# Vaccine Efficacy after a Sanitation Campaign: A Natural Experiment

> **NIH NIH R03** · UNIVERSITY OF CALIFORNIA-IRVINE · 2020 · $70,818

## Abstract

ABSTRACT
Open defecation contaminates ambient environment and water sources with pathogenic bacteria and
may, over time, decrease vaccine efficacy and increase childhood malnutrition. Prolonged exposure to
fecal pathogens causes a condition called environmental enteropathy, which is characterized by
malabsorption, atrophy of intestinal villi, crypt hyperplasia, T-cell infiltration and inflammation of the
jejunum. These changes can diminish a vaccine-specific response, or destroy an attenuated vaccine by
an aggressive local immune response in the digestive tract. Furthermore, hyperplasia or thickening of
small intestine walls may obstruct proper absorption of nutrients, leading to malnutrition. However,
alarmingly few community interventions with strong study designs quantify the relation between open
defecation, vaccine efficacy, diarrhea and child malnutrition. We propose a state and district-level
analysis of India's national disease surveillance and regional survey data from two-time periods, 2013
and 2016, to estimate this relation by using as a natural experiment India's national sanitation
campaign, Swachh Bharat Mission (SBM). SBM is a restructured version of India's Total Sanitation
Campaign (TSC), which was originally initiated in 1999, but revamped in 2014 with the goal of complete
eradication of open defecation, and installation of toilets in every household across the country by
2019. The election of a new federal government in 2014 brought in a strong, national mandate on
sanitation and hygiene. According to national estimates, > 10 million toilets have been constructed thus
far, with an annual funding of over $ 1 billion allotted exclusively towards SBM. We hypothesize that
increased toilet construction owing to implementation of SBM by India's newly elected central
government (in 2014) precedes a reduction in vaccine preventable illnesses (diphtheria, pertussis,
tetanus and measles), diarrhea and malnutrition (stunting, wasting and underweight) in children less
than 5 years of age. We further aim to test the association between political impetus towards SBM
implementation and child health outcomes using data on state and district level utilization of
government funding allocated for SBM. We will use high-quality data from India's Demographic and
Health Survey (comprising District Level Household & Facility Survey, Annual Health Survey, and
National Family Health Survey) and national administrative Health Surveillance Reports to achieve our
study Aims. The results of this study may hold strong implications for control of diarrheal diseases and
vaccine efficacy. Our collaboration with the Indian Institute of Management Bangalore (IIMB),
moreover, on this topic aligns well with NIH's Indo-US Vaccine Action Program (VAP) Small Research
Grant's stated goal of supporting collaborative vaccine-related research that may ultimately reduce the
burden of infectious diseases in India.

## Key facts

- **NIH application ID:** 9878751
- **Project number:** 5R03AI135322-02
- **Recipient organization:** UNIVERSITY OF CALIFORNIA-IRVINE
- **Principal Investigator:** Tim Allen Bruckner
- **Activity code:** R03 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $70,818
- **Award type:** 5
- **Project period:** 2019-02-21 → 2021-07-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9878751

## Citation

> US National Institutes of Health, RePORTER application 9878751, Vaccine Efficacy after a Sanitation Campaign: A Natural Experiment (5R03AI135322-02). Retrieved via AI Analytics 2026-05-21 from https://api.ai-analytics.org/grant/nih/9878751. Licensed CC0.

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