Prevalence estimate of blood doping in elite track and field at the introduction of the Athlete Biological Passport

Mapping Intimacies ◽

10.1101/736801 ◽

2019 ◽

Cited By ~ 1

Author(s):

Raphael Faiss ◽

Jonas Saugy ◽

Alix Zollinger ◽

Neil Robinson ◽

Frédéric Schütz ◽

...

Keyword(s):

Endurance Athletes ◽

Cumulative Distribution ◽

Haematological Parameters ◽

List Type ◽

Biological Parameters ◽

Blood Doping ◽

Blood Profile ◽

Biological Passport ◽

New Findings ◽

International Events

AbstractIn elite sport, the Athlete Biological Passport (ABP) was invented to tackle cheaters by monitoring closely changes in biological parameters, flagging atypical variations. The haematological module of the ABP was indeed adopted in 2011 by the International Association of Athletics Federations (IAAF). This study estimates the prevalence of blood doping based on haematological parameters in a large cohort of track & field athletes measured at two international major events (2011 & 2013 IAAF World Championships) with a hypothesized decrease in prevalence due to the ABP introduction.A total of 3683 blood samples were collected and analysed from all participating athletes originating from 209 countries. The estimate of doping prevalence was obtained by using a Bayesian network with seven variables, as well as “doping” as a variable mimicking doping with low-doses of recombinant human erythropoietin (rhEPO), to generate reference cumulative distribution functions (CDFs) for the Abnormal Blood Profile Score (ABPS) from the ABP.Our results from robust haematological parameters indicate an estimation of an overall blood doping prevalence of 18% in average in endurance athletes (95% Confidence Interval (C.I.) 14-22%). A higher prevalence was observed in female athletes (22%, C.I. 16-28%) than in male athletes (15%, C.I. 9-20%). In conclusion, this study presents the first comparison of blood doping prevalence in elite athletes based on biological measurements from major international events that may help scientists and experts to use the ABP in a more efficient and deterrent way.What are the new findings ?This study presents the first comparison of blood doping prevalence in elite track & field athletes based on biological measurements from major international eventsOur results from robust haematological parameters indicate an estimation of an overall blood doping prevalence of 18% in average in endurance athletes.The confidence intervals for blood doping prevalence range from 9-28% with wide discrepancies between certain countries.How might it impact on clinical practice in the near futureThe further development of the Athlete Biological Passport with a careful monitoring of biological parameters still represents the most consistent approach to thwart athletes using undetectable prohibited substances or methods.This study describes a method to define blood doping prevalence with the analysis of robust haematological parametersEstimates of doping prevalence in subpopulations of athletes may represent a valuable tool for the antidoping authorities to perform a risk assessment in their sport.

Hypoxic training from the athlete´s biological passport point of view

Proceedings of the 12th International Conference on Kinanthropology ◽

10.5817/cz.muni.p210-9631-2020-49 ◽

2020 ◽

Author(s):

Martin Pupiš ◽

Vladimír Franek ◽

Zuzana Pupišová

Keyword(s):

Body Weight ◽

Body Height ◽

Point Of View ◽

Endurance Athletes ◽

Haematological Parameters ◽

Altitude Training ◽

Long Distance ◽

Intermittent Hypoxic Training ◽

Hypoxic Training ◽

Biological Passport

Purpose: Hypoxic training is frequent part of preparation of endurance athletes, but in the last years there are many polemics about effects of hypoxic training on the haemato-logical parameters analysing in athlete´s biological passport. The aim of the research was to detect the effect of three different methods of hypoxic training (high altitude training, intermittent hypoxic training, sleeping in hypoxic tent) on haematological parameters which are analysing in athlete´s biological passport. Methods: Three types of hypoxic preparation were compared. The ensemble contained of 7 long-distance men race walkers (age 27.4 years (SD ± 3.6); body height 177.0 cm (SD ± 8.1); body weight 63.1 kg (SD ± 5.3). Results: We detected statistical significant increase in haemoglobin level about 12.57 g.l-1 (p 0.05), the decrease of off-score after sleeping in hypoxic tent was about 1.8 (p > 0.05) and the decrease of off-score by intermittent hypoxic training was about 5.46 (p > 0.05). Conclusion: Participation of hypoxic preparation can significantly influence parameters in athlete biological passport. According results of our research, we assume that all methods of hypoxic training can affect haematological parameters analysing in athlete´s biological passport (haemoglobin, reticulocytes).

