Handwashing CEA [moral weights updated Feb 2021] (public)

	A	B	C	D	E	F	G	H	I
1			Source	Optimistic	Best guess	Pessimistic	Note
2	Benefits
3
4		Diarrheal disease. Under-5 deaths per 100,000 per year	GBD 2015, IHME	593.5	191.4	18.2	Country with highest diarrheal+pneumonia death rate in SSA (Chad).	Average for SSA	Country with lowest diarrhea+pneumonia burden in SSA (Cape Verde)
5		Likelihood of under-5 dying of diarrhea each year		0.59%	0.19%	0.02%
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7		Reduction in incidence of under-5 diarrhea due to intervention	Ejemot-Nwadiaro et al 2015	34.00%	28.00%		“Hand washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevents around one-third of diarrhoea episodes in high income countries (rate ratio 0.70; 95% CI 0.58 to 0.85; nine trials, 4664 participants, high quality evidence), and may prevent a similar proportion in LMICs but only two trials from urban Egypt and Kenya have evaluated this (rate ratio 0.66, 95% CI 0.43 to 0.99; two trials, 45,380 participants, low quality evidence).” Ejemot-Nwadiaro et al 2015	“Hand washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (rate ratio 0.72, 95% CI 0.62 to 0.83; eight trials, 14,726 participants, moderate quality evidence).” Ejemot-Nwadiaro et al 2015
8		Internal validity adjustment			70.00%		See interim intervention report for overview of considerations
9		External validity adjustment			90.00%		See interim intervention report for overview of considerations
10		Reduction in overall mortality risk from reductions in diarrhea		0.10%	0.03%	0.00%
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12		Number of under-5 deaths for pneumonia per 100,000 people per year.	GBD 2015, IHME	511.4	215.0	56.2
13		Likelihood of under-5 dying of pneumonia each year		0.51%	0.21%	0.06%
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15		Reduction in incidence of under-5 pneumonia due to intervention	Luby 2005	50.00%	47.50%	45.00%	"Children younger than 5 years in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than controls (95% CI –65% to –34%)." Luby 2005, Pg 225	Average of plain and antibacterial soap	"Antibacterial soap. Difference vs control -45% (-64% to -26%)." Table 2, Luby 2005, Pg 228
16		Internal validity adjustment			80.00%		See interim intervention report for overview of considerations
17		External validity adjustment			70.00%		See interim intervention report for overview of considerations
18		Reduction in overall mortality risk from reductions in pneumonia		0.14%	0.06%	0.01%
19
20		Number of years the benefits persist for			1		"All included trials were relatively small-sized and of short follow-up duration including intensive monitoring and they demonstrated significant reduction in the risk of diarrhoea after hand hygiene intervention. However, in one relatively large trial, Bowen 2004 CHN, and one with longer follow-up, Luby 2006 PAK, there were no apparent benefits as no significant differences between the incidence or longitudinal prevalence of diarrhoea was found. Therefore, we are unclear if the reductions in incidence of diarrhoea would be maintained if these trials had been larger and conducted over a longer time period." Ejemot-Nwadiaro et al 2015
21
22		Deaths averted per child under-5 treated		0.00241	0.00091	0.00018
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24	Costs
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26		Cost per person (1999 USD)	Sijbesma and Christoffers 2009	1.1	1.3	1.7	"Irrespective of their results, their costs ranged from US$1.05 to 1.74/pp/yr, with an average of US$1.31" Sijbesma and Christoffers 2009, P.426
27		Inflation adjustment to March 2017 USD	https://data.bls.gov/cgi-bin/cpicalc.pl?cost1=1&year1=199906&year2=201703		1.5
28		Cost per person (March 2017 USD)		1.5	1.9	2.6
29		Proportion of population under the age of 5 (SSA)	https://www.populationpyramid.net/sub-saharan-africa/2016/		16.20%		Assume the population served has the same proportion of people under the age of 5 as Sub Saharan Africa
30		Cost per under-5 served		10	12	16
31
32	Cost-effectiveness
33
34		Cost per under-5 life saved		$3,958	$13,069	$86,975
35
36		Value assigned to averting the death of an individual under 5 from diarrhea or pneumonia		108.00	108.00	108.00	This row relies on more recent data on the number of under-5 deaths due to diarrhea and lower respiratory infections than the rows above ("Diarrheal disease. Under-5 deaths per 100,000 per year" and "Number of under-5 deaths for pneumonia per 100,000 people per year")
37		Total units of value generated from hypothetical donation ($100,000)		2,728.86	826.40	124.17
38		Total units of value generated with hypothetical donation ($100,000) to GiveDirectly (unconditional cash transfers)		344.00	344.00	344.00
39
40		Handwashing promotion vs cash		7.9	2.4	0.4
41
42	Sources
43
44		GBD 2015, IHME, diarrheal disease and pneumonia	http://ihmeuw.org/435b
45		Sijbesma and Christoffers 2009	https://www.ncbi.nlm.nih.gov/pubmed/19703917
46		Ejemot-Nwadiaro et al 2015	http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004265.pub3/full
47		Luby 2005	http://hope-ngo.com/Portals/0/PDF/SoapHealth%20ARI%20Lancet%20Man%20Report%203.pdf
48
49	Notes and Limitations
50			Rationale
51		Cost per person is based on the cost of handwashing materials, and may not reflect the cost of implementing the program	Depends on specific charity/program
52		Incidence of diarrhea and pneumonia will depend on the specific population and could be higher than the most optimistic estimate	Depends on specific charity/program
53		Potential impact on worm infections and intensity not included	Lack of evidence
54		Reduction in treatment costs not included	Consistency with other CEAs
55		Assumes no effect on those over the age of 5	Lack of evidence
56		Assumes reduction in mortality is proportional to reduction in incidence	Lack of evidence
57
58	Note: This CEA was created in May 2017 (original here). Moral weights were updated in February 2021
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