title: A Comparison of Diarrheal Severity Scores in the MAL-ED Multisite Community-Based Cohort Study.
abstract: There is a lack of consensus on how to measure diarrheal severity. Within the context of a multisite, prospective cohort study, we evaluated the performance of a modified Vesikari score (MAL-ED), 2 previously published scores (Clark and CODA [a diarrheal severity score (Community DiarrheA) published by Lee et al]), and a modified definition of moderate-to-severe diarrhea (MSD) based on dysentery and health care worker diagnosed dehydration.
  
  
  
  Scores were built using maternally reported symptoms or fieldworker-reported clinical signs obtained during the first 7 days of a diarrheal episode. The association between these and the risk of hospitalization were tested using receiver operating characteristic analysis. Severity scores were also related to illness etiology, and the likelihood of the episode subsequently becoming prolonged or persistent.
  
  
  
  Of 10,159 episodes from 1681 children, 143 (4.0%) resulted in hospitalization. The area under the curve of each score as a predictor of hospitalization was 0.84 (95% confidence interval: 0.81, 0.87) (Clark), 0.85 (0.82, 0.88) (MAL-ED), and 0.87 (0.84, 0.89) (CODA). Severity was also associated with etiology and episode duration. Although families were more likely to seek care for severe diarrhea, approximately half of severe cases never reached the health system.
  
  
  
  Community-based diarrheal severity scores are predictive of relevant child health outcomes. Because they require no assumptions about health care access or utilization, they are useful in refining estimates of the burden of diarrheal disease, in estimating the effect of disease control interventions, and in triaging children for referral in low- and middle-income countries in which the rates of morbidity and mortality after diarrhea remain high.
authors.affiliation: *Johns Hopkins Bloomberg School of Public Health, Baltimore †Fogarty International Center, National Institutes of Health, Bethesda, MD ‡Christian Medical College, Vellore, India §University of Virginia, Charlottesville ||Temple University, Philadelphia, PA ¶Aga Khan University, Karachi, Pakistan #icddr,b (formerly International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh **Haydom Lutheran Hospital, Haydom, Manyara Region, Tanzania ††Federal University of Ceará, Fortaleza, Brazil ‡‡University of Venda, Thohoyandou, South Africa §§Centre for International Health, University of Bergen, Bergen, Norway ||||Department of Child Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal ¶¶Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.
authors.forename: Gwenyth O
authors.initials: GO
authors.lastname: Lee
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Richard
authors.forename: Gagandeep
authors.initials: G
authors.lastname: Kang
authors.forename: Eric R
authors.initials: ER
authors.lastname: Houpt
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Seidman
authors.forename: Laura L
authors.initials: LL
authors.lastname: Pendergast
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
authors.forename: Tahmeed
authors.initials: T
authors.lastname: Ahmed
authors.forename: Estomih R
authors.initials: ER
authors.lastname: Mduma
authors.forename: Aldo A
authors.initials: AA
authors.lastname: Lima
authors.forename: Pascal
authors.initials: P
authors.lastname: Bessong
authors.forename: Mats Steffi
authors.initials: MS
authors.lastname: Jennifer
authors.forename: Md Iqbal
authors.initials: MI
authors.lastname: Hossain
authors.forename: Ram Krishna
authors.initials: RK
authors.lastname: Chandyo
authors.forename: Emanuel
authors.initials: E
authors.lastname: Nyathi
authors.forename: Ila F
authors.initials: IF
authors.lastname: Lima
authors.forename: John
authors.initials: J
authors.lastname: Pascal
authors.forename: Sajid
authors.initials: S
authors.lastname: Soofi
authors.forename: Bodhidatta
authors.initials: B
authors.lastname: Ladaporn
authors.forename: Richard L
authors.initials: RL
authors.lastname: Guerrant
authors.forename: Laura E
authors.initials: LE
authors.lastname: Caulfield
authors.forename: Robert E
authors.initials: RE
authors.lastname: Black
authors.forename: Margaret N
authors.initials: MN
authors.lastname: Kosek
mesh_terms: D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003906:Developing Countries; D003967:Diarrhea / Q000175:diagnosis* / Q000209:etiology; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008297:Male; D012372:ROC Curve; D012720:Severity of Illness Index