Prevalence of Blood Doping in Samples Collected from Elite Track and Field Athletes

Clinical Chemistry ◽

10.1373/clinchem.2010.156067 ◽

2011 ◽

Vol 57 (5) ◽

pp. 762-769 ◽

Cited By ~ 75

Author(s):

Pierre-Edouard Sottas ◽

Neil Robinson ◽

Giuseppe Fischetto ◽

Gabriel Dollé ◽

Juan Manuel Alonso ◽

...

Keyword(s):

Distribution Functions ◽

Cumulative Distribution ◽

Birth Date ◽

Reliable Estimate ◽

Blood Doping ◽

Blood Profile ◽

Entire Study ◽

Period Prevalence ◽

Cumulative Distribution Functions ◽

Elite Sports

BACKGROUND No reliable estimate of the prevalence of doping in elite sports has been published. Since 2001, the international governing body for athletics has implemented a blood-testing program to detect altered hematological profiles in the world's top-level athletes. METHODS A total of 7289 blood samples were collected from 2737 athletes out of and during international athletic competitions. Data were collected in parallel on each sample, including the age, sex, nationality, and birth date of the athlete; testing date; sport; venue; and instrument technology. Period prevalence of blood-doping in samples was estimated by comparing empirical cumulative distribution functions of the abnormal blood profile score computed for subpopulations with stratified reference cumulative distribution functions. RESULTS In addition to an expected difference between endurance and nonendurance athletes, we found nationality to be the major factor of heterogeneity. Estimates of the prevalence of blood doping ranged from 1% to 48% for subpopulations of samples and a mean of 14% for the entire study population. Extreme cases of secondary polycythemia highlighted the health risks associated with blood manipulations. CONCLUSIONS When applied at a population level, in this case the population of samples, hematological data can be used to estimate period prevalence of blood doping in elite sports. We found that the world's top-level athletes are not only heterogeneous in physiological and anthropometric factors but also in their doping behavior, with contrasting attitudes toward doping between countries. When applied at the individual level, the same biomarkers, as formalized in the Athlete Biological Passport paradigm, can be used in analysis of the observed different physiological characteristics and behavioral heterogeneities.

Suboptimal HIV status ascertainment at antenatal clinics and the impact on HIV prevalence estimates

10.1101/2021.10.04.21262474 ◽

2021 ◽

Author(s):

Fatihiyya Wangara ◽

Janne Estill ◽

Hillary Kipruto ◽

Kara Wools-Kaloustian ◽

Wendy Chege ◽

...

Keyword(s):

