 2) triage testing of the small minority of women that screen positive to determine need for treatment, and 3) treatment of triage-positive women thought to be at highest risk of precancer or even cancer. In each phase, attention must now be paid to safety in relation to SARS-CoV-2 transmission. The new imperatives of the COVID-19 pandemic support self-sampled HPV testing as the primary cervical screening method. Most women can be reassured for several years by a negative test performed on a self-sample collected at home, without need of clinic visit and speculum examination. The advent of relatively inexpensive, rapid and accurate HPV DNA testing makes it possible to return screening results from self-sampling very soon after specimen collection, minimizing loss to follow-up. Partial HPV typing provides important risk stratification useful for triage of HPV-positive women. A second "triage" test is often useful to guide management. In lower-resource settings, visual inspection with acetic acid (VIA) is still proposed but it is inaccurate and poorly reproducible, misclassifying the risk stratification gained by primary HPV testing. A deep-learning based approach to recognizing cervical precancer, adaptable to a smartphone camera, is being validated to improve VIA performance. The advent and approval of thermal ablation permits quick, affordable and safe, immediate treatment at the triage clinic of the majority of HPV-positive, triage-positive women. CONCLUSIONS: Overall, only a small percentage of women in cervical screening programs need to attend the hospital clinic for a surgical procedure, particularly when screening is targeted to the optimal age range for detection of precancer rather than older ages with decreased visual screening performance and higher risks of hard-to-treat outcomes including invasive cancer.

A rapid, high-volume cervical screening project using self-sampling and isothermal PCR HPV testing.

OBJECTIVE: Rapid, high-volume screening programs are needed as part of cervical cancer prevention in China. METHODS: In a 5-day screening project in Inner Mongolia, 3345 women volunteered following a community awareness campaign, and self-swabbed to permit rapid HPV testing. Two AmpFire™ HPV detection systems (Atila Biosystems) were sufficient to provide pooled 15-HPV type data within an hour. HPV+ patients had same-day digital colposcopy (DC) performed by 1 of 6 physicians, using the EVA™ system (MobileODT). Digital images were obtained and, after biopsy of suspected lesions for later confirmatory diagnosis, women were treated immediately based on colposcopic impression. Suspected low- grade lesions were offered treatment with thermal ablation (Wisap), and suspected high-grade lesions were treated with LLETZ. RESULTS: Of 3345 women screened, 624 (18.7%) were HPV+. Of these, 88.5% HPV+ women underwent same-day colposcopy and 78 were treated. Later consensus histology results obtained on 197 women indicated 20 CIN2+, of whom 15 were detected and treated/referred at screening (10 by thermal ablation, 4 by LLETZ, 1 by referral). CONCLUSIONS: Global control of cervical cancer will require both vaccination and screening of a huge number of women. This study illustrates a cervical screening strategy that can be used to screen-and-treat large numbers of women. HPV self-sampling facilitates high-volume screening. Specimens can be tested rapidly, promoting minimal loss-to-follow-up. Specifically, the AmpFire™ system used in this study is highly portable, simple, rapid (92 specimens per 65 min per unit), and economical. Visual triage can be performed on HPV+ women with a portable digital colposcope that provides magnification, lighting, and a recorded image. Diagnosis and appropriate treatment remain the most subjective elements. The digital image is under study for deep-learning based automated evaluation that could assist the management decision, either by itself or combined with HPV typing.

Environment and psychosocial factors are more important than clinical factors in determining quality of life of HIV-positive patients on antiretroviral therapy.

Assessing quality of life (QOL) outcome helps to show the effect of antiretroviral therapy (ART) on the subjective perception of its benefits among patients with HIV. A cross-sectional assessment of QOL, using the World Health Organization WHOQOL-HIV, on 204 HIV patients taking ART in western India showed patients with HIV on ART as having the best QOL score in the spiritual domain and the worst in the environment domain. Patients who are single, highly educated, of higher occupational status, with no HIV-positive children, not undergoing frequent hospital admissions, with access to a counsellor for support, who are not stigmatised or discriminated against due to HIV status, who do not have guilt or suicidal ideas, and who are theist, tend to have a better QOL, irrespective of their clinical condition or ART regimen. Patients' personal perceptions and feelings, societal support or stigma, and sociodemographic status have a more significant influence on QOL than clinical variables.

Follow-up Assessment of Under-nourished Children Under Integrated Child Development Services Scheme in Tapi District, India.

BACKGROUND: India shares the largest burden of under-nutrition in world. The aim of this study was to conduct follow-up assessment of under-nourished children attending anganwadi center (AWC). METHODS: This was a retrospective cohort study conducted in 50 AWC of Tapi district. Total 529 children aged 1-6 years diagnosed as under-nourished before 1 year were included. Pre-structured questionnaire was used for present day assessment of these children followed by Epi-info mediated analysis. RESULTS: Children of literate mothers had higher weight gain. Ninety percent of children attended anganwadi regularly, however 25% of children dropped out for more than 1 month. In 1 year, growth had faltered in 20% children and was stagnant in 63% of them. Children who were treated for under-nutrition; that completed course at Child Development and Nutrition Center; and whose parents were counseled about the under-nourished status of child had higher weight gain than their counterparts. CONCLUSIONS: Parents of under-nourished children must be counseled about the nutritional status of their child. In cases of under-nourished child, referral to higher center must be ensured by health worker. Supplementary feeding as a long-term solution to country's under-nutrition problem should be studied in detail with the alternative solutions.