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Asante KP, Mathanga DP, Milligan P, Akech S, Oduro A, Mwapasa V, Moore KA, Kwambai TK, Hamel MJ, Gyan T, Westercamp N, Kapito-Tembo A, Njuguna P, Ansong D, Kariuki S, Mvalo T, Snell P, Schellenberg D, Welega P, Otieno L, Chimala A, Afari EA, Bejon P, Maleta K, Agbenyega T, Snow RW, Zulu M, Chinkhumba J, Samuels AM. Feasibility, safety, and impact of the RTS,S/AS01 E malaria vaccine when implemented through national immunisation programmes: evaluation of cluster-randomised introduction of the vaccine in Ghana, Kenya, and Malawi. Lancet 2024; 403:1660-1670. [PMID: 38583454 DOI: 10.1016/s0140-6736(24)00004-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The RTS,S/AS01E malaria vaccine (RTS,S) was introduced by national immunisation programmes in Ghana, Kenya, and Malawi in 2019 in large-scale pilot schemes. We aimed to address questions about feasibility and impact, and to assess safety signals that had been observed in the phase 3 trial that included an excess of meningitis and cerebral malaria cases in RTS,S recipients, and the possibility of an excess of deaths among girls who received RTS,S than in controls, to inform decisions about wider use. METHODS In this prospective evaluation, 158 geographical clusters (66 districts in Ghana; 46 sub-counties in Kenya; and 46 groups of immunisation clinic catchment areas in Malawi) were randomly assigned to early or delayed introduction of RTS,S, with three doses to be administered between the ages of 5 months and 9 months and a fourth dose at the age of approximately 2 years. Primary outcomes of the evaluation, planned over 4 years, were mortality from all causes except injury (impact), hospital admission with severe malaria (impact), hospital admission with meningitis or cerebral malaria (safety), deaths in girls compared with boys (safety), and vaccination coverage (feasibility). Mortality was monitored in children aged 1-59 months throughout the pilot areas. Surveillance for meningitis and severe malaria was established in eight sentinel hospitals in Ghana, six in Kenya, and four in Malawi. Vaccine uptake was measured in surveys of children aged 12-23 months about 18 months after vaccine introduction. We estimated that sufficient data would have accrued after 24 months to evaluate each of the safety signals and the impact on severe malaria in a pooled analysis of the data from the three countries. We estimated incidence rate ratios (IRRs) by comparing the ratio of the number of events in children age-eligible to have received at least one dose of the vaccine (for safety outcomes), or age-eligible to have received three doses (for impact outcomes), to that in non-eligible age groups in implementation areas with the equivalent ratio in comparison areas. To establish whether there was evidence of a difference between girls and boys in the vaccine's impact on mortality, the female-to-male mortality ratio in age groups eligible to receive the vaccine (relative to the ratio in non-eligible children) was compared between implementation and comparison areas. Preliminary findings contributed to WHO's recommendation in 2021 for widespread use of RTS,S in areas of moderate-to-high malaria transmission. FINDINGS By April 30, 2021, 652 673 children had received at least one dose of RTS,S and 494 745 children had received three doses. Coverage of the first dose was 76% in Ghana, 79% in Kenya, and 73% in Malawi, and coverage of the third dose was 66% in Ghana, 62% in Kenya, and 62% in Malawi. 26 285 children aged 1-59 months were admitted to sentinel hospitals and 13 198 deaths were reported through mortality surveillance. Among children eligible to have received at least one dose of RTS,S, there was no evidence of an excess of meningitis or cerebral malaria cases in implementation areas compared with comparison areas (hospital admission with meningitis: IRR 0·63 [95% CI 0·22-1·79]; hospital admission with cerebral malaria: IRR 1·03 [95% CI 0·61-1·74]). The impact of RTS,S introduction on mortality was similar for girls and boys (relative mortality ratio 1·03 [95% CI 0·88-1·21]). Among children eligible for three vaccine doses, RTS,S introduction was associated with a 32% reduction (95% CI 5-51%) in hospital admission with severe malaria, and a 9% reduction (95% CI 0-18%) in all-cause mortality (excluding injury). INTERPRETATION In the first 2 years of implementation of RTS,S, the three primary doses were effectively deployed through national immunisation programmes. There was no evidence of the safety signals that had been observed in the phase 3 trial, and introduction of the vaccine was associated with substantial reductions in hospital admission with severe malaria. Evaluation continues to assess the impact of four doses of RTS,S. FUNDING Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Unitaid.
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Affiliation(s)
- Kwaku Poku Asante
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo North Municipality, Ghana; London School of Hygiene & Tropical Medicine, London, UK.
| | - Don P Mathanga
- School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi; Malaria Alert Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Paul Milligan
- London School of Hygiene & Tropical Medicine, London, UK.
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Abraham Oduro
- Navrongo Health Research Centre, Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Victor Mwapasa
- School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kerryn A Moore
- London School of Hygiene & Tropical Medicine, London, UK; Murdoch Children's Research Institute, Infection and Immunity, New Vaccines, Parkville, VIC, Australia
| | - Titus K Kwambai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Mary J Hamel
- Department of Immunizations, Vaccines, and Biologicals, WHO, Geneva, Switzerland
| | - Thomas Gyan
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo North Municipality, Ghana
| | - Nelli Westercamp
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Daniel Ansong
- Agogo Malaria Research Centre, Agogo, Ghana; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Simon Kariuki
- Centre for Global Health Research, KEMRI, Kisumu, Kenya
| | - Tisungane Mvalo
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Paul Snell
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Paul Welega
- Navrongo Health Research Centre, Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Lucas Otieno
- KEMRI-US Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Alfred Chimala
- Malaria Alert Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Edwin A Afari
- School of Public Health, University of Ghana, Accra, Ghana
| | - Philip Bejon
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kenneth Maleta
- School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tsiri Agbenyega
- Agogo Malaria Research Centre, Agogo, Ghana; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Robert W Snow
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Madaliso Zulu
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Jobiba Chinkhumba
- School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Aaron M Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya; Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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2
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Oldenburg CE, Ouattara M, Bountogo M, Boudo V, Ouedraogo T, Compaoré G, Dah C, Zakane A, Coulibaly B, Bagagnan C, Hu H, O’Brien KS, Nyatigo F, Keenan JD, Doan T, Porco TC, Arnold BF, Lebas E, Sié A, Lietman TM. Mass Azithromycin Distribution to Prevent Child Mortality in Burkina Faso: The CHAT Randomized Clinical Trial. JAMA 2024; 331:482-490. [PMID: 38349371 PMCID: PMC10865159 DOI: 10.1001/jama.2023.27393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/14/2023] [Indexed: 02/15/2024]
Abstract
Importance Repeated mass distribution of azithromycin has been shown to reduce childhood mortality by 14% in sub-Saharan Africa. However, the estimated effect varied by location, suggesting that the intervention may not be effective in different geographical areas, time periods, or conditions. Objective To evaluate the efficacy of twice-yearly azithromycin to reduce mortality in children in the presence of seasonal malaria chemoprevention. Design, Setting, and Participants This cluster randomized placebo-controlled trial evaluating the efficacy of single-dose azithromycin for prevention of all-cause childhood mortality included 341 communities in the Nouna district in rural northwestern Burkina Faso. Participants were children aged 1 to 59 months living in the study communities. Interventions Communities were randomized in a 1:1 ratio to receive oral azithromycin or placebo distribution. Children aged 1 to 59 months were offered single-dose treatment twice yearly for 3 years (6 distributions) from August 2019 to February 2023. Main Outcomes and Measures The primary outcome was all-cause childhood mortality, measured during a twice-yearly enumerative census. Results A total of 34 399 children (mean [SD] age, 25.2 [18] months) in the azithromycin group and 33 847 children (mean [SD] age, 25.6 [18] months) in the placebo group were included. A mean (SD) of 90.1% (16.0%) of the censused children received the scheduled study drug in the azithromycin group and 89.8% (17.1%) received the scheduled study drug in the placebo group. In the azithromycin group, 498 deaths were recorded over 60 592 person-years (8.2 deaths/1000 person-years). In the placebo group, 588 deaths were recorded over 58 547 person-years (10.0 deaths/1000 person-years). The incidence rate ratio for mortality was 0.82 (95% CI, 0.67-1.02; P = .07) in the azithromycin group compared with the placebo group. The incidence rate ratio was 0.99 (95% CI, 0.72-1.36) in those aged 1 to 11 months, 0.92 (95% CI, 0.67-1.27) in those aged 12 to 23 months, and 0.73 (95% CI, 0.57-0.94) in those aged 24 to 59 months. Conclusions and Relevance Mortality in children (aged 1-59 months) was lower with biannual mass azithromycin distribution in a setting in which seasonal malaria chemoprevention was also being distributed, but the difference was not statistically significant. The study may have been underpowered to detect a clinically relevant difference. Trial Registration ClinicalTrials.gov Identifier: NCT03676764.
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Affiliation(s)
- Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco
| | | | | | | | | | | | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | | | | | | | - Huiyu Hu
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Fanice Nyatigo
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Jeremy D. Keenan
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thuy Doan
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Benjamin F. Arnold
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco
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John CC, Namazzi R, Schneider JG. Azithromycin for Prevention of Mortality in African Children: More Data, More Questions. JAMA 2024; 331:475-476. [PMID: 38349381 DOI: 10.1001/jama.2023.27329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Affiliation(s)
| | - Ruth Namazzi
- Makerere University College of Health Sciences, Kampala, Uganda
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Sié A, Ouattara M, Bountogo M, Boudo V, Ouedraogo T, Compaoré G, Dah C, Bagagnan C, Lebas E, Hu H, Rice J, Porco TC, Arnold BF, Lietman TM, Oldenburg CE. Azithromycin during Routine Well-Infant Visits to Prevent Death. N Engl J Med 2024; 390:221-229. [PMID: 38231623 DOI: 10.1056/nejmoa2309495] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Mass distribution of azithromycin to children 1 to 59 months of age has been shown to reduce childhood all-cause mortality in some sub-Saharan African regions, with the largest reduction seen among infants younger than 12 months of age. Whether the administration of azithromycin at routine health care visits for infants would be effective in preventing death is unclear. METHODS We conducted a randomized, placebo-controlled trial of a single dose of azithromycin (20 mg per kilogram of body weight) as compared with placebo, administered during infancy (5 to 12 weeks of age). The primary end point was death before 6 months of age. Infants were recruited at routine vaccination or other well-child visits in clinics and through community outreach in three regions of Burkina Faso. Vital status was assessed at 6 months of age. RESULTS Of the 32,877 infants enrolled from September 2019 through October 2022, a total of 16,416 infants were randomly assigned to azithromycin and 16,461 to placebo. Eighty-two infants in the azithromycin group and 75 infants in the placebo group died before 6 months of age (hazard ratio, 1.09; 95% confidence interval [CI], 0.80 to 1.49; P = 0.58); the absolute difference in mortality was 0.04 percentage points (95% CI, -0.10 to 0.21). There was no evidence of an effect of azithromycin on mortality in any of the prespecified subgroups, including subgroups defined according to age, sex, and baseline weight, and no evidence of a difference between the two trial groups in the incidence of adverse events. CONCLUSIONS In this trial conducted in Burkina Faso, we found that administration of azithromycin to infants through the existing health care system did not prevent death. (Funded by the Bill and Melinda Gates Foundation; CHAT ClinicalTrials.gov number, NCT03676764.).
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Affiliation(s)
- Ali Sié
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Mamadou Ouattara
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Mamadou Bountogo
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Valentin Boudo
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Thierry Ouedraogo
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Guillaume Compaoré
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Clarisse Dah
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Cheik Bagagnan
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Elodie Lebas
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Huiyu Hu
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Jessica Rice
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Travis C Porco
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Benjamin F Arnold
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Thomas M Lietman
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Catherine E Oldenburg
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
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5
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Dicko A, Ouedraogo JB, Zongo I, Sagara I, Cairns M, Yerbanga RS, Issiaka D, Zoungrana C, Sidibe Y, Tapily A, Nikièma F, Sompougdou F, Sanogo K, Kaya M, Yalcouye H, Dicko OM, Diarra M, Diarra K, Thera I, Haro A, Sienou AA, Traore S, Mahamar A, Dolo A, Kuepfer I, Snell P, Grant J, Webster J, Milligan P, Lee C, Ockenhouse C, Ofori-Anyinam O, Tinto H, Djimde A, Chandramohan D, Greenwood B. Seasonal vaccination with RTS,S/AS01 E vaccine with or without seasonal malaria chemoprevention in children up to the age of 5 years in Burkina Faso and Mali: a double-blind, randomised, controlled, phase 3 trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:75-86. [PMID: 37625434 DOI: 10.1016/s1473-3099(23)00368-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Seasonal vaccination with the RTS,S/AS01E vaccine combined with seasonal malaria chemoprevention (SMC) prevented malaria in young children more effectively than either intervention given alone over a 3 year period. The objective of this study was to establish whether the added protection provided by the combination could be sustained for a further 2 years. METHODS This was a double-blind, individually randomised, controlled, non-inferiority and superiority, phase 3 trial done at two sites: the Bougouni district and neighbouring areas in Mali and Houndé district, Burkina Faso. Children who had been enrolled in the initial 3-year trial when aged 5-17 months were initially randomly assigned individually to receive SMC with sulphadoxine-pyrimethamine and amodiaquine plus control vaccines, RTS,S/AS01E plus placebo SMC, or SMC plus RTS,S/AS01E. They continued to receive the same interventions until the age of 5 years. The primary trial endpoint was the incidence of clinical malaria over the 5-year trial period in both the modified intention-to-treat and per-protocol populations. Over the 5-year period, non-inferiority was defined as a 20% increase in clinical malaria in the RTS,S/AS01E-alone group compared with the SMC alone group. Superiority was defined as a 12% difference in the incidence of clinical malaria between the combined and single intervention groups. The study is registered with ClinicalTrials.gov, NCT04319380, and is complete. FINDINGS In April, 2020, of 6861 children originally recruited, 5098 (94%) of the 5433 children who completed the initial 3-year follow-up were re-enrolled in the extension study. Over 5 years, the incidence of clinical malaria per 1000 person-years at risk was 313 in the SMC alone group, 320 in the RTS,S/AS01E-alone group, and 133 in the combined group. The combination of RTS,S/AS01E and SMC was superior to SMC (protective efficacy 57·7%, 95% CI 53·3 to 61·7) and to RTS,S/AS01E (protective efficacy 59·0%, 54·7 to 62·8) in preventing clinical malaria. RTS,S/AS01E was non-inferior to SMC (hazard ratio 1·03 [95% CI 0·95 to 1·12]). The protective efficacy of the combination versus SMC over the 5-year period of the study was very similar to that seen in the first 3 years with the protective efficacy of the combination versus SMC being 57·7% (53·3 to 61·7) and versus RTS/AS01E-alone being 59·0% (54·7 to 62·8). The comparable figures for the first 3 years of the study were 62·8% (58·4 to 66·8) and 59·6% (54·7 to 64·0%), respectively. Hospital admissions for WHO-defined severe malaria were reduced by 66·8% (95% CI 40·3 to 81·5), for malarial anaemia by 65·9% (34·1 to 82·4), for blood transfusion by 68·1% (32·6 to 84·9), for all-cause deaths by 44·5% (2·8 to 68·3), for deaths excluding external causes or surgery by 41·1% (-9·2 to 68·3), and for deaths from malaria by 66·8% (-2·7 to 89·3) in the combined group compared with the SMC alone group. No safety signals were detected. INTERPRETATION Substantial protection against malaria was sustained over 5 years by combining seasonal malaria vaccination with seasonal chemoprevention, offering a potential new approach to malaria control in areas with seasonal malaria transmission. FUNDING UK Joint Global Health Trials and PATH's Malaria Vaccine Initiative (through a grant from the Bill & Melinda Gates Foundation). TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Alassane Dicko
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Jean-Bosco Ouedraogo
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Issaka Zongo
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Issaka Sagara
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Matthew Cairns
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rakiswendé Serge Yerbanga
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Djibrilla Issiaka
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Charles Zoungrana
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Youssoufa Sidibe
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Amadou Tapily
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Frédéric Nikièma
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Frédéric Sompougdou
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Koualy Sanogo
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Mahamadou Kaya
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Hama Yalcouye
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Oumar Mohamed Dicko
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Modibo Diarra
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Kalifa Diarra
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Ismaila Thera
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Alassane Haro
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Abdoul Aziz Sienou
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Seydou Traore
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Almahamoudou Mahamar
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Amagana Dolo
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Irene Kuepfer
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Paul Snell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Jane Grant
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Jayne Webster
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Paul Milligan
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Halidou Tinto
- Institut des Sciences et Techniques-Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Abdoulaye Djimde
- The Malaria Research and Training Center, University of Science, Technology and Techniques of Bamako, Bamako, Mali
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Brian Greenwood
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK.
