From my experience it is borderline implausible that 5.8% of diarrhoeal episodes lead to hospitalisation. I’m not sure if you referenced where this number came from? I’ve worked in Northern Uganda for 10 years and diarrhoea is a far less common than you would expect reason for presentation to primary care (Under 3% of our OneDay Health Patients present with diarrhoea) and at best an uncommon reason for hospitalisation. I even removed treating diarrhoea from our OneDay Health cost-effectiveness analysis because it appeared insignificant (both because the effect of treating one patient is so small, and because we treat so few patients for it)
It took a while, but we finally found some good empirical data regarding hospitalization rates due to diarrhea in LMICs, beyond the four smaller studies GiveWell references for justifying their 5.8% estimate [1].
So, the Global Enteric Multicenter Study of Diarrheal Disease in Infants and Young Children in Developing Countries (GEMS) was a 3-year, multi-site case-control study focusing on diarrhea in children under 5 years old living in seven low-income countries in sub-Saharan Africa and South Asia (source).
Even though the main GEMS study had a focus on moderate and severe cases, it was preceded by a preparatory survey called “Health Care Utilization and Attitudes Survey (HUAS)”. According to their “Establishing a Sampling Frame for the Case/Control Study and Selecting Health Centers for Case Recruitment” section:
In preparation for the case/control study, we performed a Health Care Utilization and Attitudes Survey (HUAS). An age-stratified sample of approximately 1000 children aged 0–59 months per site randomly selected from each updated DSS [demographic surveillance system] dataset was visited at home, and parents/primary caretakers were asked whether their child had experienced diarrhea during the previous 14 days. If so, the presence of findings suggestive of MSD [moderate-to-severe diarrhea] was solicited (sunken eyes, wrinkled skin, hospitalization, receipt of intravenous hydration, or dysentery), and source(s) of healthcare were recorded. These data were used to adjust the size of the DSS population at each site as necessary to contribute the requisite number of cases of MSD to each age stratum, and to select 1 or more “sentinel” health centers (SHCs) serving the DSS population at each site (Table 1) as venues for the case/control study based on their potential to capture MSD cases from the DSS.
It turns out that the resulting data from the HUAS study is easily accessible for anyone to consult. And it recorded the number of children under 5 who reportedly had diarrhea during the 14 days previous to the interview, and whether they were admitted to a hospital.
According to this data, out of 5,171 who reportedly suffered from diarrhea in the previous 14 days, and for whom data for this variable was available, 270 children were admitted to hospitals. This gives a 5.22% hospitalization rate (95% CI: 4.65-5.86%), which is roughly what GiveWell estimated from a set of smaller studies.
Therefore, we think this part of the CEA is also roughly aligned with evidence.
Finally, about the other points you raised, we recommend you (and everyone interested in the theme) check the new version of the report published by Ambitious Impact/Charity Entrepreneurship when recommending this intervention for CE’s next incubation round[1].
AIM/CE researchers dedicated a few hours to polishing the remaining loose ends in our previous version. It includes a model for calculating the mortality reductions based on diarrhea case-fatality rates. This is a slightly enhanced version of our model and represents an interesting proposition on how to extrapolate the effect of the intervention from cases to mortality—given more time, it could even be expanded to consider pathogen-specific case-fatality rates, which should be even better.
About this other point:
It took a while, but we finally found some good empirical data regarding hospitalization rates due to diarrhea in LMICs, beyond the four smaller studies GiveWell references for justifying their 5.8% estimate [1].
So, the Global Enteric Multicenter Study of Diarrheal Disease in Infants and Young Children in Developing Countries (GEMS) was a 3-year, multi-site case-control study focusing on diarrhea in children under 5 years old living in seven low-income countries in sub-Saharan Africa and South Asia (source).
Even though the main GEMS study had a focus on moderate and severe cases, it was preceded by a preparatory survey called “Health Care Utilization and Attitudes Survey (HUAS)”. According to their “Establishing a Sampling Frame for the Case/Control Study and Selecting Health Centers for Case Recruitment” section:
It turns out that the resulting data from the HUAS study is easily accessible for anyone to consult. And it recorded the number of children under 5 who reportedly had diarrhea during the 14 days previous to the interview, and whether they were admitted to a hospital.
According to this data, out of 5,171 who reportedly suffered from diarrhea in the previous 14 days, and for whom data for this variable was available, 270 children were admitted to hospitals. This gives a 5.22% hospitalization rate (95% CI: 4.65-5.86%), which is roughly what GiveWell estimated from a set of smaller studies.
Therefore, we think this part of the CEA is also roughly aligned with evidence.
The four studies are Burton et al. 2011, Page et al. 2011, Breiman et al. 2011, and Omore et al. 2013. See footnote #92 of GW’s report.
Finally, about the other points you raised, we recommend you (and everyone interested in the theme) check the new version of the report published by Ambitious Impact/Charity Entrepreneurship when recommending this intervention for CE’s next incubation round [1].
AIM/CE researchers dedicated a few hours to polishing the remaining loose ends in our previous version. It includes a model for calculating the mortality reductions based on diarrhea case-fatality rates. This is a slightly enhanced version of our model and represents an interesting proposition on how to extrapolate the effect of the intervention from cases to mortality—given more time, it could even be expanded to consider pathogen-specific case-fatality rates, which should be even better.
We, the authors of the originial report, had only very limited participation in the changes made between the two versions.