Hiv Testing ◽

Routine Data ◽

Hiv Prevalence ◽

Sentinel Surveillance ◽

List Type ◽

Hiv Status ◽

Hiv Surveillance ◽

New Findings ◽

Prevalence Estimates ◽

Antenatal Clinics

AbstractIntroductionHIV prevalence estimates is a key indicator to inform the coverage and effectiveness of HIV prevention measures. Many countries including Kenya transitioned from sentinel surveillance to the use of routine antenatal care data to estimate the burden of HIV. Countries in Sub Saharan Africa reported several challenges of this transition, including low uptake of HIV testing and sub national / site-level differences in HIV prevalence estimates.MethodsWe examine routine data from Kwale County, Kenya, for the period January 2015 to December 2019 and predict HIV prevalence among women attending antenatal care (ANC) at 100% HIV status ascertainment. We estimate the bias in HIV prevalence estimates as a result of imperfect uptake of HIV testing and make recommendations to improve the utility of ANC routine data for HIV surveillance. We used a generalized estimating equation with binomial distribution to model the observed HIV prevalence as explained by HIV status ascertainment and region (Sub County). We then used marginal standardization to predict the HIV prevalence at 100% HIV status ascertainment.ResultsHIV testing at ANC was at 91.3%, slightly above the global target of 90%. If there was 100% HIV status ascertainment at ANC, the HIV prevalence would be 2.7% (95% CI 2.3-3.2). This was 0.3% lower than the observed prevalence. Similar trends were observed with yearly predictions except for 2018 where the HIV prevalence was underestimated with an absolute bias of -0.2%. This implies missed opportunities for identifying new HIV infections in the year 2018.ConclusionsImperfect HIV status ascertainment at ANC overestimates HIV prevalence among women attending ANC in Kwale County. However, the use of ANC routine data may underestimate the true population prevalence. There is need to address both community level and health facility level barriers to the uptake of ANC services.Key questionsWhat is already known?▪HIV surveillance estimates from antenatal clinics (ANC) can serve as a useful proxy for HIV prevalence trends in the general female population.▪Kenya has conducted multiple studies which have shown that national HIV prevalence estimates from sentinel surveillance and those from routine program data to be similar.▪However, these studies have also revealed ongoing challenges to the suitability of using routine data as compared to sentinel surveillance including sub optimal uptake of HIV testing and sub national/ site-level differences in HIV prevalence estimates.What are the new findings?▪HIV positive pregnant women are more likely to be tested at ANC as compared to HIV negative women, leading to higher HIV prevalence estimates among women attending ANC.▪Health facility level HIV prevalence estimates are lower than that of the general population.What do the new findings imply?▪HIV positive women are underrepresented in antenatal clinics.▪In Kwale County (and similar contexts), use of routine ANC data is still not a reliable method to estimate HIV prevalence, both at facility and community level.

Ketamine effects on anxiety and fear-related behaviors: current literature evidence and new findings

10.1101/793398 ◽

2019 ◽

Author(s):

Gabriela P. Silote ◽

Sabrina F.S. de Oliveira ◽

Deidiane E. Ribeiro ◽

Mayara S. Machado ◽

Roberto Andreatini ◽

...

Keyword(s):

Nmda Antagonist ◽

Inhibitory Avoidance ◽

Nmda Receptor Antagonist ◽

Mixed Effects ◽

Antidepressant Effect ◽

List Type ◽

Mk 801 ◽

New Findings ◽

Male Wistar Rats ◽

Animal Tests

AbstractKetamine, a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist, presents rapid and sustained antidepressant effect in clinical and preclinical studies. Regarding ketamine effects on anxiety, there is a widespread discordance among pre-clinical studies. To address this issue, the present study reviewed the literature (electronic database MEDLINE) to summarize the profile of ketamine effects in animal tests of anxiety/fear. We found that ketamine anxiety/fear-related effects may depend on the anxiety paradigm, schedule of ketamine administration and tested species. Moreover, there was no report of ketamine effects in animal tests of fear related to panic disorder (PD). Based on that finding, we evaluated if treatment with ketamine and another NMDA antagonist, MK-801, would induce acute and sustained (24 hours later) anxiolytic and/or panicolytic-like effects in animals exposed to the elevated T-maze (ETM). The ETM evaluates, in the same animal, conflict-evoked and fear behaviors, which are related, respectively, to generalized anxiety disorder and PD. Male Wistar rats were systemically treated with racemic ketamine (10, 30 and 80 mg/kg) or MK-801 (0.05 and 0.1 mg/kg) and tested in the ETM in the same day or 24 hours after their administration. Ketamine did not affect the behavioral tasks performed in the ETM acutely or 24 h later. MK-801 impaired inhibitory avoidance in the ETM only at 45 min post-injection, suggesting a rapid but not sustained anxiolytic-like effect. Altogether our results suggest that ketamine might have mixed effects in anxiety tests while it does not affect panic-related behaviors.HighlightsKetamine induces mixed effects in animal anxiety testsFew studies investigated the individual effects of S-ketamine in anxiety/fear testsNone study evaluated the effects of R-Ketamine on anxiety/fear-related behaviorsSystemic ketamine does not affect panic-like behaviors in the elevated T-maze

Strengthening public COVID-19 response with private facilities in Kisumu, Kenya

10.1101/2021.08.31.21262891 ◽

2021 ◽

Author(s):

Shannen van Duijn ◽

Hellen C. Barsosio ◽

Mevis Omollo ◽

Emmanuel Milimo ◽

Isdorah A. Odero ◽

...