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Driscoll AJ, Haidara FC, Tapia MD, Deichsel EL, Samake OS, Bocoum T, Bailey JA, Fitzpatrick MC, Goldenberg RL, Kodio M, Moulton LH, Nasrin D, Onwuchekwa U, Shaffer AM, Sow SO, Kotloff KL. Antenatal, intrapartum and infant azithromycin to prevent stillbirths and infant deaths: study protocol for SANTE, a 2×2 factorial randomised controlled trial in Mali. BMJ Open 2023; 13:e067581. [PMID: 37648393 PMCID: PMC10471877 DOI: 10.1136/bmjopen-2022-067581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/24/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION In high mortality settings, prophylactic azithromycin has been shown to improve birth weight and gestational age at birth when administered antenatally, to reduce the incidence of neonatal infections when administered intrapartum, and to improve survival when administered in infancy. Questions remain regarding whether azithromycin can prevent stillbirths, and regarding the optimal strategy for the delivery of azithromycin to pregnant women and their infants. METHODS AND ANALYSIS Sauver avec l'Azithromycine en Traitant les Femmes Enceintes et les Enfants (SANTE) is a 2×2 factorial, individually randomised, placebo-controlled, double-masked trial in rural Mali. The primary aims are: (1A) to assess the efficacy of antenatal and intrapartum azithromycin on a composite outcome of stillbirths and infant mortality through 6-12 months and (1B) to assess the efficacy of azithromycin administered concurrently with the first and third doses of pentavalent vaccines (Penta-1/3) on infant mortality through 6-12 months. Pregnant participants (n=49 600) and their infants are randomised 1:1:1:1 to one of four treatment arms: (1) mother and infant receive azithromycin, (2) mother and infant receive placebo, (3) mother receives azithromycin and infant receives placebo or (4) mother receives placebo and infant receives azithromycin. Pregnant participants receive three single 2 g doses: two antepartum and one intrapartum. Infants receive a single 20 mg/kg dose at the Penta-1 and 3 visits. An additional cohort of 12 000 infants is recruited at the Penta-1 visit and randomised 1:1 to receive azithromycin or placebo at the same time points. The SANTE trial will inform guidelines and policies regarding the administration of antenatal and infant azithromycin using routine healthcare delivery platforms. ETHICS AND DISSEMINATION This trial was approved by the Institutional Review Board at the University of Maryland School of Medicine (Protocol #HP-00084242) and the Faculté de Médecine et d'Odonto-Stomatologie in Mali. The findings of this trial will be published in open access peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03909737.
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Affiliation(s)
- Amanda J Driscoll
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Milagritos D Tapia
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily L Deichsel
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | - Jason A Bailey
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Meagan C Fitzpatrick
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Robert L Goldenberg
- Obstetrics and Gynecology, Columbia University School of Medicine, New York, New York, USA
| | | | - Lawrence H Moulton
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dilruba Nasrin
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Allison M Shaffer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Samba O Sow
- Centre pour le Développement des Vaccins, Bamako, Mali
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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7
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Grant J, Diawara H, Traore S, Koita F, Myers J, Sagara I, Chandramohan D, Dicko A, Greenwood B, Webster J. Delivery strategies for malaria vaccination in areas with seasonal malaria transmission. BMJ Glob Health 2023; 8:e011838. [PMID: 37147016 PMCID: PMC10163455 DOI: 10.1136/bmjgh-2023-011838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/11/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Seasonal vaccination with the RTS,S/AS01E malaria vaccine given alongside seasonal malaria chemoprevention (SMC) substantially reduces malaria in young children. The WHO has recommended the use of RTS,S/AS01E, including seasonal vaccination, in areas with seasonal malaria transmission. This study aimed to identify potential strategies to deliver RTS,S/AS01E, and assess the considerations and recommendations for delivery of seasonal malaria vaccination in Mali, a country with highly seasonal malaria. METHODS Potential delivery strategies for RTS,S/AS01E in areas with seasonal malaria were identified through a series of high level discussions with the RTS,S/AS01E plus SMC trial investigators, international and national immunisation and malaria experts, and through the development of a theory of change. These were explored through qualitative in-depth interviews with 108 participants, including national-level, regional-level and district-level malaria and immunisation programme managers, health workers, caregivers of children under 5 years of age, and community stakeholders. A national-level workshop was held to confirm the qualitative findings and work towards consensus on an appropriate strategy. RESULTS Four delivery strategies were identified: age-based vaccination delivered via the Essential Programme on Immunisation (EPI); seasonal vaccination via EPI mass vaccination campaigns (MVCs); a combination of age-based priming vaccination doses delivered via the EPI clinics and seasonal booster doses delivered via MVCs; and a combination of age-based priming vaccination doses and seasonal booster doses, all delivered via the EPI clinics, which was the preferred strategy for delivery of RTS,S/AS01E in Mali identified during the national workshop. Participants recommended that supportive interventions, including communications and mobilisation, would be needed for this strategy to achieve required coverage. CONCLUSIONS Four delivery strategies were identified for administration of RTS,S/AS01E alongside SMC in countries with seasonal malaria transmission. Components of these delivery strategies were defined as the vaccination schedule, and the delivery system(s) plus the supportive interventions needed for the strategies to be effective. Further implementation research and evaluation is needed to explore how, where, when and what effective coverage is achievable via these new strategies and their supportive interventions.
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Affiliation(s)
- Jane Grant
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Halimatou Diawara
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Seydou Traore
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Fatoumata Koita
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Jessica Myers
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Issaka Sagara
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Daniel Chandramohan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Alassane Dicko
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Brian Greenwood
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jayne Webster
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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8
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Roca A, Camara B, Bognini JD, Nakakana UN, Somé AM, Beloum N, Rouamba T, Sillah F, Danso M, Jones JC, Graves S, Jagne I, Getanda P, Darboe S, Tahita MC, Ndure E, Franck HS, Edmond SY, Dondeh BL, Nassa WGJ, Garba Z, Bojang A, Njie Y, Bottomley C, Tinto H, D’Alessandro U. Effect of Intrapartum Azithromycin vs Placebo on Neonatal Sepsis and Death: A Randomized Clinical Trial. JAMA 2023; 329:716-724. [PMID: 36881034 PMCID: PMC9993186 DOI: 10.1001/jama.2022.24388] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/25/2023] [Indexed: 03/08/2023]
Abstract
Importance Neonatal sepsis is a leading cause of neonatal mortality. New interventions are needed to decrease neonatal sepsis and mortality in regions with highest burden. Objective To evaluate the efficacy of intrapartum azithromycin to reduce neonatal sepsis or mortality, as well as neonatal and maternal infections. Design, Setting, and Participants This double-blind, placebo-controlled, randomized clinical trial enrolled and followed up birthing parents and their infants at 10 health facilities in The Gambia and Burkina Faso, West Africa, between October 2017 and May 2021. Interventions Participants were assigned at random to receive oral azithromycin (2 g) or placebo (ratio 1:1) during labor. Main Outcomes and Measures The primary outcome was a composite of neonatal sepsis or mortality, with the former defined based on microbiologic or clinical criteria. Secondary outcomes were neonatal infections (skin, umbilical, eye and ear infections), malaria, and fever; postpartum infections (puerperal sepsis, mastitis), fever, and malaria; and use of antibiotics during 4-week follow-up. Results The trial randomized 11 983 persons in labor (median age, 29.9 years). Overall, 225 newborns (1.9% of 11 783 live births) met the primary end point. The incidence of neonatal mortality or sepsis was similar in the azithromycin and placebo groups (2.0% [115/5889] vs 1.9% [110/5894]; risk difference [RD], 0.09 [95% CI, -0.39 to 0.57]), as was the incidence of neonatal mortality (0.8% vs 0.8%; RD, 0.04 [95% CI, -0.27 to 0.35]) and neonatal sepsis (1.3% vs 1.3%; RD, 0.02 [95% CI, -0.38 to 0.43]). Newborns in the azithromycin group compared with the placebo group had lower incidence of skin infections (0.8% vs 1.7%; RD, -0.90 [95% CI, -1.30 to -0.49]) and need for antibiotics (6.2% vs 7.8%; RD, -1.58 [95% CI, -2.49 to -0.67]). Postpartum parents in the azithromycin group had lower incidence of mastitis (0.3% vs 0.5%; RD, -0.24 [95% CI, -0.47 to -0.01]) and puerperal fever (0.1% vs 0.3%; RD, -0.19 [95% CI, -0.36 to -0.01]). Conclusions and Relevance Azithromycin administered orally during labor did not reduce neonatal sepsis or mortality. These results do not support routine introduction of oral intrapartum azithromycin for this purpose. Trial Registration ClinicalTrials.gov Identifier: NCT03199547.
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Affiliation(s)
- Anna Roca
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Bully Camara
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Joel D. Bognini
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Usman N. Nakakana
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Athasana M. Somé
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Nathalie Beloum
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Toussaint Rouamba
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Fatoumata Sillah
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Madikoi Danso
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Joquina C. Jones
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Shashu Graves
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Isatou Jagne
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Pauline Getanda
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Saffiatou Darboe
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Marc C. Tahita
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Ebrahim Ndure
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Hien S. Franck
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Sawadogo Y. Edmond
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Bai L. Dondeh
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Wilfried G. J. Nassa
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Zakaria Garba
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Abdoulie Bojang
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Yusupha Njie
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | | | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé–Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Umberto D’Alessandro
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
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Kahn R, Eyal N, Sow SO, Lipsitch M. Mass drug administration of azithromycin: an analysis. Clin Microbiol Infect 2023; 29:326-331. [PMID: 36309328 DOI: 10.1016/j.cmi.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND WHO recommends mass drug administration (MDA) of the antibiotic azithromycin for children aged 1-11 months in areas with high rates of infant and child mortality. Notwithstanding the substantial potential benefits of lowering childhood mortality, MDA raises understandable concerns about exacerbating antibiotic resistance. OBJECTIVES In this study, we aimed to evaluate the use of MDA using both quantitative and ethical considerations. SOURCES We performed a series of literature searches between July 2019 and June 2022. CONTENT We first compared MDA with other uses of antibiotics using the standard metric of 'number needed to treat', and five additional criteria: (1) other widely accepted uses of anti-infectives (2) absolute use (i.e. total number), of antibiotics, (3) risk-benefit trade-off, (4) availability of short-term alternatives, and (5) the precedent for implementing similar interventions. We found that MDA falls well within a justifiable range when compared with widely accepted uses of antibiotics in terms of the number needed to treat. The other five criteria we considered provided further support for the use of MDA to prevent childhood mortality. IMPLICATIONS Although better data on antibiotic use and resistance are needed, efforts to reduce antibiotic use and resistance should not start with halting MDA of azithromycin in the areas with the highest rates of childhood mortality. Improving data to inform this decision is critical. However, on the basis of the best evidence available, we believe that concerns regarding resistance should not thwart MDA; instead, MDA should be accompanied by robust plans to monitor its efficacy and changes in resistance levels. Similar considerations could be included in a framework for evaluating the benefits of antibiotics against the risk of resistance in other contexts.
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Affiliation(s)
- Rebecca Kahn
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Nir Eyal
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, NJ, USA; Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA; Department of Philosophy, Rutgers University, New Brunswick, NJ, USA
| | - Samba O Sow
- Centre pour le Développement des Vaccins (CVD-Mali), Ministère de La Santé, BP251, Bamako, Mali; Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Adubra L, Alber D, Ashorn P, Ashorn U, Cheung YB, Cloutman-Green E, Diallo F, Ducker C, Elovainio R, Fan YM, Gates L, Gruffudd G, Haapaniemi T, Haidara F, Hallamaa L, Ihamuotila R, Klein N, Luoma J, Martell O, Sow S, Vehmasto T. Testing the effects of mass drug administration of azithromycin on mortality and other outcomes among 1-11-month-old infants in Mali (LAKANA): study protocol for a cluster-randomized, placebo-controlled, double-blinded, parallel-group, three-arm clinical trial. Trials 2023; 24:5. [PMID: 36597115 PMCID: PMC9809521 DOI: 10.1186/s13063-022-06966-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Mass drug administration (MDA) of azithromycin (AZI) has been shown to reduce under-5 mortality in some but not all sub-Saharan African settings. A large-scale cluster-randomized trial conducted in Malawi, Niger, and Tanzania suggested that the effect differs by country, may be stronger in infants, and may be concentrated within the first 3 months after treatment. Another study found no effect when azithromycin was given concomitantly with seasonal malaria chemoprevention (SMC). Given the observed heterogeneity and possible effect modification by other co-interventions, further trials are needed to determine the efficacy in additional settings and to determine the most effective treatment regimen. METHODS LAKANA stands for Large-scale Assessment of the Key health-promoting Activities of two New mass drug administration regimens with Azithromycin. The LAKANA trial is designed to address the mortality and health impacts of 4 or 2 annual rounds of azithromycin MDA delivered to 1-11-month-old (29-364 days) infants, in a high-mortality and malaria holoendemic Malian setting where there is a national SMC program. Participating villages (clusters) are randomly allocated in a ratio of 3:2:4 to three groups: placebo (control):4-dose AZI:2-dose AZI. The primary outcome measured is mortality. Antimicrobial resistance (AMR) will be monitored closely before, during, and after the intervention and both among those receiving and those not receiving MDA with the study drugs. Other outcomes, from a subset of villages, comprise efficacy outcomes related to morbidity, growth and nutritional status, outcomes related to the mechanism of azithromycin activity through measures of malaria parasitemia and inflammation, safety outcomes (AMR, adverse and serious adverse events), and outcomes related to the implementation of the intervention documenting feasibility, acceptability, and economic aspects. The enrolment commenced in October 2020 and is planned to be completed by the end of 2022. The expected date of study completion is December 2024. DISCUSSION If LAKANA provides evidence in support of a positive mortality benefit resulting from azithromycin MDA, it will significantly contribute to the options for successfully promoting child survival in Mali, and elsewhere in sub-Saharan Africa. TRIAL REGISTRATION ClinicalTrials.gov NCT04424511. Registered on 11 June 2020.
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Affiliation(s)
- Laura Adubra
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Dagmar Alber
- grid.83440.3b0000000121901201Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Per Ashorn
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland ,grid.412330.70000 0004 0628 2985Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Yin Bun Cheung
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland ,grid.428397.30000 0004 0385 0924Program in Health Services and Systems Research and Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Elaine Cloutman-Green
- grid.83440.3b0000000121901201Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | | | - Riku Elovainio
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Yue-Mei Fan
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Lily Gates
- grid.83440.3b0000000121901201Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Tiia Haapaniemi
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Lotta Hallamaa
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Rikhard Ihamuotila
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Nigel Klein
- grid.83440.3b0000000121901201Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Juho Luoma
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Samba Sow
- Center for Vaccine Development, Bamako, Mali
| | - Taru Vehmasto
- grid.502801.e0000 0001 2314 6254Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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11
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Sié A, Bountogo M, Zakane A, Compaoré G, Ouedraogo T, Lebas E, Nyatigo F, Hu H, Brogdon J, Arnold BF, Lietman TM, Oldenburg CE. Effect of Neonatal Azithromycin on All-Cause and Cause-Specific Infant Mortality: A Randomized Controlled Trial. Am J Trop Med Hyg 2022; 107:1331-1336. [PMID: 36343592 PMCID: PMC9768279 DOI: 10.4269/ajtmh.22-0245] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/20/2022] [Indexed: 11/09/2022] Open
Abstract
Mass azithromycin distribution reduces all-cause childhood mortality in some high-mortality settings in sub-Saharan Africa. Although the greatest benefits have been shown in children 1 to 5 months old living in areas with high mortality rates, no evidence of a benefit was found of neonatal azithromycin in a low-mortality setting on mortality at 6 months. We conducted a 1:1 randomized, placebo-controlled trial evaluating the effect of a single oral 20-mg/kg dose of azithromycin or matching placebo administered during the neonatal period on all-cause and cause-specific infant mortality at 12 months of age in five regions of Burkina Faso. Neonates were eligible if they were between the ages of 8 and 27 days and weighed at least 2,500 g at enrollment. Cause of death was determined via the WHO 2016 verbal autopsy tool. We compared all-cause and cause-specific mortality using binomial regression. Of 21,832 infants enrolled in the study, 116 died by 12 months of age. There was no significant difference in all-cause mortality between the azithromycin and placebo groups (azithromycin: 52 deaths, 0.5%; placebo, 64 deaths, 0.7%; hazard ratio, 0.81; 95% CI, 0.56-1.17; P = 0.30). There was no evidence of a difference in the distribution of causes of death (P = 0.40) and no significant difference in any specific cause of death between groups. Mortality rates were low at 12 months of age, and there was no evidence of an effect of neonatal azithromycin on all-cause or cause-specific mortality.
