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  • By contrast the trials in India

    2019-06-18

    By contrast, the trials in India show that if most of the target Chlorhexidine digluconate has no demand for sanitation then even a well-funded campaign will not succeed, and to study health effects will be pointless. The reasons for India\'s traditionally low demand for sanitation are complex, probably including cultural, religious, caste, and gender issues. The Indian Government\'s ongoing attempts to force sanitation changes by offering increasingly generous subsidies alongside modest demand creation activities have been criticised. Alternative approaches have so far only shown promise on a small scale. All seven sanitation trials published so far might underestimate the true health effect of sanitation because they were undertaken in rural villages, whereas sanitation interventions could be more effective in dense urban slums. Completing a trial in this setting, however, would be difficult. Additionally, the timeline to implement and assess the interventions might have been unrealistically short to achieve a health effect. Improving sanitation takes years rather than months, but there are clear ethical and logistical barriers to undertaking longer-term trials. Therefore, the study by Pickering and colleagues might be as good as it gets, and their results provide much needed encouragement in this important area of public health. Additional evidence would be desirable, but might not be achieved.
    In the Global Burden of Disease (GBD) 2010 study, disability weights for a large number of diseases and disabilities were estimated from judgements of health states elicited in household surveys in Bangladesh, Indonesia, Tanzania, Peru, and the USA, and in an open access web-based survey. In a useful update by Salomon and colleagues, participants in the GBD project show that judgments in four European countries are mostly quite similar to those obtained in the previous study. Salomon and colleagues also show that judgments are quite robust as to whether disorders are described as chronic or temporary. For 30 of the health states in the 2010 study, descriptions were revised in the 2013 study. As a result, valuations of some of the states changed substantially. In particular, deafness, in 2010, was assigned the implausible weight of 0·03, and being in a wheelchair with a spinal cord lesion below the neck 0·05. I suggested that this was due to the GBD being about losses in health and respondents thinking that people with the two disorders had disability rather than poor health. The GBD responded by adding information in the 2013 study about health effects of the two disorders. The weights then became 0·22 for deafness and 0·30 for being in a wheelchair with a spinal cord lesion below the neck, which is still debateable, but much more plausible than before.
    The arrival of the next generation of advanced diagnostic point-of-care tests was announced on July 28, 2015, when Cepheid and their non-profit partner, FIND, unveiled a new device called GeneXpert Omni. Although this device might seem to be yet another rapid nucleic acid amplification test, it is small (23 cm tall), lightweight (1 kg), easy to use, powered by a rechargeable battery, and has wireless connectivity, making it the first true point-of-care molecular assay. This portable device will allow health-care workers to do sophisticated molecular testing in the most remote areas of the world. Since it operates all the same PCR-based cartridge tests as Cepheid\'s existing GeneXpert, it is already capable of performing multiple diagnostic tests, including tests for tuberculosis, drug-resistant tuberculosis, HIV, and Ebola virus. GeneXpert Omni builds on the global successes of first-generation diagnostic point-of-care tests and Cepheid\'s laboratory-based GeneXpert system. These first-generation tests are straightforward assays to indicate the presence (or amount) of a molecule or an antigen on a strip of paper, and they have substantially improved the management and diagnosis of important conditions and diseases. For example, millions of patients with diabetes worldwide optimise their blood sugar level by inserting a blood-saturated strip of paper into a small, battery-powered glucometer; women collectively use roughly 300 000 urine tests per day in the comfort of their home to know their pregnancy status; and rapid HIV tests have helped 600 million adults to know their HIV serostatus in 122 low-income and middle-income countries in 2010–14.