Keyword(s):

Private Sector ◽

Healthcare Workers ◽

Scale Up ◽

Public Private Partnership ◽

Healthcare Sector ◽

List Type ◽

Private Partnership ◽

Healthcare Facilities ◽

New Findings ◽

The Way

AbstractINTRODUCTIONSARS-CoV-2 testing is one of the options to combat COVID-19 in Kenya. In the first COVID-19 year there was limited tapping of the private sector’s potential to scale up testing in Kenya. In April 2020, we initiated a unique public-private partnership (PPP) project in Kisumu County connecting the private sector to centralized testing supported by the ministry of health (MoH), ‘COVID-Dx’, to accelerate the local response to COVID-19. Within COVID-Dx, we aimed to demonstrate this PPP’s performance as a replicable model for effective public-private collaboration in responding to the COVID-19 pandemic in similar settings.METHODSKEMRI, Department of Health Kisumu County, PharmAccess Foundation, and local faith-based and private healthcare facilities collaborated in COVID-Dx. COVID-Dx was implemented from June 01, 2020, to March 31, 2021, in Kisumu County, Kenya. Trained laboratory technologists in participating healthcare facilities collected nasopharyngeal and oropharyngeal samples from patients meeting the MoH COVID-19 case definition. Samples were tested at the central laboratory in KEMRI via SARS-CoV-2 RT-PCR. Healthcare workers in participating facilities collected data using the digitized MoH COVID-19 Case Identification Form. We shared aggregated results from these data via (semi-) live dashboard to all relevant stakeholders. We did descriptive statistical analyses using Stata 16 to inform project processes.RESULTSNine facilities participated in the project. A total of 4,324 PCR tests for SARS-CoV-2 were done, with 425 positives. We noted differences in positivity rates between the facilities. Healthcare workers were the largest group tested in the project, 1009, representing 43% of the Kisumu healthcare workforce.CONCLUSIONCOVID-Dx can serve as a model for PPPs scale-up testing, especially LMICs, and digitizing the MoH case report form improved reporting efficiency, demonstrating that digital is the way forward. The COVID-Dx PPP has led to another collaboration with Kisumu County aimed towards extending the COVID-Dx model to other counties.SUMMARY BOXWhat is already known?In sub-Saharan Africa, COVID-19 responses are mainly rolled out through the public healthcare sector, even though the private sector plays a significant role in health service deliveryThe challenge is to combine private and public efforts in healthcare delivery in a mutually supportive and collaborative manner, especially during large outbreaks such as COVID-19.What are the new findings?The development of a public-private partnership (COVID-Dx) at the start of a global pandemic - COVID-19 – is challenging, but PPPs are essential for epidemic preparedness.The development of a digital app with a corresponding dashboard, ensures transparency and efficiency. It has shown to enable data-driven decision-making and provides insight into how to prioritize funding streams.What do the new findings imply?This PPP model is replicable and can serve as an example of PPPs for epidemic preparedness in similar settings in LMICs.Digital is the way going forward when combatting large outbreaks in the future, especially in LMICs

P87 The Swiss Association of Perinatal Pharmacology, SAPP: goals

Archives of Disease in Childhood ◽

10.1136/archdischild-2019-esdppp.125 ◽

2019 ◽

Vol 104 (6) ◽

pp. e53.2-e53

Author(s):

L Schenkel ◽

U von Mandach ◽

Keyword(s):