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Affiliation(s)
- Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | | | | | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Fanice Nyatigo
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Huiyu Hu
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Jessica Brogdon
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Benjamin F. Arnold
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Thomas M. Lietman
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
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12
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Burns AL, Sleebs BE, Gancheva M, McLean KT, Siddiqui G, Venter H, Beeson JG, O’Handley R, Creek DJ, Ma S, Frölich S, Goodman CD, McFadden GI, Wilson DW. Targeting malaria parasites with novel derivatives of azithromycin. Front Cell Infect Microbiol 2022; 12:1063407. [PMID: 36530422 PMCID: PMC9748569 DOI: 10.3389/fcimb.2022.1063407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/09/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction The spread of artemisinin resistant Plasmodium falciparum parasites is of global concern and highlights the need to identify new antimalarials for future treatments. Azithromycin, a macrolide antibiotic used clinically against malaria, kills parasites via two mechanisms: 'delayed death' by inhibiting the bacterium-like ribosomes of the apicoplast, and 'quick-killing' that kills rapidly across the entire blood stage development. Methods Here, 22 azithromycin analogues were explored for delayed death and quick-killing activities against P. falciparum (the most virulent human malaria) and P. knowlesi (a monkey parasite that frequently infects humans). Results Seventeen analogues showed improved quick-killing against both Plasmodium species, with up to 38 to 20-fold higher potency over azithromycin after less than 48 or 28 hours of treatment for P. falciparum and P. knowlesi, respectively. Quick-killing analogues maintained activity throughout the blood stage lifecycle, including ring stages of P. falciparum parasites (<12 hrs treatment) and were >5-fold more selective against P. falciparum than human cells. Isopentenyl pyrophosphate supplemented parasites that lacked an apicoplast were equally sensitive to quick-killing analogues, confirming that the quick killing activity of these drugs was not directed at the apicoplast. Further, activity against the related apicoplast containing parasite Toxoplasma gondii and the gram-positive bacterium Streptococcus pneumoniae did not show improvement over azithromycin, highlighting the specific improvement in antimalarial quick-killing activity. Metabolomic profiling of parasites subjected to the most potent compound showed a build-up of non-haemoglobin derived peptides that was similar to chloroquine, while also exhibiting accumulation of haemoglobin-derived peptides that was absent for chloroquine treatment. Discussion The azithromycin analogues characterised in this study expand the structural diversity over previously reported quick-killing compounds and provide new starting points to develop azithromycin analogues with quick-killing antimalarial activity.
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Affiliation(s)
- Amy L. Burns
- Research Centre for Infectious Diseases, School of Biological Sciences, the University of Adelaide, Adelaide, SA, Australia,School of Science and Technology, the University of New England, Armidale, NSW, Australia
| | - Brad E. Sleebs
- ACRF Chemical Biology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Maria Gancheva
- Research Centre for Infectious Diseases, School of Biological Sciences, the University of Adelaide, Adelaide, SA, Australia
| | - Kimberley T. McLean
- Research Centre for Infectious Diseases, School of Biological Sciences, the University of Adelaide, Adelaide, SA, Australia
| | - Ghizal Siddiqui
- Drug Delivery Disposition and Dynamics, Monash University, Parkville, VIC, Australia
| | - Henrietta Venter
- Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - James G. Beeson
- Healthy Mothers, Healthy Babies Program, Burnet Institute, Melbourne, VIC, Australia,Department of Medicine, University of Melbourne, Parkville, VIC, Australia,Central Clinical School, Monash University, Melbourne, Vic, Australia,Department of Microbiology, Monash University, Melbourne, Vic, Australia
| | - Ryan O’Handley
- School of Animal and Veterinary Science, University of Adelaide, Adelaide, SA, Australia,Australian Centre for Antimicrobial Resistance Ecology, The University of Adelaide, Adelaide, SA, Australia
| | - Darren J. Creek
- Drug Delivery Disposition and Dynamics, Monash University, Parkville, VIC, Australia
| | - Shutao Ma
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology, Ministry of Education, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Sonja Frölich
- Research Centre for Infectious Diseases, School of Biological Sciences, the University of Adelaide, Adelaide, SA, Australia
| | | | | | - Danny W. Wilson
- Research Centre for Infectious Diseases, School of Biological Sciences, the University of Adelaide, Adelaide, SA, Australia,Healthy Mothers, Healthy Babies Program, Burnet Institute, Melbourne, VIC, Australia,Australian Centre for Antimicrobial Resistance Ecology, The University of Adelaide, Adelaide, SA, Australia,*Correspondence: Danny W. Wilson,
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13
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Li J, Xiong T, Yue Y, Choonara I, Qazi S, Tang J, Shi J, Wang H, Qu Y, Mu D. Secondary Effects from Mass Azithromycin Administration: A Systematic Review and Meta-analysis. Am J Trop Med Hyg 2022; 107:904-911. [PMID: 35970284 PMCID: PMC9651525 DOI: 10.4269/ajtmh.22-0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/23/2022] [Indexed: 11/07/2022] Open
Abstract
The effects of azithromycin mass drug administration (MDA) on trachoma and yaws have been addressed. However, the secondary effects of azithromycin MDA remain unclear. This study aimed to explore the secondary effects of azithromycin MDA. PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov were searched from conception to January 5, 2022. Studies on secondary effects of azithromycin MDA were included. A total of 34 studies were included. Six of them reported on child mortality, 10 on malaria, and 20 on general morbidity and condition. Azithromycin MDA reduced child mortality, and quarterly MDA may be most beneficial for reducing child mortality. The effect of azithromycin MDA on malaria was weak. No association was observed between azithromycin MDA and malaria parasitemia (rate ratio: 0.71, 95% confidence interval: 0.43-1.15). Azithromycin MDA was associated with a lower risk of respiratory tract infections and diarrhea. Additionally, it was associated with a lower risk of fever, vomiting, and headache. The carriage of pathogenic organisms such as Streptococcus pneumoniae and gut Campylobacter species was reduced. However, these secondary effects of azithromycin MDA appeared to last only a few weeks. Moreover, no association was observed between azithromycin MDA and nutritional improvement in children. In conclusion, azithromycin MDA had favorable secondary effects on child mortality and morbidity. However, the effects were short term.
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Affiliation(s)
- Jinhui Li
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Xiong
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Yue
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children’s Hospital, Derby, United Kingdom
| | - Shamim Qazi
- World Health Organization, Department of Maternal Newborn Child and Adolescent Health, Geneva, Switzerland
| | - Jun Tang
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Shi
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hua Wang
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Qu
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dezhi Mu
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pharmacy, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, Chengdu, Sichuan, China
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14
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Alasmar A, Kong AC, So AD, DeCamp M. Ethical challenges in mass drug administration for reducing childhood mortality: a qualitative study. Infect Dis Poverty 2022; 11:99. [PMID: 36114588 PMCID: PMC9482260 DOI: 10.1186/s40249-022-01023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Mass drug administration (MDA) of medications to entire at-risk communities or populations has shown promise in the control and elimination of global infectious diseases. MDA of the broad-spectrum antibiotic azithromycin has demonstrated the potential to reduce childhood mortality in children at risk of premature death in some global settings. However, MDA of antibiotics raises complex ethical challenges, including weighing near-term benefits against longer-term risks—particularly the development of antimicrobial resistance that could diminish antibiotic effectiveness for current or future generations. The aim of this study was to understand how key actors involved in MDA perceive the ethical challenges of MDA. Methods We conducted 35 semi-structured interviews from December 2020–February 2022 with investigators, funders, bioethicists, research ethics committee members, industry representatives, and others from both high-income countries (HICs) and low- and middle-income countries (LMICs). Interview participants were identified via one of seven MDA studies purposively chosen to represent diversity in terms of use of the antibiotic azithromycin; use of a primary mortality endpoint; and whether the study occurred in a high child mortality country. Data were analyzed using constructivist grounded theory methodology. Results The most frequently discussed ethical challenges related to meaningful community engagement, how to weigh risks and benefits, and the need to target MDA We developed a concept map of how participants considered ethical issues in MDA for child mortality; it emphasizes MDA’s place alongside other public health interventions, empowerment, and equity. Concerns over an ethical double standard in weighing risks and benefits emerged as a unifying theme, albeit one that participants interpreted in radically different ways. Some thought MDA for reducing child mortality was ethically obligatory; others suggested it was impermissible. Conclusions Ethical challenges raised by MDA of antibiotics for childhood mortality—which span socio-cultural issues, the environment, and effects on future generations—require consideration beyond traditional clinical trial review. The appropriate role of MDA also requires attention to concerns over ethical double standards and power dynamics in global health that affect how we view antibiotic use in HICs versus LMICs. Our findings suggest the need to develop additional, comprehensive guidance on managing ethical challenges in MDA. Graphical Abstract ![]()
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15
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Sagara I, Zongo I, Cairns M, Yerbanga RS, Mahamar A, Nikièma F, Tapily A, Sompougdou F, Diarra M, Zoungrana C, Issiaka D, Haro A, Sanogo K, Aziz Sienou A, Kaya M, Traore S, Thera I, Diarra K, Dolo A, Kuepfer I, Snell P, Milligan P, Ockenhouse C, Ofori-Anyinam O, Tinto H, Djimde A, Ouedraogo JB, Dicko A, Chandramohan D, Greenwood B. The Anti-Circumsporozoite Antibody Response of Children to Seasonal Vaccination With the RTS,S/AS01E Malaria Vaccine. Clin Infect Dis 2022; 75:613-622. [PMID: 34894221 PMCID: PMC9464075 DOI: 10.1093/cid/ciab1017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND A trial in African children showed that combining seasonal vaccination with the RTS,S/AS01E vaccine with seasonal malaria chemoprevention reduced the incidence of uncomplicated and severe malaria compared with either intervention given alone. Here, we report on the anti-circumsporozoite antibody response to seasonal RTS,S/AS01E vaccination in children in this trial. METHODS Sera from a randomly selected subset of children collected before and 1 month after 3 priming doses of RTS,S/AS01E and before and 1 month after 2 seasonal booster doses were tested for anti-circumsporozoite antibodies using enzyme-linked immunosorbent assay. The association between post-vaccination antibody titer and incidence of malaria was explored. RESULTS A strong anti-circumsporozoite antibody response to 3 priming doses of RTS,S/AS01E was seen (geometric mean titer, 368.9 enzyme-linked immunosorbent assay units/mL), but titers fell prior to the first booster dose. A strong antibody response to an annual, pre-malaria transmission season booster dose was observed, but this was lower than after the primary vaccination series and lower after the second than after the first booster dose (ratio of geometric mean rise, 0.66; 95% confidence interval [CI], .57-.77). Children whose antibody response was in the upper tercile post-vaccination had a lower incidence of malaria during the following year than children in the lowest tercile (hazard ratio, 0.43; 95% CI, .28-.66). CONCLUSIONS Seasonal vaccination with RTS,S/AS01E induced a strong booster antibody response that was lower after the second than after the first booster dose. The diminished antibody response to the second booster dose was not associated with diminished efficacy. CLINICAL TRIALS REGISTRATION NCT03143218.
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Affiliation(s)
| | | | - Matthew Cairns
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Almahamoudou Mahamar
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Frédéric Nikièma
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Amadou Tapily
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | | | - Modibo Diarra
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Charles Zoungrana
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Djibrilla Issiaka
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Alassane Haro
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Koualy Sanogo
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Abdoul Aziz Sienou
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Mahamadou Kaya
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Seydou Traore
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Ismaila Thera
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Kalifa Diarra
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Amagana Dolo
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | - Irene Kuepfer
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Paul Snell
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Paul Milligan
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Abdoulaye Djimde
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | | | - Alassane Dicko
- The Malaria Research and Training Center, University of Sciences, Techniques and Technologies, Bamako, Mali
| | | | - Brian Greenwood
- Correspondence: B. Greenwood, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK ()
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16
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Olesen SW. Uses of mathematical modeling to estimate the impact of mass drug administration of antibiotics on antimicrobial resistance within and between communities. Infect Dis Poverty 2022; 11:75. [PMID: 35773748 PMCID: PMC9245243 DOI: 10.1186/s40249-022-00997-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 06/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background Antibiotics are a key part of modern healthcare, but their use has downsides, including selecting for antibiotic resistance, both in the individuals treated with antibiotics and in the community at large. When evaluating the benefits and costs of mass administration of azithromycin to reduce childhood mortality, effects of antibiotic use on antibiotic resistance are important but difficult to measure, especially when evaluating resistance that “spills over” from antibiotic-treated individuals to other members of their community. The aim of this scoping review was to identify how the existing literature on antibiotic resistance modeling could be better leveraged to understand the effect of mass drug administration (MDA) on antibiotic resistance. Main text Mathematical models of antibiotic use and resistance may be useful for estimating the expected effects of different MDA implementations on different populations, as well as aiding interpretation of existing data and guiding future experimental design. Here, strengths and limitations of models of antibiotic resistance are reviewed, and possible applications of those models in the context of mass drug administration with azithromycin are discussed. Conclusions Statistical models of antibiotic use and resistance may provide robust and relevant estimates of the possible effects of MDA on resistance. Mechanistic models of resistance, while able to more precisely estimate the effects of different implementations of MDA on resistance, may require more data from MDA trials to be accurately parameterized. Graphical Abstract ![]()
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Affiliation(s)
- Scott W Olesen
- Department of Immunology and Infectious Diseases, Harvard Chan School, Boston, MA, USA.
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17
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Rolfe RJ, Shaikh H, Tillekeratne LG. Mass drug administration of antibacterials: weighing the evidence regarding benefits and risks. Infect Dis Poverty 2022; 11:77. [PMID: 35773722 PMCID: PMC9243730 DOI: 10.1186/s40249-022-00998-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Mass drug administration (MDA) is a strategy to improve health at the population level through widespread delivery of medicine in a community. We surveyed the literature to summarize the benefits and potential risks associated with MDA of antibacterials, focusing predominantly on azithromycin as it has the greatest evidence base.
Main body High-quality evidence from randomized controlled trials (RCTs) indicate that MDA-azithromycin is effective in reducing the prevalence of infection due to yaws and trachoma. In addition, RCTs suggest that MDA-azithromycin reduces under-five mortality in certain low-resource settings that have high childhood mortality rates at baseline. This reduction in mortality appears to be sustained over time with twice-yearly MDA-azithromycin, with the greatest effect observed in children < 1 year of age. In addition, observational data suggest that infections such as skin and soft tissue infections, rheumatic heart disease, acute respiratory illness, diarrheal illness, and malaria may all be treated by azithromycin and thus incidentally impacted by MDA-azithromycin. However, the mechanism by which MDA-azithromycin reduces childhood mortality remains unclear. Verbal autopsies performed in MDA-azithromycin childhood mortality studies have produced conflicting data and are underpowered to answer this question. In addition to benefits, there are several important risks associated with MDA-azithromycin. Direct adverse effects potentially resulting from MDA-azithromycin include gastrointestinal side effects, idiopathic hypertrophic pyloric stenosis, cardiovascular side effects, and increase in chronic diseases such as asthma and obesity. Antibacterial resistance is also a risk associated with MDA-azithromycin and has been reported for both gram-positive and enteric organisms. Further, there is the risk for cross-resistance with other antibacterial agents, especially clindamycin. Conclusions Evidence shows that MDA-azithromycin programs may be beneficial for reducing trachoma, yaws, and mortality in children < 5 years of age in certain under-resourced settings. However, there are significant potential risks that need to be considered when deciding how, when, and where to implement these programs. Robust systems to monitor benefits as well as adverse effects and antibacterial resistance are warranted in communities where MDA-azithromycin programs are implemented. Graphical Abstract ![]()
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Affiliation(s)
- Robert J Rolfe
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Hassaan Shaikh
- Department of Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - L Gayani Tillekeratne
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA. .,Duke Global Health Institute, Duke University, Durham, NC, USA. .,Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.
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18
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Brogdon J, Dah C, Sié A, Bountogo M, Coulibaly B, Kouanda I, Ouattara M, Compaoré G, Nebie E, Seynou M, Lebas E, Nyatigo F, Hu H, Arnold BF, Lietman TM, Oldenburg CE. Malaria positivity following a single oral dose of azithromycin among children in Burkina Faso: a randomized controlled trial. BMC Infect Dis 2022; 22:285. [PMID: 35337289 PMCID: PMC8957146 DOI: 10.1186/s12879-022-07296-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 03/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background Azithromycin is a broad-spectrum antibiotic that has moderate antimalarial activity and has been shown to reduce all-cause mortality when biannually administered to children under five in high mortality settings in sub-Saharan Africa. One potential mechanism for this observed reduction in mortality is via a reduction in malaria transmission. Methods We evaluated whether a single oral dose of azithromycin reduces malaria positivity by rapid diagnostic test (RDT). We conducted an individually randomized placebo-controlled trial in Burkina Faso during the high malaria transmission season in August 2020. Children aged 8 days to 59 months old were randomized to a single oral dose of azithromycin (20 mg/kg) or matching placebo. At baseline and 14 days following treatment, we administered a rapid diagnostic test (RDT) to detect Plasmodium falciparum and measured tympanic temperature for all children. Caregiver-reported adverse events and clinic visits were recorded at the day 14 visit. Results We enrolled 449 children with 221 randomized to azithromycin and 228 to placebo. The median age was 32 months and 48% were female. A total of 8% of children had a positive RDT for malaria at baseline and 11% had a fever (tympanic temperature ≥ 37.5 °C). In the azithromycin arm, 8% of children had a positive RDT for malaria at 14 days compared to 7% in the placebo arm (P = 0.65). Fifteen percent of children in the azithromycin arm had a fever ≥ 37.5 °C compared to 21% in the placebo arm (P = 0.12). Caregivers of children in the azithromycin group had lower odds of reporting fever as an adverse event compared to children in the placebo group (OR 0.41, 95% CI 0.18–0.96, P = 0.04). Caregiver-reported clinic visits were uncommon, and there were no observed differences between arms (P = 0.32). Conclusions We did not find evidence that a single oral dose of azithromycin reduced malaria positivity during the high transmission season. Caregiver-reported fever occurred less often in children receiving azithromycin compared to placebo, indicating that azithromycin may have some effect on non-malarial infections. Trial registration Clinicaltrials.gov NCT04315272, registered 19/03/2020
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Affiliation(s)
- Jessica Brogdon
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois Street, Floor 2, San Francisco, CA, 94158, USA
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | | | | | | | - Eric Nebie
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Mariam Seynou
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois Street, Floor 2, San Francisco, CA, 94158, USA
| | - Fanice Nyatigo
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois Street, Floor 2, San Francisco, CA, 94158, USA
| | - Huiyu Hu
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois Street, Floor 2, San Francisco, CA, 94158, USA
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois Street, Floor 2, San Francisco, CA, 94158, USA.,Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Thomas M Lietman
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois Street, Floor 2, San Francisco, CA, 94158, USA.,Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Catherine E Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois Street, Floor 2, San Francisco, CA, 94158, USA. .,Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA. .,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
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19
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Ahmed T, Chisti MJ, Rahman MW, Alam T, Ahmed D, Parvin I, Kabir MF, Sazawal S, Dhingra P, Dutta A, Deb S, Chouhan A, Sharma AK, Jaiswal VK, Dhingra U, Walson JL, Singa BO, Pavlinac PB, McGrath CJ, Nyabinda C, Deichsel EL, Anyango M, Kariuki KM, Rwigi D, Tornberg-Belanger SN, Kotloff KL, Sow SO, Tapia MD, Haidara FC, Mehta A, Coulibaly F, Badji H, Permala-Booth J, Tennant SM, Malle D, Bar-Zeev N, Dube Q, Freyne B, Cunliffe N, Ndeketa L, Witte D, Ndamala C, Cornick J, Qamar FN, Yousafzai MT, Qureshi S, Shakoor S, Thobani R, Hotwani A, Kabir F, Mohammed J, Manji K, Duggan CP, Kisenge R, Sudfeld CR, Kibwana U, Somji S, Bakari M, Msemwa C, Samma A, Bahl R, De Costa A, Simon J, Ashorn P. Effect of 3 Days of Oral Azithromycin on Young Children With Acute Diarrhea in Low-Resource Settings: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2136726. [PMID: 34913980 PMCID: PMC8678692 DOI: 10.1001/jamanetworkopen.2021.36726] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022] Open
Abstract
Importance World Health Organization (WHO) guidelines do not recommend routine antibiotic use for children with acute watery diarrhea. However, recent studies suggest that a significant proportion of such episodes have a bacterial cause and are associated with mortality and growth impairment, especially among children at high risk of diarrhea-associated mortality. Expanding antibiotic use among dehydrated or undernourished children may reduce diarrhea-associated mortality and improve growth. Objective To determine whether the addition of azithromycin to standard case management of acute nonbloody watery diarrhea for children aged 2 to 23 months who are dehydrated or undernourished could reduce mortality and improve linear growth. Design, Setting, and Participants The Antibiotics for Children with Diarrhea (ABCD) trial was a multicountry, randomized, double-blind, clinical trial among 8266 high-risk children aged 2 to 23 months presenting with acute nonbloody diarrhea. Participants were recruited between July 1, 2017, and July 10, 2019, from 36 outpatient hospital departments or community health centers in a mixture of urban and rural settings in Bangladesh, India, Kenya, Malawi, Mali, Pakistan, and Tanzania. Each participant was followed up for 180 days. Primary analysis included all randomized participants by intention to treat. Interventions Enrolled children were randomly assigned to receive either oral azithromycin, 10 mg/kg, or placebo once daily for 3 days in addition to standard WHO case management protocols for the management of acute watery diarrhea. Main Outcomes and Measures Primary outcomes included all-cause mortality up to 180 days after enrollment and linear growth faltering 90 days after enrollment. Results A total of 8266 children (4463 boys [54.0%]; mean [SD] age, 11.6 [5.3] months) were randomized. A total of 20 of 4133 children in the azithromycin group (0.5%) and 28 of 4135 children in the placebo group (0.7%) died (relative risk, 0.72; 95% CI, 0.40-1.27). The mean (SD) change in length-for-age z scores 90 days after enrollment was -0.16 (0.59) in the azithromycin group and -0.19 (0.60) in the placebo group (risk difference, 0.03; 95% CI, 0.01-0.06). Overall mortality was much lower than anticipated, and the trial was stopped for futility at the prespecified interim analysis. Conclusions and Relevance The study did not detect a survival benefit for children from the addition of azithromycin to standard WHO case management of acute watery diarrhea in low-resource settings. There was a small reduction in linear growth faltering in the azithromycin group, although the magnitude of this effect was not likely to be clinically significant. In low-resource settings, expansion of antibiotic use is not warranted. Adherence to current WHO case management protocols for watery diarrhea remains appropriate and should be encouraged. Trial Registration ClinicalTrials.gov Identifier: NCT03130114.
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Affiliation(s)
- Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Muhammad Waliur Rahman
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmina Alam
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Dilruba Ahmed
- Laboratory Sciences and Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Irin Parvin
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Farhad Kabir
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sunil Sazawal
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | | | - Arup Dutta
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | - Saikat Deb
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | | | | | | | - Usha Dhingra
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | - Judd L Walson
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
- Department of Medicine (Allergy and Infectious Diseases), University of Washington, Seattle
| | - Benson O Singa
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - Emily L Deichsel
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | | | | | - Doreen Rwigi
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Karen L Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Samba O Sow
- Centre pour le Développement des Vaccins, Bamako, Mali
| | - Milagritos D Tapia
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Fadima Cheick Haidara
- Division of Advanced Primary Health Care Research and Clinical Trials, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Ashka Mehta
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Flanon Coulibaly
- Division of Advanced Primary Health Care Research and Clinical Trials, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Henry Badji
- Division of Clinical Microbiology and Molecular Biology, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Jasnehta Permala-Booth
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Sharon M Tennant
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Dramane Malle
- Division of Clinical Microbiology and Molecular Biology, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Naor Bar-Zeev
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Queen Dube
- Department of Pediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bridget Freyne
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Institute of Infection, Veterinary and Ecological Sciences, The University of Liverpool, Blantyre, Malawi
| | - Nigel Cunliffe
- National Institutes of Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
| | - Latif Ndeketa
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine, Blantyre, Malawi
| | - Desiree Witte
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Chifundo Ndamala
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Jennifer Cornick
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Institute of Infection, Veterinary and Ecological Sciences, The University of Liverpool, Blantyre, Malawi
| | - Farah Naz Qamar
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | | | - Shahida Qureshi
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Sadia Shakoor
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Rozina Thobani
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Furqan Kabir
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Jan Mohammed
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher P Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Upendo Kibwana
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohamed Bakari
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Cecylia Msemwa
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abraham Samma
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rajiv Bahl
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Ayesha De Costa
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Jonathon Simon
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Per Ashorn
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
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20
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Hema-Ouangraoua S, Tranchot-Diallo J, Zongo I, Kabore NF, Nikièma F, Yerbanga RS, Tinto H, Chandramohan D, Ouedraogo GA, Greenwood B, Ouedraogo JB. Impact of mass administration of azithromycin as a preventive treatment on the prevalence and resistance of nasopharyngeal carriage of Staphylococcus aureus. PLoS One 2021; 16:e0257190. [PMID: 34644317 PMCID: PMC8513893 DOI: 10.1371/journal.pone.0257190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 07/27/2021] [Indexed: 12/03/2022] Open
Abstract
Staphylococcus aureus is a major cause of serious illness and death in children, indicating the need to monitor prevalent strains, particularly in the vulnerable pediatric population. Nasal carriage of S. aureus is important as carriers have an increased risk of serious illness due to systemic invasion by this pathogen and can transmit the infection. Recent studies have demonstrated the effectiveness of azithromycin in reducing the prevalence of nasopharyngeal carrying of pneumococci, which are often implicated in respiratory infections in children. However, very few studies of the impact of azithromycin on staphylococci have been undertaken. During a clinical trial under taken in 2016, nasal swabs were collected from 778 children aged 3 to 59 months including 385 children who were swabbed before administration of azithromycin or placebo and 393 after administration of azithromycin or placebo. Azithromycin was given in a dose of 100 mg for three days, together with the antimalarials sulfadoxine-pyrimethamine and amodiaquine, on four occasions at monthly intervals during the malaria transmission season. These samples were cultured for S. aureus as well as for the pneumococcus. The S. aureus isolates were tested for their susceptibility to azithromycin (15 g), penicillin (10 IU), and cefoxitine (30 g) (Oxoid Ltd). S. aureus was isolated from 13.77% (53/385) swabs before administration of azithromycin and from 20.10% (79/393) six months after administration (PR = 1.46 [1.06; 2.01], p = 0.020). Azithromycin resistance found in isolates of S. aureus did not differ significantly before and after intervention (26.42% [14/53] vs 16.46% [13/79], (PR = 0.62 [0.32; 1.23], p = 0.172). Penicillin resistance was very pronounced, 88.68% and 96.20% in pre-intervention and in post-intervention isolates respectively, but very little Methicillin Resistance (MRSA) was detected (2 cases before and 2 cases after intervention). Monitoring antibiotic resistance in S. aureus and other bacteria is especially important in Burkina Faso due to unregulated consumption of antibiotics putting children and others at risk.
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Affiliation(s)
| | | | - Issaka Zongo
- Institut de Recherche en Sciences de la Santé (IRSS), Direction Régionale de l’Ouest (DRO), Bobo-Dioulasso, Burkina Faso
| | | | - Frédéric Nikièma
- Institut de Recherche en Sciences de la Santé (IRSS), Direction Régionale de l’Ouest (DRO), Bobo-Dioulasso, Burkina Faso
| | - Rakiswende Serge Yerbanga
- Institut de Recherche en Sciences de la Santé (IRSS), Direction Régionale de l’Ouest (DRO), Bobo-Dioulasso, Burkina Faso
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé (IRSS), Direction Régionale de l’Ouest (DRO), Bobo-Dioulasso, Burkina Faso
| | | | | | - Brian Greenwood
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jean-Bosco Ouedraogo
- Institut de Recherche en Sciences de la Santé (IRSS), Direction Régionale de l’Ouest (DRO), Bobo-Dioulasso, Burkina Faso
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21
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Phiri MD, Cairns M, Zongo I, Nikiema F, Diarra M, Yerbanga RS, Barry A, Tapily A, Coumare S, Thera I, Kuepfer I, Milligan P, Tinto H, Dicko A, Ouédraogo JB, Greenwood B, Chandramohan D, Sagara I. The Duration of Protection from Azithromycin Against Malaria, Acute Respiratory, Gastrointestinal, and Skin Infections When Given Alongside Seasonal Malaria Chemoprevention: Secondary Analyses of Data from a Clinical Trial in Houndé, Burkina Faso, and Bougouni, Mali. Clin Infect Dis 2021; 73:e2379-e2386. [PMID: 33417683 PMCID: PMC8492219 DOI: 10.1093/cid/ciaa1905] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Mass drug administration (MDA) with azithromycin (AZ) is being considered as a strategy to promote child survival in sub-Saharan Africa, but the mechanism by which AZ reduces mortality is unclear. To better understand the nature and extent of protection provided by AZ, we explored the profile of protection by time since administration, using data from a household-randomized, placebo-controlled trial in Burkina Faso and Mali. METHODS Between 2014 and 2016, 30 977 children aged 3-59 months received seasonal malaria chemoprevention (SMC) with sulfadoxine-pyrimethamine plus amodiaquine and either AZ or placebo monthly, on 4 occasions each year. Poisson regression with gamma-distributed random effects, accounting for the household randomization and within-individual clustering of illness episodes, was used to compare incidence of prespecified outcomes between SMC+AZ versus SMC+placebo groups in fixed time strata post-treatment. The likelihood ratio test was used to assess evidence for a time-treatment group interaction. RESULTS Relative to SMC+placebo, there was no evidence of protection from SMC+AZ against hospital admissions and deaths. Additional protection from SMC+AZ against malaria was confined to the first 2 weeks post-administration (protective efficacy (PE): 24.2% [95% CI: 17.8%, 30.1%]). Gastroenteritis and pneumonia were reduced by 29.9% [21.7; 37.3%], and 34.3% [14.9; 49.3%], respectively, in the first 2 weeks postadministration. Protection against nonmalaria fevers with a skin condition persisted up to 28 days: PE: 46.3% [35.1; 55.6%]. CONCLUSIONS The benefits of AZ-MDA are broad-ranging but short-lived. To maximize impact, timing of AZ-MDA must address the challenge of targeting asynchronous morbidity and mortality peaks from different causes.
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Affiliation(s)
- Mphatso Dennis Phiri
- Malaria Epidemiology Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Matthew Cairns
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Issaka Zongo
- Le Département Biomédical et de Santé Publique, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Frederic Nikiema
- Le Département Biomédical et de Santé Publique, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Modibo Diarra
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Rakiswendé Serge Yerbanga
- Le Département Biomédical et de Santé Publique, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Amadou Barry
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Amadou Tapily
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Samba Coumare
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Ismaila Thera
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Irene Kuepfer
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Paul Milligan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Halidou Tinto
- Le Département Biomédical et de Santé Publique, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Alassane Dicko
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Jean Bosco Ouédraogo
- Le Département Biomédical et de Santé Publique, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Brian Greenwood
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Daniel Chandramohan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Issaka Sagara
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
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22
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Pavlinac PB, Singa BO, Tickell KD, Brander RL, McGrath CJ, Amondi M, Otieno J, Akinyi E, Rwigi D, Carreon JD, Tornberg-Belanger SN, Nduati R, Babigumira JB, Meshak L, Bogonko G, Kariuki S, Richardson BA, John-Stewart GC, Walson JL. Azithromycin for the prevention of rehospitalisation and death among Kenyan children being discharged from hospital: a double-blind, placebo-controlled, randomised controlled trial. LANCET GLOBAL HEALTH 2021; 9:e1569-e1578. [PMID: 34559992 PMCID: PMC8638697 DOI: 10.1016/s2214-109x(21)00347-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/23/2021] [Accepted: 07/21/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Mass drug administration of azithromycin to children in sub-Saharan Africa has been shown to improve survival in high-mortality settings. The period after hospital discharge is a time of elevated risk unaddressed by current interventions and might provide an opportunity for targeting empirical azithromycin administration. We aimed to assess the efficacy of azithromycin administered at hospital discharge on risk of death and rehospitalisation in Kenyan children younger than 5 years. METHODS In this double-blind, placebo-controlled randomised trial, children were randomly assigned (1:1) to receive a 5-day course of azithromycin (oral suspension 10 mg/kg on day 1, followed by 5mg/kg per day on days 2-5) or identically appearing and tasting placebo at discharge from four hospitals in western Kenya. Children were eligible if they were aged 1-59 months at hospital discharge, weighed at least 2 kg, and had been admitted to hospital for any medical reason other than trauma, poisoning, or congenital anomaly. The primary outcome was death or rehospitalisation in the subsequent 6-month period in a modified intention-to-treat population, compared by randomisation group with Cox proportional hazards regression and Kaplan-Meier. Azithromycin resistance in Escherichia coli isolates from a random subset of children was compared by randomisation group with generalised estimating equations. This trial is registered with ClinicalTrials.gov, NCT02414399. FINDINGS Between June 28, 2016, and Nov 4, 2019, 1400 children were enrolled in the trial at discharge from hospital, with 703 (50·2%) randomly assigned to azithromycin and 697 (49·8%) to placebo. Among the 1398 children included in the modified intention-to-treat analysis (702 in the azithromycin group and 696 in the placebo group), the incidence of death or rehospitalisation was 20·4 per 100 child-years in the azithromycin group and 22·5 per 100 child-years in the placebo group (adjusted hazard ratio 0·91, 95·5% CI 0·64-1·29, p=0·58). Azithromycin resistance was common in commensal E coli isolates from enrolled children before randomisation (37·7% of 406 isolates) despite only 3·7% of children having received a macrolide antibiotic during the hospitalisation. Azithromycin resistance was slightly higher at 3 months after randomisation in the azithromycin group (26·9%) than in the placebo group (19·1%; adjusted prevalence ratio 1·41, 95% CI 0·95-2·09, p=0·088), with no difference observed at 6 months (1·17, 0·78-1·76, p=0·44). INTERPRETATION We did not observe a significant benefit of a 5-day course of azithromycin delivered to children younger than 5 years at hospital discharge despite the overall high risk of mortality and rehospitalisation. These findings highlight the need for more research into mechanisms and interventions for prevention of morbidity and mortality in the post-discharge period. FUNDING Eunice Kennedy Shriver National Institute of Child Health & Human Development.