Pregnant Women ◽

Primary Objective ◽

Grand Challenge ◽

List Type ◽

Term Survival ◽

Off Label ◽

New Findings ◽

Nursing Mothers ◽

Personalized Approach ◽

The Impact

BackgroundThe medicine of pregnant women practices to a targeted personalized approach, tailored to the specific characteristics and needs the implications of interdisciplinary work between healthcare stakeholders. Perinatal pharmacology comprises the impact of substances (drugs, medications and others) in pregnant women, nursing mothers, the unborn child, the premature, the newborn baby and the breastfed baby. Most of the drugs are off-label used. In this field grand challenge for Frontiers in Medicine emphasizes the importance of translational medicine.AimThe primary goal of SAPP has always been and remains the same: it is the link between medicine and pharmacy, between practice, clinic, research and health authorities, in order to increase the safety of medicines in the population of pregnant and breastfeeding women and their newborns.1MethodsOn December 6, 2007, an interdisciplinary team of 8 physicians and pharmacists founded the Swiss Association of Perinatal Pharmacology, SAPP. It collects and promotes new findings in the field of perinatal pharmacology.ResultsSpecialists from all areas of perinatal pharmacology work together in a scientific committee to develop and update evidence-based principles for work in everyday clinical practice (hospitals, doctor´s surgeries, pharmacies). Today, around 200 members benefit from this, who can orient themselves in regular further training courses and basic documents (monographs of active substances, therapy recommendations based on original literature). The SAPP thus closes the gap resulting from the predominant off-label use and the resulting lack of information on drugs in this population.ConclusionThe primary objective of SAPP has been achieved - it provides guidance for the practioners in the broad field of perinatal pharmacology and bridges the gap caused by the lack of drug approvals in this population. Long-term survival will be ensured by measures anchored in law.Referencewww.sappinfo.chDisclosure(s)Nothing to disclose

Haemoglobin, Blood Volume, Cardiac Function, and Aerobic Power

Canadian Journal of Applied Physiology ◽

10.1139/h99-006 ◽

1999 ◽

Vol 24 (1) ◽

pp. 54-65 ◽

Cited By ~ 51

Author(s):

Norman Gledhill ◽

Darren Warburton ◽

Veronica Jamnik

Keyword(s):

Cardiac Output ◽

Aerobic Power ◽

Endurance Performance ◽

Endurance Athletes ◽

Aerobic Performance ◽

Arterial Oxygen ◽

Blood Doping ◽

Arterial Oxygen Content ◽

The Difference ◽

Key Words Blood

Alterations in [Hb], which are mediated through changes in arterial oxygen content, and alterations in BV, which are mediated through changes in cardiac output [Formula: see text] have a significant effect on both [Formula: see text] and aerobic performance. If BV is held constant, a decrease in [Hb] (anaemia) causes a decrease in [Formula: see text] and aerobic performance, while an increase in [Hb] (blood doping) causes an increase in [Formula: see text] and aerobic performance. If [Hb] is held constant, an increase in BV can cause an increase in both [Formula: see text] and aerobic performance, while a decrease in BV can cause a decrease in both [Formula: see text] and aerobic performance. In addition, an increase in BV can compensate for moderate reductions in [Hb] through increases in [Formula: see text], allowing [Formula: see text] to remain unchanged or even increase. Also, a large portion of the difference in the enhanced cardiovascular function of endurance athletes is due to their high BV and the resultant enhancement of diastolic function. Hence, optimizing both [Hb] and BV is a very important consideration for endurance performance. Key words: blood doping, sport anemia, stroke volume

State of the evidence: a survey of global disparities in clinical trials

10.1101/2020.10.08.20209353 ◽

2020 ◽

Author(s):

Iain J Marshall ◽

Veline L’Esperence ◽

Rachel Marshall ◽

James Thomas ◽

Anna Noel-Storr ◽

...

Keyword(s):