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Affiliation(s)
| | - Benson O Singa
- Department of Global Health, University of Washington, Seattle, WA, USA; Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | | | - Christine J McGrath
- Department of Global Health, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Mary Amondi
- International AIDS Vaccine Initiative, Nairobi, Kenya
| | - Joyce Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Akinyi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Doreen Rwigi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Ruth Nduati
- Department of Pediatrics and Child Health, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Liru Meshak
- Homa Bay Teaching and Referral Hospital, Homa Bay, Kenya
| | | | - Samuel Kariuki
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Departments of Pediatrics and Medicine-Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Departments of Pediatrics and Medicine-Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
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Causes of death after biannual azithromycin treatment: A community-level randomized clinical trial. PLoS One 2021; 16:e0250197. [PMID: 34559801 PMCID: PMC8462712 DOI: 10.1371/journal.pone.0250197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/29/2021] [Indexed: 11/03/2022] Open
Abstract
The MORDOR study, a masked, community-level randomized clinical trial conducted in Niger, Malawi and Tanzania (2015 to 2017), showed that biannual administration of single-dose azithromycin to preschool children reduced all-cause mortality. We sought to evaluate its impact on causes of death in children aged 1–59 months in Tanzania. A random sampling of 614 communities was conducted in Kilosa District, Tanzania, with simple random assignment of communities to receive either azithromycin or placebo. In these communities, a census was carried out every 6 months and children aged 1–59 months received biannual (every 6 months), single-dose azithromycin (~20mg/kg) or placebo depending on community assignment, over a 2-year period. Mortality was determined at the time of the biannual census. For child deaths, a verbal autopsy was performed to ascertain the cause using a standardized diagnostic classification. A total of 190- (0.58 /100 person-years) and 200 deaths (0.59/100 person-years) were reported in the azithromycin and placebo arms, respectively. Malaria, pneumonia and diarrhea, accounted for 71% and 68% of deaths in the respective arms. Overall, the mortality was not different by treatment arm, nor were the distribution of causes of death after adjusting for community clustering. The cause-specific mortality for diarrhea/pneumonia was no different over time. In children aged 1–5 months, 32 deaths occurred in the placebo arm and 25 deaths occurred in the azithromycin arm; 20 (62.5%) deaths in the placebo- and 10 (40%) in the azithromycin arm were attributed to diarrhea or pneumonia. Neither differences in the number of deaths nor the diarrhea/pneumonia attribution was statistically significant after adjusting for community clustering. In conclusion, azithromycin was not associated with a significant decline in deaths by specific causes compared to placebo. The non-significant lower rates of diarrhea or pneumonia in children <6 months who received azithromycin merit further investigation in high-mortality settings. Trial registration:NCT02048007.
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24
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Chandramohan D, Zongo I, Sagara I, Cairns M, Yerbanga RS, Diarra M, Nikièma F, Tapily A, Sompougdou F, Issiaka D, Zoungrana C, Sanogo K, Haro A, Kaya M, Sienou AA, Traore S, Mahamar A, Thera I, Diarra K, Dolo A, Kuepfer I, Snell P, Milligan P, Ockenhouse C, Ofori-Anyinam O, Tinto H, Djimde A, Ouédraogo JB, Dicko A, Greenwood B. Seasonal Malaria Vaccination with or without Seasonal Malaria Chemoprevention. N Engl J Med 2021; 385:1005-1017. [PMID: 34432975 DOI: 10.1056/nejmoa2026330] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Malaria control remains a challenge in many parts of the Sahel and sub-Sahel regions of Africa. METHODS We conducted an individually randomized, controlled trial to assess whether seasonal vaccination with RTS,S/AS01E was noninferior to chemoprevention in preventing uncomplicated malaria and whether the two interventions combined were superior to either one alone in preventing uncomplicated malaria and severe malaria-related outcomes. RESULTS We randomly assigned 6861 children 5 to 17 months of age to receive sulfadoxine-pyrimethamine and amodiaquine (2287 children [chemoprevention-alone group]), RTS,S/AS01E (2288 children [vaccine-alone group]), or chemoprevention and RTS,S/AS01E (2286 children [combination group]). Of these, 1965, 1988, and 1967 children in the three groups, respectively, received the first dose of the assigned intervention and were followed for 3 years. Febrile seizure developed in 5 children the day after receipt of the vaccine, but the children recovered and had no sequelae. There were 305 events of uncomplicated clinical malaria per 1000 person-years at risk in the chemoprevention-alone group, 278 events per 1000 person-years in the vaccine-alone group, and 113 events per 1000 person-years in the combination group. The hazard ratio for the protective efficacy of RTS,S/AS01E as compared with chemoprevention was 0.92 (95% confidence interval [CI], 0.84 to 1.01), which excluded the prespecified noninferiority margin of 1.20. The protective efficacy of the combination as compared with chemoprevention alone was 62.8% (95% CI, 58.4 to 66.8) against clinical malaria, 70.5% (95% CI, 41.9 to 85.0) against hospital admission with severe malaria according to the World Health Organization definition, and 72.9% (95% CI, 2.9 to 92.4) against death from malaria. The protective efficacy of the combination as compared with the vaccine alone against these outcomes was 59.6% (95% CI, 54.7 to 64.0), 70.6% (95% CI, 42.3 to 85.0), and 75.3% (95% CI, 12.5 to 93.0), respectively. CONCLUSIONS Administration of RTS,S/AS01E was noninferior to chemoprevention in preventing uncomplicated malaria. The combination of these interventions resulted in a substantially lower incidence of uncomplicated malaria, severe malaria, and death from malaria than either intervention alone. (Funded by the Joint Global Health Trials and PATH; ClinicalTrials.gov number, NCT03143218.).
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Affiliation(s)
- Daniel Chandramohan
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Issaka Zongo
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Issaka Sagara
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Matthew Cairns
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Rakiswendé-Serge Yerbanga
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Modibo Diarra
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Frédéric Nikièma
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Amadou Tapily
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Frédéric Sompougdou
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Djibrilla Issiaka
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Charles Zoungrana
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Koualy Sanogo
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Alassane Haro
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Mahamadou Kaya
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Abdoul-Aziz Sienou
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Seydou Traore
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Almahamoudou Mahamar
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Ismaila Thera
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Kalifa Diarra
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Amagana Dolo
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Irene Kuepfer
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Paul Snell
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Paul Milligan
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Christian Ockenhouse
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Opokua Ofori-Anyinam
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Halidou Tinto
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Abdoulaye Djimde
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Jean-Bosco Ouédraogo
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Alassane Dicko
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
| | - Brian Greenwood
- From the London School of Hygiene and Tropical Medicine, London (D.C., M.C., I.K., P.S., P.M., B.G.); Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso (I.Z., R.-S.Y., F.N., F.S., C.Z., A.H., A.-A.S., H.T., J.-B.O.); the Malaria Research and Training Center, University of Sciences, Technologies, and Techniques of Bamako, Bamako, Mali (I.S., M.D., A.T., D.I., K.S., M.K., S.T., A.M., I.T., K.D., A. Dolo, A. Djimde, A. Dicko); PATH, Seattle (C.O.); and GlaxoSmithKline Vaccines, Rixensart, Belgium (O.O.-A.)
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25
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Coulibaly B, Sié A, Dah C, Bountogo M, Ouattara M, Compaoré A, Nikiema M, Tiansi JN, Sibiri ND, Brogdon JM, Lebas E, Doan T, Porco TC, Lietman TM, Oldenburg CE. Effect of a single dose of oral azithromycin on malaria parasitaemia in children: a randomized controlled trial. Malar J 2021; 20:360. [PMID: 34465327 PMCID: PMC8407066 DOI: 10.1186/s12936-021-03895-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background Azithromycin has recently been shown to reduce all-cause childhood mortality in sub-Saharan Africa. One potential mechanism of this effect is via the anti-malarial effect of azithromycin, which may help treat or prevent malaria infection. This study evaluated short- and longer-term effects of azithromycin on malaria outcomes in children. Methods Children aged 8 days to 59 months were randomized in a 1:1 fashion to a single oral dose of azithromycin (20 mg/kg) or matching placebo. Children were evaluated for malaria via thin and thick smear and rapid diagnostic test (for those with tympanic temperature ≥ 37.5 °C) at baseline and 14 days and 6 months after treatment. Malaria outcomes in children receiving azithromycin versus placebo were compared at each follow-up timepoint separately. Results Of 450 children enrolled, 230 were randomized to azithromycin and 220 to placebo. Children were a median of 26 months and 51% were female, and 17% were positive for malaria parasitaemia at baseline. There was no evidence of a difference in malaria parasitaemia at 14 days or 6 months after treatment. In the azithromycin arm, 20% of children were positive for parasitaemia at 14 days compared to 17% in the placebo arm (P = 0.43) and 7.6% vs. 5.6% in the azithromycin compared to placebo arms at 6 months (P = 0.47). Conclusions Azithromycin did not affect malaria outcomes in this study, possibly due to the individually randomized nature of the trial. Trial registration This study is registered at clinicaltrials.gov (NCT03676751; registered 19 September 2018). Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03895-9.
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Affiliation(s)
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | - Adama Compaoré
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | | | - Jessica M Brogdon
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois St, Floor 2, San Francisco, CA, 94143, USA
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois St, Floor 2, San Francisco, CA, 94143, USA
| | - Thuy Doan
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois St, Floor 2, San Francisco, CA, 94143, USA.,Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
| | - Travis C Porco
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois St, Floor 2, San Francisco, CA, 94143, USA.,Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
| | - Thomas M Lietman
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois St, Floor 2, San Francisco, CA, 94143, USA.,Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Catherine E Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, 490 Illinois St, Floor 2, San Francisco, CA, 94143, USA. .,Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA. .,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
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26
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Yaméogo KB, Yerbanga RS, Ouattara SB, Yao FA, Lefèvre T, Zongo I, Nikièma F, Compaoré YD, Tinto H, Chandramohan D, Greenwood B, Belem AMG, Cohuet A, Ouédraogo JB. Effect of seasonal malaria chemoprevention plus azithromycin on Plasmodium falciparum transmission: gametocyte infectivity and mosquito fitness. Malar J 2021; 20:326. [PMID: 34315475 PMCID: PMC8314489 DOI: 10.1186/s12936-021-03855-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/16/2021] [Indexed: 11/24/2022] Open
Abstract
Background Seasonal malaria chemoprevention (SMC) consists of administration of sulfadoxine-pyrimethamine (SP) + amodiaquine (AQ) at monthly intervals to children during the malaria transmission period. Whether the addition of azithromycin (AZ) to SMC could potentiate the benefit of the intervention was tested through a double-blind, randomized, placebo-controlled trial. The effect of SMC and the addition of AZ, on malaria transmission and on the life history traits of Anopheles gambiae mosquitoes have been investigated. Methods The study included 438 children randomly selected from among participants in the SMC + AZ trial and 198 children from the same area who did not receive chemoprevention. For each participant in the SMC + AZ trial, blood was collected 14 to 21 days post treatment, examined for the presence of malaria sexual and asexual stages and provided as a blood meal to An. gambiae females using a direct membrane-feeding assay. Results The SMC treatment, with or without AZ, significantly reduced the prevalence of asexual Plasmodium falciparum (LRT X22 = 69, P < 0.0001) and the gametocyte prevalence (LRT X22 = 54, P < 0.0001). In addition, the proportion of infectious feeds (LRT X22 = 61, P < 0.0001) and the prevalence of oocysts among exposed mosquitoes (LRT X22 = 22.8, P < 0.001) was reduced when mosquitoes were fed on blood from treated children compared to untreated controls. The addition of AZ to SPAQ was associated with an increased proportion of infectious feeds (LRT X21 = 5.2, P = 0.02), suggesting a significant effect of AZ on gametocyte infectivity. There was a slight negative effect of SPAQ and SPAQ + AZ on mosquito survival compared to mosquitoes fed with blood from control children (LRTX22 = 330, P < 0.0001). Conclusion This study demonstrates that SMC may contribute to a reduction in human to mosquito transmission of P. falciparum, and the reduced mosquito longevity observed for females fed on treated blood may increase the benefit of this intervention in control of malaria. The addition of AZ to SPAQ in SMC appeared to enhance the infectivity of gametocytes providing further evidence that this combination is not an appropriate intervention.
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Affiliation(s)
- Koudraogo Bienvenue Yaméogo
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso. .,Université Nazi Boni, Bobo-Dioulasso, Burkina Faso.
| | - Rakiswendé Serge Yerbanga
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso.,Institut des Sciences et Techniques (INSTech Bobo), BP2779, Bobo-Dioulasso, Burkina Faso
| | | | - Franck A Yao
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Thierry Lefèvre
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso.,MIVEGEC, University of Montpellier, IRD, CNRS, Montpellier, France.,Laboratoire Mixte International Sur Les Vecteurs (LAMIVECT), Bobo Dioulasso, Burkina Faso.,Centre de Recherche en Écologie et Évolution de la Santé (CREES), Montpellier, France
| | - Issaka Zongo
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Frederic Nikièma
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | | | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | | | | | | | - Anna Cohuet
- MIVEGEC, University of Montpellier, IRD, CNRS, Montpellier, France.,Laboratoire Mixte International Sur Les Vecteurs (LAMIVECT), Bobo Dioulasso, Burkina Faso
| | - Jean Bosco Ouédraogo
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso.,Institut des Sciences et Techniques (INSTech Bobo), BP2779, Bobo-Dioulasso, Burkina Faso
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27
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de Wit M, Cairns M, Compaoré YD, Sagara I, Kuepfer I, Zongo I, Barry A, Diarra M, Tapily A, Coumare S, Thera I, Nikiema F, Yerbanga RS, Guissou RM, Tinto H, Dicko A, Chandramohan D, Greenwood B, Ouedraogo JB. Nutritional status in young children prior to the malaria transmission season in Burkina Faso and Mali, and its impact on the incidence of clinical malaria. Malar J 2021; 20:274. [PMID: 34158054 PMCID: PMC8220741 DOI: 10.1186/s12936-021-03802-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria and malnutrition remain major problems in Sahel countries, especially in young children. The direct effect of malnutrition on malaria remains poorly understood, and may have important implications for malaria control. In this study, nutritional status and the association between malnutrition and subsequent incidence of symptomatic malaria were examined in children in Burkina Faso and Mali who received either azithromycin or placebo, alongside seasonal malaria chemoprevention. METHODS Mid-upper arm circumference (MUAC) was measured in all 20,185 children who attended a screening visit prior to the malaria transmission season in 2015. Prior to the 2016 malaria season, weight, height and MUAC were measured among 4149 randomly selected children. Height-for-age, weight-for-age, weight-for-height, and MUAC-for-age were calculated as indicators of nutritional status. Malaria incidence was measured during the following rainy seasons. Multivariable random effects Poisson models were created for each nutritional indicator to study the effect of malnutrition on clinical malaria incidence for each country. RESULTS In both 2015 and 2016, nutritional status prior to the malaria season was poor. The most prevalent form of malnutrition in Burkina Faso was being underweight (30.5%; 95% CI 28.6-32.6), whereas in Mali stunting was most prevalent (27.5%; 95% CI 25.6-29.5). In 2016, clinical malaria incidence was 675 per 1000 person-years (95% CI 613-744) in Burkina Faso, and 1245 per 1000 person-years (95% CI 1152-1347) in Mali. There was some evidence that severe stunting was associated with lower incidence of malaria in Mali (RR 0.81; 95% CI 0.64-1.02; p = 0.08), but this association was not seen in Burkina Faso. Being moderately underweight tended to be associated with higher incidence of clinical malaria in Burkina Faso (RR 1.27; 95% CI 0.98-1.64; p = 0.07), while this was the case in Mali for moderate wasting (RR 1.27; 95% CI 0.98-1.64; p = 0.07). However, these associations were not observed in severely affected children, nor consistent between countries. MUAC-for-age was not associated with malaria risk. CONCLUSIONS Both malnutrition and malaria were common in the study areas, high despite high coverage of seasonal malaria chemoprevention and long-lasting insecticidal nets. However, no strong or consistent evidence was found for an association between any of the nutritional indicators and the subsequent incidence of clinical malaria.
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Affiliation(s)
- Mariken de Wit
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Matthew Cairns
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Issaka Sagara
- Malaria Research and Training Centre, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Irene Kuepfer
- London School of Hygiene and Tropical Medicine, London, UK
| | - Issaka Zongo
- Institut de Recherche en Sciences de La Santé, Bobo-Dioulasso, Burkina Faso
| | - Amadou Barry
- Malaria Research and Training Centre, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Modibo Diarra
- Malaria Research and Training Centre, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Amadou Tapily
- Malaria Research and Training Centre, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Samba Coumare
- Malaria Research and Training Centre, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Ismaila Thera
- Malaria Research and Training Centre, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Frederic Nikiema
- Institut de Recherche en Sciences de La Santé, Bobo-Dioulasso, Burkina Faso
| | - R Serge Yerbanga
- Institut de Recherche en Sciences de La Santé, Bobo-Dioulasso, Burkina Faso
| | | | - Halidou Tinto
- Institut de Recherche en Sciences de La Santé, Bobo-Dioulasso, Burkina Faso
| | - Alassane Dicko
- Malaria Research and Training Centre, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
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28
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Ramblière L, Guillemot D, Delarocque-Astagneau E, Huynh BT. Impact of mass and systematic antibiotic administration on antibiotic resistance in low- and middle-income countries? A systematic review. Int J Antimicrob Agents 2021; 58:106364. [PMID: 34044108 DOI: 10.1016/j.ijantimicag.2021.106364] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/09/2021] [Accepted: 05/15/2021] [Indexed: 11/29/2022]
Abstract
Antibiotic consumption is a key driver of antimicrobial resistance (AR), particularly in low- and middle-income countries (LMICs) where risk factors for AR emergence and spread are prevalent. However, the potential contribution of mass drug administration (MDA) and systematic drug administration (SDA) of antibiotics to AR spread is unknown. We conducted a systematic review to provide an overview of MDA/SDA in LMICs, including indications, antibiotics used and, if investigated, levels of AR over time. This systematic review is reported in accordance with the PRISMA statement. Of 2438 identified articles, 63 were reviewed: indications for MDA/SDA were various, and targeted populations were particularly vulnerable, including pregnant women, children, human immunodeficiency virus (HIV)-infected populations, and communities in outbreak settings. Available data suggest that MDA/SDA may lead to a significant increase in AR, especially following azithromycin administration. However, only 40% of studies evaluated AR. Integrative approaches that evaluate AR in addition to clinical outcomes are needed to understand the consequences of MDA/SDA implementation, combined with standardised AR surveillance for timely detection of AR emergence.
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Affiliation(s)
- Lison Ramblière
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective Evasion and Pharmacoepidemiology Team, F- 78180, Montigny-Le-Bretonneux, France; Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), F-75015, Paris, France.
| | - Didier Guillemot
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective Evasion and Pharmacoepidemiology Team, F- 78180, Montigny-Le-Bretonneux, France; Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), F-75015, Paris, France; AP-HP Paris Saclay, Public Health, Medical Information, Clinical Research, F-94276, Le Kremlin-Bicêtre, France
| | - Elisabeth Delarocque-Astagneau
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective Evasion and Pharmacoepidemiology Team, F- 78180, Montigny-Le-Bretonneux, France; AP-HP Paris Saclay, Public Health, Medical Information, Clinical Research, F-94276, Le Kremlin-Bicêtre, France
| | - Bich-Tram Huynh
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective Evasion and Pharmacoepidemiology Team, F- 78180, Montigny-Le-Bretonneux, France; Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), F-75015, Paris, France
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29
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O'Brien KS, Arzika AM, Amza A, Maliki R, Ousmane S, Kadri B, Nassirou B, Mankara AK, Harouna AN, Colby E, Lebas E, Liu Z, Le V, Nguyen W, Keenan JD, Oldenburg CE, Porco TC, Doan T, Arnold BF, Lietman TM. Age-based targeting of biannual azithromycin distribution for child survival in Niger: an adaptive cluster-randomized trial protocol (AVENIR). BMC Public Health 2021; 21:822. [PMID: 33926403 PMCID: PMC8082631 DOI: 10.1186/s12889-021-10824-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Biannual distribution of azithromycin to children 1-59 months old reduced mortality by 14% in a cluster-randomized trial. The World Health Organization has proposed targeting this intervention to the subgroup of children 1-11 months old to reduce selection for antimicrobial resistance. Here, we describe a trial designed to determine the impact of age-based targeting of biannual azithromycin on mortality and antimicrobial resistance. METHODS AVENIR is a cluster-randomized, placebo-controlled, double-masked, response-adaptive large simple trial in Niger. During the 2.5-year study period, 3350 communities are targeted for enrollment. In the first year, communities in the Dosso region will be randomized 1:1:1 to 1) azithromycin 1-11: biannual azithromycin to children 1-11 months old with placebo to children 12-59 months old, 2) azithromycin 1-59: biannual azithromycin to children 1-59 months old, or 3) placebo: biannual placebo to children 1-59 months old. Regions enrolled after the first year will be randomized with an updated allocation based on the probability of mortality in children 1-59 months in each arm during the preceding study period. A biannual door-to-door census will be conducted to enumerate the population, distribute azithromycin and placebo, and monitor vital status. Primary mortality outcomes are defined as all-cause mortality rate (deaths per 1000 person-years) after 2.5 years from the first enrollment in 1) children 1-59 months old comparing the azithromycin 1-59 and placebo arms, 2) children 1-11 months old comparing the azithromycin 1-11 and placebo arm, and 3) children 12-59 months in the azithromycin 1-11 and azithromycin 1-59 arms. In the Dosso region, 50 communities from each arm will be followed to monitor antimicrobial resistance. Primary resistance outcomes will be assessed after 2 years of distributions and include 1) prevalence of genetic determinants of macrolide resistance in nasopharyngeal samples from children 1-59 months old, and 2) load of genetic determinants of macrolide resistance in rectal samples from children 1-59 months old. DISCUSSION As high-mortality settings consider this intervention, the results of this trial will provide evidence to support programmatic and policy decision-making on age-based strategies for azithromycin distribution to promote child survival. TRIAL REGISTRATION This trial was registered on January 13, 2020 (clinicaltrials.gov: NCT04224987 ).
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Affiliation(s)
- Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco, USA
| | - Ahmed M Arzika
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger.,Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Abdou Amza
- Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Ramatou Maliki
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger.,Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Sani Ousmane
- Centre de Recherche Médical et Sanitaire, Niamey, Niger
| | | | | | - Alio Karamba Mankara
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger.,Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Abdoul Naser Harouna
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger.,Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Emily Colby
- Francis I. Proctor Foundation, University of California, San Francisco, USA
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, USA
| | - Zijun Liu
- Francis I. Proctor Foundation, University of California, San Francisco, USA
| | - Victoria Le
- Francis I. Proctor Foundation, University of California, San Francisco, USA
| | - William Nguyen
- Francis I. Proctor Foundation, University of California, San Francisco, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, USA.,Department of Ophthalmology, University of California, 490 Illinois Street, San Francisco, CA, 94158, USA
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco, USA.,Department of Ophthalmology, University of California, 490 Illinois Street, San Francisco, CA, 94158, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, USA.,Institute for Global Health Sciences, University of California, San Francisco, USA
| | - Thuy Doan
- Francis I. Proctor Foundation, University of California, San Francisco, USA.,Department of Ophthalmology, University of California, 490 Illinois Street, San Francisco, CA, 94158, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, USA.,Department of Ophthalmology, University of California, 490 Illinois Street, San Francisco, CA, 94158, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, USA. .,Department of Ophthalmology, University of California, 490 Illinois Street, San Francisco, CA, 94158, USA. .,Department of Epidemiology and Biostatistics, University of California, San Francisco, USA. .,Institute for Global Health Sciences, University of California, San Francisco, USA.
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30
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Batiha GES, Zayed MA, Awad AA, Shaheen HM, Mustapha S, Herrera-Calderon O, Pagnossa JP, Algammal AM, Zahoor M, Adhikari A, Pandey I, Elazab ST, Rengasamy KRR, Cruz-Martins N, Hetta HF. Management of SARS-CoV-2 Infection: Key Focus in Macrolides Efficacy for COVID-19. Front Med (Lausanne) 2021; 8:642313. [PMID: 33937285 PMCID: PMC8079973 DOI: 10.3389/fmed.2021.642313] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/23/2021] [Indexed: 12/24/2022] Open
Abstract
Macrolides (e.g., erythromycin, fidaxomicin, clarithromycin, and azithromycin) are a class of bacteriostatic antibiotics commonly employed in medicine against various gram-positive and atypical bacterial species mostly related to respiratory tract infections, besides they possess anti-inflammatory and immunomodulatory effects. Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome of coronavirus 2 (SARS-CoV-2). It was first detected in Wuhan, Hubei, China, in December 2019 and resulted in a continuing pandemic. Macrolides have been extensively researched as broad adjunctive therapy for COVID-19 due to its immunostimulant abilities. Among such class of drugs, azithromycin is described as azalide and is well-known for its ability to decrease the production of pro-inflammatory cytokines, including matrix metalloproteinases, tumor necrosis factor-alpha, interleukin (IL)-6, and IL-8. In fact, a report recently published highlighted the effectiveness of combining azithromycin and hydroxychloroquine for COVID-19 treatment. Indeed, it has been underlined that azithromycin quickly prevents SARS-CoV-2 infection by raising the levels of both interferons and interferon-stimulated proteins at the same time which reduces the virus replication and release. In this sense, the current review aims to evaluate the applications of macrolides for the treatment of COVID-19.
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Affiliation(s)
- Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, Egypt
| | - Marwa A. Zayed
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, Egypt
| | - Aya A. Awad
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, Egypt
| | - Hazem M. Shaheen
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, Egypt
| | - Suleiman Mustapha
- Department of Crop Protection, University of Ilorin, Ilorin, Nigeria
| | - Oscar Herrera-Calderon
- Department of Pharmacology, Bromatology and Toxicology, Faculty of Pharmacy and Biochemistry, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Abdelazeem M. Algammal
- Department of Bacteriology, Immunology, and Mycology, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt
| | - Muhammad Zahoor
- Department of Biochemistry, University of Malakand, Chakdara, Pakistan
| | - Achyut Adhikari
- Central Department of Chemistry, Tribhuwan University, Kritipur, Nepal
| | - Ishan Pandey
- Department of Pathology, Motilal Nehru Medical College, Prayagraj, India
| | - Sara T. Elazab
- Department of Pharmacology, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| | - Kannan R. R. Rengasamy
- Green Biotechnologies Research Centre of Excellence, University of Limpopo, Polokwane, South Africa
| | - Natália Cruz-Martins
- Faculty of Medicine, University of Porto, Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, Porto, Portugal
- Laboratory of Neuropsychophysiology, Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal
| | - Helal F. Hetta
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
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31
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Near-term climate change impacts on sub-national malaria transmission. Sci Rep 2021; 11:751. [PMID: 33436862 PMCID: PMC7803742 DOI: 10.1038/s41598-020-80432-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/17/2020] [Indexed: 01/29/2023] Open
Abstract
The role of climate change on global malaria is often highlighted in World Health Organisation reports. We modelled a Zambian socio-environmental dataset from 2000 to 2016, against malaria trends and investigated the relationship of near-term environmental change with malaria incidence using Bayesian spatio-temporal, and negative binomial mixed regression models. We introduced the diurnal temperature range (DTR) as an alternative environmental measure to the widely used mean temperature. We found substantial sub-national near-term variations and significant associations with malaria incidence-trends. Significant spatio-temporal shifts in DTR/environmental predictors influenced malaria incidence-rates, even in areas with declining trends. We highlight the impact of seasonally sensitive DTR, especially in the first two quarters of the year and demonstrate how substantial investment in intervention programmes is negatively impacted by near-term climate change, most notably since 2010. We argue for targeted seasonally-sensitive malaria chemoprevention programmes.
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32
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Sié A, Dah C, Bountogo M, Ouattara M, Nebie E, Coulibaly B, Brogdon JM, Godwin WW, Lebas E, Doan T, Arnold BF, Porco TC, Lietman TM, Oldenburg CE, For The Gamin Study Group. Adverse Events and Clinic Visits following a Single Dose of Oral Azithromycin among Preschool Children: A Randomized Placebo-Controlled Trial. Am J Trop Med Hyg 2020; 104:1137-1141. [PMID: 33350370 PMCID: PMC7941837 DOI: 10.4269/ajtmh.20-1002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/16/2020] [Indexed: 12/18/2022] Open
Abstract
Biannual mass azithromycin distribution reduces all-cause child mortality in some settings in sub-Saharan Africa; however, adverse events and short-term infectious outcomes following treatment have not been well characterized. Children aged 0–59 months were recruited in Nouna Town, Burkina Faso, and randomized 1:1 to a single directly observed oral 20 mg/kg dose of azithromycin or placebo. At 14 days after treatment, caregivers were interviewed about adverse event symptoms their child experienced since treatment and if they had sought health care for their child. All children had tympanic temperature measured at the 14-day visit. We compared adverse events and clinic visits using logistic regression models between azithromycin- and placebo-controlled children. Of 450 children enrolled, 230 were randomized to azithromycin and 220 to placebo. On average, children were aged 28 months, and 50.9% were female. Caregivers of 20% of children reported that their child experienced at least one adverse event, with no significant difference between study arms (19.9% azithromycin; 20.0% placebo, logistic regression P = 0.96). Vomiting was more often reported by caregivers of azithromycin-treated children than by those of placebo-treated children (7.2% azithromycin, 1.9% placebo, logistic regression P = 0.01). There were no significant differences in other adverse events or clinic visits. Adverse events following a single oral dose of azithromycin in preschool children were rare and mild. Azithromycin administration appears safe in this population.
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Affiliation(s)
- Ali Sié
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | | | | | - Eric Nebie
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | | | - Jessica M Brogdon
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - William W Godwin
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Thuy Doan
- Department of Ophthalmology, University of California, San Francisco, California.,Francis I Proctor Foundation, University of California, San Francisco, California
| | - Benjamin F Arnold
- Department of Ophthalmology, University of California, San Francisco, California.,Francis I Proctor Foundation, University of California, San Francisco, California
| | - Travis C Porco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, California.,Francis I Proctor Foundation, University of California, San Francisco, California
| | - Thomas M Lietman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, California.,Francis I Proctor Foundation, University of California, San Francisco, California
| | - Catherine E Oldenburg
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California.,Francis I Proctor Foundation, University of California, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, California
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33
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Hart JD, Kalua K, Keenan JD, Lietman TM, Bailey RL. Effect of Mass Treatment with Azithromycin on Causes of Death in Children in Malawi: Secondary Analysis from the MORDOR Trial. Am J Trop Med Hyg 2020; 103:1319-1328. [PMID: 32342837 PMCID: PMC7470551 DOI: 10.4269/ajtmh.19-0613] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Recent evidence indicates mass drug administration with azithromycin may reduce child mortality. This study uses verbal autopsy (VA) to investigate the causes of individual deaths during the Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) trial in Malawi. Cluster randomization was performed as part of MORDOR. Biannual household visits were conducted to distribute azithromycin or placebo to children aged 1–59 months and update the census to identify deaths for VA. MORDOR was not powered to investigate mortality effects at individual sites, but the available evidence is presented here for hypothesis generation regarding the mechanism through which azithromycin may reduce child mortality. Automated VA analysis was performed to infer the likely cause of death using two major analysis programs, InterVA and SmartVA. A total of 334 communities were randomized to azithromycin or placebo, with more than 130,000 person-years of follow-up. During the study, there were 1,184 deaths, of which 1,131 were followed up with VA. Mortality was 9% lower in azithromycin-treated communities than in placebo communities (rate ratio 0.91 [95% CI: 0.79–1.05]; P = 0.20). The intention-to-treat analysis by cause using InterVA suggested fewer HIV/AIDS deaths in azithromycin-treated communities (rate ratio 0.70 [95% CI: 0.50–0.97]; P = 0.03) and fewer pneumonia deaths (rate ratio 0.82 [95% CI: 0.60–1.12]; P = 0.22). The use of the SmartVA algorithm suggested fewer diarrhea deaths (rate ratio 0.71 [95% CI: 0.51–1.00]; P = 0.05) and fewer pneumonia deaths (rate ratio 0.58 [95% CI: 0.33–1.00]; P = 0.05). Although this study is not able to provide strong evidence, the data suggest that the mortality reduction during MORDOR in Malawi may have been due to effects on pneumonia and diarrhea or HIV/AIDS mortality.