Economic Development ◽

Burden Of Disease ◽

Disease Burden ◽

Health Conditions ◽

Global Burden Of Disease ◽

Global Burden ◽

List Type ◽

New Findings ◽

Socio Economic Development ◽

Global Disease Burden

ABSTRACTIntroductionIdeally, health conditions causing the greatest global disease burden should attract increased research attention. We conducted a comprehensive global study investigating the number of randomised controlled trials (RCTs) published on different health conditions, and how this compares with the global disease burden that they impose.MethodsWe use machine learning to monitor PubMed daily, and find and analyse RCT reports. We assessed RCTs investigating the leading causes of morbidity and mortality from the Global Burden of Disease study. Using regression models, we compared numbers of actual RCTs in different health conditions to numbers predicted from their global disease burden (Disability-Adjusted Life Years [DALYs]). We investigated whether RCT numbers differed for conditions disproportionately affecting countries with lower socio-economic development.ResultsWe estimate 463,000 articles describing RCTs (95% prediction interval 439,000–485,000) were published from 1990 to July 2020. RCTs recruited a median of 72 participants (interquartile range 32–195). 82% of RCTs were conducted by researchers in the top fifth of countries by socio-economic development. As DALYs increased for a particular health condition by 10%, the number of RCTs in the same year increased by 5% (3.2%–6.9%), but the association was weak (adjusted R2=0.13). Conditions disproportionately affecting countries with lower socio-economic development, including respiratory infections and tuberculosis (7 thousand RCTs below predicted) and enteric infections (10 thousand RCTs below predicted), appear relatively under-researched for their disease burden. Each 10% shift in DALYs towards countries with low and middle socio-economic development was associated with a 4% reduction in RCTs (3.7%–4.9%). These disparities have not changed substantially over time.ConclusionResearch priorities are not well optimized to reduce the global burden of disease. Most RCTs are produced by highly developed countries, and the health needs of these countries have been, on average, favoured.Key questionsWhat is already known?Prior studies have manually investigated the relationship between published research in different health conditions and the global burden of disease that they impose.However, these analyses have been mostly limited to estimates of research funding from national funders, or smaller scale analysis of older publication records.These studies have highlighted disparities in research relative to burden, but they are not sufficient to enable global targeting of research to optimise improvements in disease burden.What are the new findings?We automatically process all of PubMed, allowing us to conduct a continually updated, comprehensive analysis of published reports of RCTs, including the number of participants per RCT and the health conditions studied.We found that considerable disparities exist between the relative volume of evidence on some conditions and the global burden of disease that they impose, as calculated by the Global Burden of Disease study.Further, our analysis suggests that there exists a smaller amount of evidence for conditions that impose a comparatively large burden of disease in lower-income countries.What do the new findings imply?Looking at numbers of RCTs published, and the numbers of participants in these trials, it seems that research priorities are not optimized to reduce the global burden of disease, and that research for conditions affecting higher-income countries has, on average, been favoured.The findings from this study could help research funders to focus research investment in areas where the largest reductions in disease burden could be made.

Tuberculosis diagnosis cascade in Blantyre, Malawi: a prospective cohort study

10.1101/2020.06.16.20132472 ◽

2020 ◽

Author(s):

Helena R A Feasey ◽

Elizabeth L Corbett ◽

Marriott Nliwasa ◽

Luke Mair ◽

Titus H Divala ◽

...

Keyword(s):