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Affiliation(s)
- John D Hart
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Khumbo Kalua
- Blantyre Institute for Community Outreach and College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jeremy D Keenan
- Department of Ophthalmology, Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Thomas M Lietman
- Department of Ophthalmology, Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Robin L Bailey
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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34
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Evaluation of the Combination of Azithromycin and Naphthoquine in Animal Malaria Models. Antimicrob Agents Chemother 2020; 64:AAC.02307-19. [DOI: 10.1128/aac.02307-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 08/18/2020] [Indexed: 11/20/2022] Open
Abstract
Combination therapy using drugs with different mechanisms of action is the current state of the art in antimalarial treatment. However, except for artemisinin-based combination therapies, only a few other combinations are now available. Increasing concern regarding the emergence and spread of artemisinin resistance in
Plasmodium falciparum
has led to a need for the development of new antimalarials. Moreover, the efficacy of current available chemoprophylaxis is compromised by drug resistance and noncompliance due to intolerable adverse effects or complicated dosing regimens.
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35
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Ashley EA, Poespoprodjo JR. Treatment and prevention of malaria in children. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:775-789. [PMID: 32946831 DOI: 10.1016/s2352-4642(20)30127-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/11/2020] [Accepted: 03/25/2020] [Indexed: 10/23/2022]
Abstract
Malaria disproportionately affects children younger than 5 years. Falciparum malaria is responsible for more than 200 000 child deaths per year in Africa and vivax malaria is well documented as a cause of severe anaemia and excess mortality in children in Asia and Oceania. For the treatment of malaria in children, paediatric dosing recommendations for several agents, including parenteral artesunate and dihydroartemisinin-piperaquine, have belatedly been shown to be suboptimal. Worsening antimalarial resistance in Plasmodium falciparum in the Greater Mekong Subregion threatens to undermine global efforts to control malaria. Triple antimalarial combination therapies are being evaluated to try to impede this threat. The RTS,S/AS01 vaccine gives partial protection against falciparum malaria and is being evaluated in large, pilot studies in Ghana, Malawi, and Kenya as a complementary tool to other preventive measures. Seasonal malaria chemoprevention in west Africa has resulted in declines in malaria incidence and deaths and there is interest in scaling up efforts by expanding the age range of eligible recipients. Preventing relapse in Plasmodium vivax infection with primaquine is challenging because treating children who have G6PD deficiency with primaquine can cause acute haemolytic anaemia. The safety of escalating dose regimens for primaquine is being studied to mitigate this risk.
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Affiliation(s)
- Elizabeth A Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Jeanne Rini Poespoprodjo
- Timika Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Department of Child Health, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia
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36
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Chandramohan D, Dicko A, Zongo I, Sagara I, Cairns M, Kuepfer I, Diarra M, Tapily A, Issiaka D, Sanogo K, Mahamar A, Sompougdou F, Yerbanga S, Thera I, Milligan P, Tinto H, Ofori-Anyinam O, Ouedraogo JB, Greenwood B. Seasonal malaria vaccination: protocol of a phase 3 trial of seasonal vaccination with the RTS,S/AS01 E vaccine, seasonal malaria chemoprevention and the combination of vaccination and chemoprevention. BMJ Open 2020; 10:e035433. [PMID: 32933955 PMCID: PMC7493088 DOI: 10.1136/bmjopen-2019-035433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Seasonal malaria chemoprevention (SMC), with sulphadoxine-pyrimethamine plus amodiaquine (SP+AQ) is effective but does not provide complete protection against clinical malaria. The RTS,S/AS01E malaria vaccine provides a high level of protection shortly after vaccination, but this wanes rapidly. Such a vaccine could be an alternative or additive to SMC. This trial aims to determine whether seasonal vaccination with RTS,S/AS01E vaccine could be an alternative to SMC and whether a combination of the two interventions would provide added benefits. METHODS AND ANALYSIS This is an individually randomised, double-blind, placebo-controlled trial. 5920 children aged 5-17 months were enrolled in April 2017 in Mali and Burkina Faso. Children in group 1 received three priming doses of RTS,S/AS01E vaccine before the start of the 2017 malaria transmission season and a booster dose at the beginning of two subsequent transmission seasons. In addition, they received SMC SP+AQ placebo on four occasions each year. Children in group 2 received three doses of rabies vaccine in year 1 and hepatitis A vaccine in years 2 and 3 together with four cycles of SMC SP+AQ each year. Children in group 3 received RTS,S/AS01E vaccine and four courses of SMC SP+AQ. Incidence of clinical malaria is determined by case detection at health facilities. Weekly active surveillance for malaria is undertaken in a randomly selected subset of children. The prevalence of malaria is measured in surveys at the end of each transmission season. The primary endpoint is the incidence of clinical malaria confirmed by a positive blood film with a minimum parasite density of 5000 /µL. Primary analysis will be by modified intention to treat defined as children who have received the first dose of the malaria or control vaccine. ETHICS AND DISSEMINATION The protocol was approved by the national ethics committees of Mali and Burkina Faso and the London School of Hygiene and Tropical Medicine. The results will be presented to all stakeholders and published in open access journals. TRIAL REGISTRATION NUMBER NCT03143218; Pre-results.
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Affiliation(s)
- Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Issaka Zongo
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | | | - Matthew Cairns
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Irene Kuepfer
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | - Serge Yerbanga
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | | | - Paul Milligan
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | | | | | - B Greenwood
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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37
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Cairns ME, Sagara I, Zongo I, Kuepfer I, Thera I, Nikiema F, Diarra M, Yerbanga SR, Barry A, Tapily A, Coumare S, Milligan P, Tinto H, Ouédraogo JB, Chandramohan D, Greenwood B, Djimde A, Dicko A. Evaluation of seasonal malaria chemoprevention in two areas of intense seasonal malaria transmission: Secondary analysis of a household-randomised, placebo-controlled trial in Houndé District, Burkina Faso and Bougouni District, Mali. PLoS Med 2020; 17:e1003214. [PMID: 32822362 PMCID: PMC7442230 DOI: 10.1371/journal.pmed.1003214] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 07/31/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Seasonal malaria chemoprevention (SMC) is now widely deployed in the Sahel, including several countries that are major contributors to the global burden of malaria. Consequently, it is important to understand whether SMC continues to provide a high level of protection and how SMC might be improved. SMC was evaluated using data from a large, household-randomised trial in Houndé, Burkina Faso and Bougouni, Mali. METHODS AND FINDINGS The parent trial evaluated monthly SMC plus either azithromycin (AZ) or placebo, administered as directly observed therapy 4 times per year between August and November (2014-2016). In July 2014, 19,578 children aged 3-59 months were randomised by household to study group. Children who remained within the age range 3-59 months in August each year, plus children born into study households or who moved into the study area, received study drugs in 2015 and 2016. These analyses focus on the approximately 10,000 children (5,000 per country) under observation each year in the SMC plus placebo group. Despite high coverage and high adherence to SMC, the incidence of hospitalisations or deaths due to malaria and uncomplicated clinical malaria remained high in the study areas (overall incidence rates 12.5 [95% confidence interval (CI): 11.2, 14.1] and 871.1 [95% CI: 852.3, 890.6] cases per 1,000 person-years, respectively) and peaked in July each year, before SMC delivery began in August. The incidence rate ratio comparing SMC within the past 28 days with SMC more than 35 days ago-adjusted for age, country, and household clustering-was 0.13 (95% CI: 0.08, 0.20), P < 0.001 for malaria hospitalisations and deaths from malaria and 0.21 (95% CI 0.20, 0.23), P < 0.001 for uncomplicated malaria, indicating protective efficacy of 87.4% (95% CI: 79.6%, 92.2%) and 78.3% (95% CI: 76.8%, 79.6%), respectively. The prevalence of malaria parasitaemia at weekly surveys during the rainy season and at the end of the transmission season was several times higher in children who missed the SMC course preceding the survey contact, and the smallest prevalence ratio observed was 2.98 (95% CI: 1.95, 4.54), P < 0.001. The frequency of molecular markers of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) resistance did not increase markedly over the study period either amongst study children or amongst school-age children resident in the study areas. After 3 years of SMC deployment, the day 28 PCR-unadjusted adequate clinical and parasitological response rate of the SP + AQ regimen in children with asymptomatic malaria was 98.3% (95% CI: 88.6%, 99.8%) in Burkina Faso and 96.1% (95% CI: 91.5%, 98.2%) in Mali. Key limitations of this study are the potential overdiagnosis of uncomplicated malaria by rapid diagnostic tests and the potential for residual confounding from factors related to adherence to the monthly SMC schedule. CONCLUSION Despite strong evidence that SMC is providing a high level of protection, the burden of malaria remains substantial in the 2 study areas. These results emphasise the need for continuing support of SMC programmes. A fifth monthly SMC course is needed to adequately cover the whole transmission season in the study areas and in settings with similar epidemiology. TRIAL REGISTRATION The AZ-SMC trial in which these data were collected was registered at clinicaltrials.gov: NCT02211729.
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Affiliation(s)
- Matthew E. Cairns
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | | | - Issaka Zongo
- Institut de Recherche en Sciences de la Santé, Bobo Dioulasso, Burkina Faso
| | - Irene Kuepfer
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Frederic Nikiema
- Institut de Recherche en Sciences de la Santé, Bobo Dioulasso, Burkina Faso
| | | | - Serge R. Yerbanga
- Institut de Recherche en Sciences de la Santé, Bobo Dioulasso, Burkina Faso
| | - Amadou Barry
- Malaria Research and Training Centre, Bamako, Mali
| | | | | | - Paul Milligan
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé, Bobo Dioulasso, Burkina Faso
| | | | - Daniel Chandramohan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Brian Greenwood
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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38
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Hanboonkunupakarn B, White NJ. Advances and roadblocks in the treatment of malaria. Br J Clin Pharmacol 2020; 88:374-382. [PMID: 32656850 PMCID: PMC9437935 DOI: 10.1111/bcp.14474] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 12/12/2022] Open
Abstract
The deployment of artesunate for severe malaria and the artemisinin combination therapies (ACTs) for uncomplicated malaria has been a major advance in antimalarial therapeutics. These drugs have reduced treated mortality, accelerated recovery and reduced treatment failure rates and transmission from the treated infection. Artemisinin derivatives remain highly effective against falciparum malaria in most malaria endemic areas, but significant resistance has emerged in the Greater Mekong subregion of Southeast Asia. Resistance to artemisinins was followed by resistance to the ACT partner drugs, and fit multidrug resistant parasite lineages have now spread widely across the region. ACTs remain highly effective against P. vivax and the other malaria species. Recent studies have shown that radical curative regimens of primaquine (to prevent relapse) can be shortened to 7 days, and that the newly introduced single dose tafenoquine is an alternative, although the currently recommended dose is insufficient in Southeast Asia and Oceania. Targeted malaria elimination using focal mass treatments with dihydroartemisinin-piperaquine have proved safe and effective malaria elimination accelerators, but progress overall towards malaria elimination is slow. Indeed since 2015 overall malaria case numbers globally have risen. As new drugs will not become widely available in the near future, active measures to preserve the current antimalarials should be given the highest priority.
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Affiliation(s)
| | - Nicholas J White
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, UK
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39
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Hema-Ouangraoua S, Zongo I, Kabore NF, Frédéric N, Yerbanga RS, Tinto H, Compaore YD, Kuepfer I, Chandramohan D, Greenwood B, Ouedraogo JB. Serotype Profile of Nasopharyngeal Isolates of Streptococcus pneumoniae Obtained from Children in Burkina Faso before and after Mass Administration of Azithromycin. Am J Trop Med Hyg 2020; 103:679-683. [PMID: 32524945 PMCID: PMC7410481 DOI: 10.4269/ajtmh.19-0944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Mass drug administration (MDA) with azithromycin (AZ) has been used successfully to control trachoma. However, several studies have shown that MDA with AZ has led to the emergence of resistance to AZ in Streptococcus pneumoniae. The emergence of resistance to AZ has also been observed when this antibiotic was combined with the antimalarials used for seasonal malaria chemoprevention (SMC). The development of antibiotic resistance, including resistance to AZ, is sometimes associated with the emergence of a bacterial clone that belongs to a specific serotype. We hypothesize that the increase in resistance of S. pneumoniae observed after 3 years of SMC with AZ might be associated with a change in the distribution of pneumococcal serotypes. Therefore, 698 randomly selected isolates from among the 1,468 isolates of S. pneumoniae obtained during carriage studies undertaken during an SMC plus AZ trial were serotyped. A polymerase chain reaction (PCR) multiplex assay using an algorithm adapted to the detection of the pneumococcal serotypes most prevalent in African countries was used for initial serotyping, and the Quellung technique was used to complement the PCR technique when necessary. Fifty-six serotypes were detected among the 698 isolates of S. pneumoniae. A swift appearance and disappearance of many serotypes was observed, but some serotypes including 6A, 19F, 19A, 23F, and 35B were persistent. The distribution of serotypes between isolates obtained from children who had received AZ or placebo was similar. An increase in AZ resistance was seen in several serotypes following exposure to AZ. Mass drug administration with AZ led to the emergence of resistance in pneumococci of several different serotypes and did not appear to be linked to the emergence of a single serotype.
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Affiliation(s)
| | - Issaka Zongo
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | | | - Nikiema Frédéric
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | | | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | - Yves Daniel Compaore
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | - Irene Kuepfer
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Brian Greenwood
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jean Bosco Ouedraogo
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
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Hart JD, Samikwa L, Sikina F, Kalua K, Keenan JD, Lietman TM, Burr SE, Bailey RL. Effects of Biannual Azithromycin Mass Drug Administration on Malaria in Malawian Children: A Cluster-Randomized Trial. Am J Trop Med Hyg 2020; 103:1329-1334. [PMID: 32342841 PMCID: PMC7470590 DOI: 10.4269/ajtmh.19-0619] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Reductions in malaria morbidity have been reported following azithromycin mass drug administration (MDA) for trachoma. The recent Macrolides Oraux pour Reduire les Deces avec un Oeil sur la Resistance (MORDOR) trial reported a reduction in child mortality following biannual azithromycin MDA. Here, we investigate the effects of azithromycin MDA on malaria at the MORDOR-Malawi study site. A cluster-randomized double-blind placebo-controlled trial, with 15 clusters per arm, was conducted. House-to-house census was updated biannually, and azithromycin or placebo syrup was distributed to children aged 1–59 months for a total of four biannual distributions. At baseline, 12-month, and 24-month follow-up visits, a random sample of 1,200 children was assessed for malaria with thick and thin blood smears and hemoglobin measurement. In the community-level analysis, there was no difference in the prevalence of parasitemia (1.0% lower in azithromycin-treated communities; 95% CI: −8.2 to 6.1), gametocytemia (0.7% lower in azithromycin-treated communities; 95% CI: −2.8 to 1.5), or anemia (1.7% lower in azithromycin-treated communities; 95% CI: −8.1 to 4.6) between placebo and azithromycin communities. Further interrogation of the data at the individual level, both per-protocol (including only those who received treatment 6 months previously) and by intention-to-treat, did not identify differences in parasitemia between treatment arms. In contrast to several previous reports, this study did not show an effect of azithromycin MDA on malaria parasitemia at the community or individual levels.
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Affiliation(s)
- John D Hart
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lyson Samikwa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Feston Sikina
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Khumbo Kalua
- Blantyre Institute for Community Outreach, Blantyre, Malawi
| | - Jeremy D Keenan
- Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Sarah E Burr
- College of Medicine, University of Malawi, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Robin L Bailey
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Juurlink DN. Safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of SARS-CoV-2 infection. CMAJ 2020; 192:E450-E453. [PMID: 32269021 PMCID: PMC7207200 DOI: 10.1503/cmaj.200528] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- David N Juurlink
- Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre; Departments of Medicine and Pediatrics, University of Toronto; ICES; Ontario Poison Centre, Toronto, Ont.
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Gore-Langton GR, Cairns M, Compaoré YD, Sagara I, Kuepfer I, Zongo I, de Wit MM, Barry A, Diarra M, Tapily A, Coumare S, Thera I, Nikiema F, Yerbanga RS, Guissou RM, Tinto H, Dicko A, Chandramohan D, Greenwood B, Ouedraogo JB. Effect of adding azithromycin to the antimalarials used for seasonal malaria chemoprevention on the nutritional status of African children. Trop Med Int Health 2020; 25:740-750. [PMID: 32166877 DOI: 10.1111/tmi.13390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Mass administration of azithromycin has reduced mortality in children in sub-Saharan Africa but its mode of action is not well characterised. A recent trial found that azithromycin given alongside seasonal malaria chemoprevention was not associated with a reduction in mortality or hospital admissions in young children. We investigated the effect of azithromycin on the nutritional status of children enrolled in this study. METHODS A total of 19 578 children in Burkina Faso and Mali were randomised to receive either azithromycin or placebo alongside seasonal malaria chemoprevention with sulfadoxine-pyrimethamine plus amodiaquine monthly for three malaria transmission seasons (2014-2016). After each transmission season, anthropometric measurements were collected from approximately 4000 randomly selected children (2000 per country) at a cross-sectional survey and used to derive nutritional status indicators. Binary and continuous outcomes between treatment arms were compared by Poisson and linear regression. RESULTS Nutritional status among children was poor in both countries with evidence of acute and chronic malnutrition (24.9-33.3% stunted, 15.8-32.0% underweight, 7.2-26.4% wasted). There was a suggestion of improvement in nutritional status in Burkina Faso and deterioration in Mali over the study period. At the end of each malaria transmission season, nutritional status of children did not differ between treatment arms (seasonal malaria chemoprevention plus azithromycin or placebo) in either the intention-to-treat or per-protocol analyses (only children with at least three cycles of SMC in the current intervention year). CONCLUSIONS The addition of azithromycin to seasonal malaria chemoprevention did not result in an improvement of nutritional outcomes in children in Burkina Faso and Mali.
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Affiliation(s)
| | - Matthew Cairns
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Issaka Sagara
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Irene Kuepfer
- London School of Hygiene and Tropical Medicine, London, UK
| | - Issaka Zongo
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | | | - Amadou Barry
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Modibo Diarra
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Amadou Tapily
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Samba Coumare
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Ismail Thera
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Frederic Nikiema
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - R Serge Yerbanga
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | | | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Alassane Dicko
- Malaria Research and Training Center, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
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A double-blind placebo-controlled trial of azithromycin to reduce mortality and improve growth in high-risk young children with non-bloody diarrhoea in low resource settings: the Antibiotics for Children with Diarrhoea (ABCD) trial protocol. Trials 2020; 21:71. [PMID: 31931848 PMCID: PMC6956478 DOI: 10.1186/s13063-019-3829-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute diarrhoea is a common cause of illness and death among children in low- to middle-income settings. World Health Organization guidelines for the clinical management of acute watery diarrhoea in children focus on oral rehydration, supplemental zinc and feeding advice. Routine use of antibiotics is not recommended except when diarrhoea is bloody or cholera is suspected. Young children who are undernourished or have a dehydrating diarrhoea are more susceptible to death at 90 days after onset of diarrhoea. Given the mortality risk associated with diarrhoea in children with malnutrition or dehydrating diarrhoea, expanding the use of antibiotics for this subset of children could be an important intervention to reduce diarrhoea-associated mortality and morbidity. We designed the Antibiotics for Childhood Diarrhoea (ABCD) trial to test this intervention. METHODS ABCD is a double-blind, randomised trial recruiting 11,500 children aged 2-23 months presenting with acute non-bloody diarrhoea who are dehydrated and/or undernourished (i.e. have a high risk for mortality). Enrolled children in Bangladesh, India, Kenya, Malawi, Mali, Pakistan and Tanzania are randomised (1:1) to oral azithromycin 10 mg/kg or placebo once daily for 3 days and followed-up for 180 days. Primary efficacy endpoints are all-cause mortality during the 180 days post-enrolment and change in linear growth 90 days post-enrolment. DISCUSSION Expanding the treatment of acute watery diarrhoea in high-risk children to include an antibiotic may offer an opportunity to reduce deaths. These benefits may result from direct antimicrobial effects on pathogens or other incompletely understood mechanisms including improved nutrition, alterations in immune responsiveness or improved enteric function. The expansion of indications for antibiotic use raises concerns about the emergence of antimicrobial resistance both within treated children and the communities in which they live. ABCD will monitor antimicrobial resistance. The ABCD trial has important policy implications. If the trial shows significant benefits of azithromycin use, this may provide evidence to support reconsideration of antibiotic indications in the present World Health Organization diarrhoea management guidelines. Conversely, if there is no evidence of benefit, these results will support the current avoidance of antibiotics except in dysentery or cholera, thereby avoiding inappropriate use of antibiotics and reaffirming the current guidelines. TRIAL REGISTRATION Clinicaltrials.gov, NCT03130114. Registered on April 26 2017.
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Jumani RS, Spector JM, Izadnegahdar R, Kelly P, Diagana TT, Manjunatha UH. Innovations in Addressing Pediatric Diarrhea in Low Resource Settings. ACS Infect Dis 2020; 6:14-24. [PMID: 31612701 DOI: 10.1021/acsinfecdis.9b00315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Diarrhea has long been recognized as an important cause of mortality during childhood. In parallel with ensuring access to proven care practices is the imperative to apply modern advances in medicine, science, and technology to accelerate progress against diarrheal disease, particularly in developing countries where the burden of avoidable harm is the greatest. In order to highlight achievements and identify outstanding areas of need, we reviewed the landscape of recent innovations that have significance for the study and clinical management of pediatric diarrhea in low resource settings.
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Affiliation(s)
- Rajiv S. Jumani
- Novartis Institute for Tropical Diseases, 5300 Chiron Way, Emeryville, California 94608, United States
| | - Jonathan M. Spector
- Novartis Institute for Tropical Diseases, 5300 Chiron Way, Emeryville, California 94608, United States
| | - Rasa Izadnegahdar
- Bill and Melinda Gates Foundation, 440 5th Ave N, Seattle, Washington 98109, United States
| | - Paul Kelly
- Blizard Institute, Barts and The London School of Medicine, Queen Mary University of London, Turner Street, London E1 2AD, United Kingdom
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Thierry T. Diagana
- Novartis Institute for Tropical Diseases, 5300 Chiron Way, Emeryville, California 94608, United States
| | - Ujjini H. Manjunatha
- Novartis Institute for Tropical Diseases, 5300 Chiron Way, Emeryville, California 94608, United States
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Hema‐Ouangraoua S, Aziz Maiga A, Cairns M, Zongo I, Frédéric N, Serge Yerbanga R, Tamboura B, Badji H, Gore‐Langton G, Kuepfer I, Tinto H, Sagara I, Dicko A, Sow SO, Chandrahoman D, Greenwood B, Bosco Ouedraogo J. Impact of the addition of azithromycin to antimalarials used for seasonal malaria chemoprevention on antimicrobial resistance of Streptococcus pneumoniae. Trop Med Int Health 2019; 24:1442-1454. [PMID: 31655020 PMCID: PMC7687265 DOI: 10.1111/tmi.13321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE A trial was conducted in Burkina Faso and Mali to investigate whether addition of azithromycin to the antimalarials used for seasonal malaria chemoprevention reduces mortality and hospital admissions of children. We tested the sensitivity of nasal isolates of Streptococcus pneumoniae obtained during this trial to azithromycin and other antibiotics. METHODS Azithromycin or placebo was administered monthly, in combination with the antimalarials used for seasonal malaria chemoprevention, for four months, over the annual malaria transmission seasons of 2014, 2015, and 2016. Nasopharyngeal swabs were collected from 2773 Burkinabe and 2709 Malian children on seven occasions: in July and December each year prior to and after drug administration, and at a final survey in early 2018. Pneumococci were isolated from nasopharyngeal swabs and tested for sensitivity to azithromycin and other antibiotics. RESULTS A total of 5482 samples were collected. In Burkina Faso, the percentage of pneumococcal isolates resistant to azithromycin among children who had received it increased from 4.9% (95% CI: 2.4%, 9.9%) before the intervention to 25.6% (95% CI: 17.6%, 35.7%) afterward. In Mali, the increase was from 7.6% (95% CI: 3.8%, 14.4%) to 68.5% (95% CI: 55.1%, 79.4%). The percentage of resistant isolates remained elevated (17.7% (95% CI: 11.1%, 27.1%) in Burkina Faso and 19.1% (95% CI: 13.5%, 26.3%) in Mali) among children who had received azithromycin 1 year after stopping the intervention. An increase in resistance to azithromycin was also observed in children who had received a placebo but it was less marked. CONCLUSION Addition of azithromycin to the antimalarial combination used for seasonal malaria chemoprevention was associated with an increase in resistance of pneumococci to azithromycin and erythromycin, which persisted 1 year after the last administration of azithromycin.
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Affiliation(s)
- Soumeya Hema‐Ouangraoua
- Centre MURAZBobo‐DioulassoBurkina Faso
- Institut de Recherche en Sciences de la SantéBobo‐DioulassoBurkina Faso
| | | | | | - Issaka Zongo
- Institut de Recherche en Sciences de la SantéBobo‐DioulassoBurkina Faso
| | - Nikiema Frédéric
- Institut de Recherche en Sciences de la SantéBobo‐DioulassoBurkina Faso
| | | | | | - Henry Badji
- Centre pour le Développement des Vaccins du MaliBamakoMali
| | | | - Irene Kuepfer
- London School of Hygiene & Tropical MedicineLondonUK
| | - Halidou Tinto
- Institut de Recherche en Sciences de la SantéBobo‐DioulassoBurkina Faso
| | - Issaka Sagara
- Malaria Research and Training Centre (MRTC)University of Science, Techniques and Technologies of BamakoBamakoMali
| | - Alassane Dicko
- Malaria Research and Training Centre (MRTC)University of Science, Techniques and Technologies of BamakoBamakoMali
| | - Samba O. Sow
- Malaria Research and Training Centre (MRTC)University of Science, Techniques and Technologies of BamakoBamakoMali
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Doan T, Hinterwirth A, Worden L, Arzika AM, Maliki R, Abdou A, Kane S, Zhong L, Cummings ME, Sakar S, Chen C, Cook C, Lebas E, Chow ED, Nachamkin I, Porco TC, Keenan JD, Lietman TM. Gut microbiome alteration in MORDOR I: a community-randomized trial of mass azithromycin distribution. Nat Med 2019; 25:1370-1376. [PMID: 31406349 DOI: 10.1038/s41591-019-0533-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 06/25/2019] [Indexed: 01/25/2023]
Abstract
The MORDOR I trial1, conducted in Niger, Malawi and Tanzania, demonstrated that mass azithromycin distribution to preschool children reduced childhood mortality1. However, the large but simple trial design precluded determination of the mechanisms involved. Here we examined the gut microbiome of preschool children from 30 Nigerien communities randomized to either biannual azithromycin or placebo. Gut microbiome γ-diversity was not significantly altered (P = 0.08), but the relative abundances of two Campylobacter species, along with another 33 gut bacteria, were significantly reduced in children treated with azithromycin at the 24-month follow-up. Metagenomic analysis revealed functional differences in gut bacteria between treatment groups. Resistome analysis showed an increase in macrolide resistance gene expression in gut microbiota in communities treated with azithromycin (P = 0.004). These results suggest that prolonged mass azithromycin distribution to reduce childhood mortality reduces certain gut bacteria, including known pathogens, while selecting for antibiotic resistance.
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Affiliation(s)
- T Doan
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, CA, USA.
| | - A Hinterwirth
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - L Worden
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | | | - R Maliki
- The Carter Center, Niamey, Niger
| | - A Abdou
- Ministry of Public Health, Niamey, Niger
- Programme National de Soins Oculaires, Niamey, Niger
| | - S Kane
- The Carter Center, Niamey, Niger
| | - L Zhong
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - M E Cummings
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - S Sakar
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - C Chen
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - C Cook
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - E Lebas
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - E D Chow
- Department of Biochemistry and Biophysics, University of California, San Francisco, CA, USA
| | - I Nachamkin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - T C Porco
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - J D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - T M Lietman
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
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Bloch EM, Munoz B, Mrango Z, Weaver J, Mboera LEG, Lietman TM, Sullivan DJ, West SK. The impact on malaria of biannual treatment with azithromycin in children age less than 5 years: a prospective study. Malar J 2019; 18:284. [PMID: 31443654 PMCID: PMC6708241 DOI: 10.1186/s12936-019-2914-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 08/17/2019] [Indexed: 01/01/2023] Open
Abstract
Background The MORDOR study, a cluster randomized clinical trial, showed that single-dose azithromycin (20 mg/kg) administered biannually for 2 years to preschool children reduced mortality; a study was conducted to determine its effect on clinical symptomatic episodes of malaria as a potential mechanism for mortality benefit. Methods A randomized control trial (RCT) was conducted, whereby 30 randomly selected communities in Kilosa District, Tanzania were randomized to receive 6-monthly treatment of children ages 1–59 months with single-dose azithromycin (20 mg/kg) vs. placebo. A prospective cohort study was nested within the RCT: children, aged 1 to 35 months at baseline, were randomly selected in each community and evaluated at 6-monthly intervals for 2 years. At each visit, the children were assessed for recent or ongoing fever and anti-malarial treatment; a rapid diagnostic test (RDT) for malaria was performed. The two major outcomes of interest were prevalence of RDT positivity and clinical malaria. The latter was defined as RDT-positivity with fever at time of evaluation and/or reported fever in the 3 days prior to evaluation. Methods that account for correlations at community level and within individuals over time were used to evaluate associations. Results At baseline, the prevalence rates in the children in the azithromycin and placebo arms were 17.6% vs. 15.5% for RDT positivity (p = 0.76) and 6.1% vs. 4.3% (p = 0.56) for clinical malaria. There was a decline in both RDT-positivity and clinical malaria over time in both arms. The difference by treatment assignment was not significant for clinical malaria; it was significant for RDT-positivity with greater odds of decline in the placebo arm (p = 0.01). Conclusions Lack of evidence for a significant difference in the prevalence of clinical malaria in children at any visit following treatment suggests that the effect of single-dose azithromycin on malaria is at best transient and limited in scope. Chance overrepresentation of non-seasonal transmission in the communities in the azithromycin arm may account for higher rates of RDT-positivity and less decline over time. Trial registration Clinicaltrials.gov NCT02047981
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Affiliation(s)
- Evan M Bloch
- Department of Pathology, Johns Hopkins School of Medicine, 600 N. Wolfe St/Carnegie 446 D1, Baltimore, MD, 21287, USA.
| | - Beatriz Munoz
- Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Zakayo Mrango
- National Institute for Medical Research, Kilosa, Tanzania
| | - Jerusha Weaver
- Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Tom M Lietman
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - David J Sullivan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sheila K West
- Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Affiliation(s)
- Naor Bar-Zeev
- From the International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - William J Moss
- From the International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore
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Biannual mass azithromycin distributions and malaria parasitemia in pre-school children in Niger: A cluster-randomized, placebo-controlled trial. PLoS Med 2019; 16:e1002835. [PMID: 31237871 PMCID: PMC6592520 DOI: 10.1371/journal.pmed.1002835] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/21/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Mass azithromycin distributions have been shown to reduce mortality in preschool children, although the factors mediating this mortality reduction are not clear. This study was performed to determine whether mass distribution of azithromycin, which has modest antimalarial activity, reduces the community burden of malaria. METHODS AND FINDINGS In a cluster-randomized trial conducted from 23 November 2014 until 31 July 2017, 30 rural communities in Niger were randomized to 2 years of biannual mass distributions of either azithromycin (20 mg/kg oral suspension) or placebo to children aged 1 to 59 months. Participants, field staff, and investigators were masked to treatment allocation. The primary malaria outcome was the community prevalence of parasitemia on thick blood smear, assessed in a random sample of children from each community at study visits 12 and 24 months after randomization. Analyses were performed in an intention-to-treat fashion. At the baseline visit, a total of 1,695 children were enumerated in the 15 azithromycin communities, and 3,029 children were enumerated in the 15 placebo communities. No communities were lost to follow-up. The mean prevalence of malaria parasitemia at baseline was 8.9% (95% CI 5.1%-15.7%; 52 of 552 children across all communities) in the azithromycin-treated group and 6.7% (95% CI 4.0%-12.6%; 36 of 542 children across all communities) in the placebo-treated group. In the prespecified primary analysis, parasitemia was lower in the azithromycin-treated group at month 12 (mean prevalence 8.8%, 95% CI 5.1%-14.3%; 51 of 551 children across all communities) and month 24 (mean 3.5%, 95% CI 1.9%-5.5%; 21 of 567 children across all communities) than it was in the placebo-treated group at month 12 (mean 15.3%, 95% CI 10.8%-20.6%; 81 of 548 children across all communities) and month 24 (mean 4.8%, 95% CI 3.3%-6.4%; 28 of 592 children across all communities) (P = 0.02). Communities treated with azithromycin had approximately half the odds of parasitemia compared to those treated with placebo (odds ratio [OR] 0.54, 95% CI 0.30 to 0.97). Parasite density was lower in the azithromycin group than the placebo group at 12 and 24 months (square root-transformed outcome; density estimates were 7,540 parasites/μl lower [95% CI -350 to -12,550 parasites/μl; P = 0.02] at a mean parasite density of 17,000, as was observed in the placebo arm). No significant difference in hemoglobin was observed between the 2 treatment groups at 12 and 24 months (mean 0.34 g/dL higher in the azithromycin arm, 95% CI -0.06 to 0.75 g/dL; P = 0.10). No serious adverse events were reported in either group, and among children aged 1 to 5 months, the most commonly reported nonserious adverse events (i.e., diarrhea, vomiting, and rash) were less common in the azithromycin-treated communities. Limitations of the trial include the timing of the treatments and monitoring visits, both of which took place before the peak malaria season, as well as the uncertain generalizability to areas with different malaria transmission dynamics. CONCLUSIONS Mass azithromycin distributions were associated with a reduced prevalence of malaria parasitemia in this trial, suggesting one possible mechanism for the mortality benefit observed with this intervention. TRIAL REGISTRATION The trial was registered on ClinicalTrials.gov (NCT02048007).
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