High Throughput ◽

Prospective Cohort ◽

Care Delivery ◽

Health Facilities ◽

List Type ◽

National Guidelines ◽

High Burden ◽

Exit Interviews ◽

Care Cascade ◽

New Findings

AbstractBackgroundTuberculosis (TB) control relies on early diagnosis and treatment. International guidelines recommend systematic TB screening at health facilities in high-burden settings, but implementation is challenging. To construct a TB diagnosis care cascade, we investigated screening guideline adherence and completion of TB testing steps in Blantyre, Malawi.MethodsA prospective cohort recruited adult (≥18) outpatients attending Bangwe acute-care primary clinic between 21/5/2018 and 6/9/2018. Entry interviews recording TB symptoms and demographic characteristics were linked to exit interviews by biometrics. Care cascades were constructed to estimate the proportion of patients progressing through each step of the diagnostic pathway. Multivariable logistic regression was used to investigate factors associated with being asked to submit sputum.ResultsOf 5,442 clinic attendances 2,397 (44%) had exit interviews. In clinically indicated participants (n=330) 203 (61.5%) were asked about cough, 39 (11.8%) were asked for sputum, 27 (8.2%) gave sputum and 1 (0.3%) received same-day results. Significant associations with request for sputum were: any TB symptom (aOR:3.20, 95%CI:2.02-5.06), increasing age (aOR:1.02, 95%CI:1.01-1.04 per year) and for HIV-negative participants only, a history of previous TB (aOR:3.37, 95%CI:1.45-7.81). Numbers requiring sputum survey (20/day) outnumbered diagnostic capacity (8-12/day).ConclusionPatients were lost at every stage of the TB care cascade, with same day sputum submission achieved in only 8.2% if clinically indicated. Infection control strategies should be implemented, with reporting on early steps of the TB care cascade formalised. High-throughput interventions, such as digital CXR, that can optimise same-day TB screening are urgently needed to meet WHO End TB goals.SummaryWhat is already known?WHO guidelines recommend systematic screening for Tuberculosis at health facilities in high-burden settings, but implementation is challenging.Care cascades have been widely used by HIV programmes to evaluate care delivery but have only recently been applied to TB care. Care cascades help to define the steps of the cascade most in need of interventionWhat are the new findings?In this study, only 8.2% of those clinically indicated to test for TB (as per national guidelines in Malawi) did so, with patients lost at every step of the diagnosis care cascade.Failure to request sputum by clinicians despite elicited symptoms led to the biggest single gap in the diagnosis care cascade, followed by not asking about symptoms.If all patients attending the clinic were screened for TB as per the guidelines, the current testing facilities would only be able to process up to two thirds of the required samples.What do the new findings imply?Interventions focusing on health worker behaviour may have the greatest potential for retaining presumptive TB patients within the diagnosis cascadeWe must formalise and strengthen reporting on the early steps in the TB care cascade: a requirement to report numbers of screened presumptive TB cases would allow greater focus on these critical steps.If identification of presumptive TB patients is subsequently improved a novel high-throughput approach to triage testing using new diagnostics will be required for LMICs to increase capacity.

Explaining the outcomes of the ‘Clean India’ campaign: institutional behaviour and sanitation transformation in India

10.1101/19004689 ◽

2019 ◽

Author(s):

Val Curtis

Keyword(s):

Sustainable Development ◽

Universal Access ◽

Theory Of Change ◽

Ethical Behaviour ◽

List Type ◽

Open Defecation ◽

Sustainable Development Goal ◽

Development Goal ◽

The Sustainable Development ◽

New Findings

AbstractIntroductionWhilst many less developed countries are struggling to provide universal access to safe sanitation, in the last five years India has almost reached its target of eliminating open defaecation. The object of this study was to understand how the Indian Government effected this sanitation transformation.MethodsThe study employed interviews with 17 actors in the Government’s ‘Clean India’ programme across the national capital and four states which were analysed using a theory of change grounded in Behaviour Centred Design.ResultsThe Swachh Bharat Mission (Gramin) claims to have improved the coverage of toilets in rural India from 39% to over 95% of households between 2014 and mid 2019. From interviews with relevant actors we constructed a theory of change for the programme in which high-level political support and disruptive leadership changed environments in districts, which led to psychological changes in district officials, which, in turn, led to changed behaviour concerning sanitation programming. The Prime Minister’s setting of the ambitious goal to eliminate open defecation by the 150th birthday of Mahatma Gandhi (October 2019) galvanised government bureaucracy, while early success in 100 flagship districts reduced the scepticism of government employees, a cadre of 500 young professionals placed in districts imparted new ideas and energy, social and mass media was used to engage and motivate the public and key players, and new norms of ethical behaviour were demonstrated by leaders. As a result, district officials engaged emotionally with the programme and felt pride at their achievements in ridding villages of open defecation.ConclusionsThough many challenges remain, Governments seeking to achieve the Sustainable Development Goal of universal access to safe sanitation can emulate the success of India’s Swachh Bharat Mission.SUMMARY BOXESWhat is already known?At least 47 countries are not on track to reach the Sustainable Development Goal of universal access to safe sanitation by 2030 and some 0.6 billion people are still defecating in the open.It is not clear how governments in low income countries can be galvanised to act to resolve this pressing public health problem.What are the new findings?The experience of the Clean India programme suggests that countries can almost eliminate open defecation.The success of the programme was due to factors including: the setting of ambitious targets; the use of modern communications strategies and monitoring technology; and the provision of visible reward and recognition for employees.What do the new findings imply?Disruptive leadership is needed to create working environments where sometimes jaded civil servants are given an opportunity to make a difference.Politicians who embrace the cause of sanitation may find that there are votes in toilets.