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Hart JD, Samikwa L, Meleke H, Burr SE, Cornick J, Kalua K, Bailey RL. Prevalence of nasopharyngeal Streptococcus pneumoniae carriage and resistance to macrolides in the setting of azithromycin mass drug administration: analysis from a cluster-randomised controlled trial in Malawi, 2015–17. THE LANCET MICROBE 2022; 3:e142-e150. [PMID: 35156069 PMCID: PMC8819720 DOI: 10.1016/s2666-5247(21)00279-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Azithromycin mass drug administration (MDA) could reduce child mortality. However, macrolide resistance, which has generally been reported to develop after whole-community MDA for trachoma control, is a concern, and it has less commonly been studied in the context of treating children to reduce mortality. Here, we report on macrolide resistance after biannual azithromycin MDA at the Malawi site of the MORDOR study. Methods In the MORDOR cluster-randomised trial in Malawi, 30 communities in Mangochi District were randomly selected. Communities were randomly assigned to receive azithromycin or placebo by simple randomisation without stratification. Children aged 1–59 months were administered azithromycin 20 mg/kg or placebo as an oral suspension biannually for a total of four treatments in 2015–17. 1200 children (40 children per community) were randomly selected for nasopharyngeal swabs at baseline, 12 months (6 months after the second treatment visit), and 24 months (6 months after the fourth treatment visit). Samples were processed to culture Streptococcus pneumoniae. The primary outcome was the proportion of S pneumoniae isolates exhibiting macrolide resistance at 12 months and 24 months, assessed in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT02048007. Findings At baseline, 3467 (76%) of 4541 eligible children in the azithromycin group and 3107 (72%) of 4308 eligible children in the placebo group were treated. 564 nasopharyngeal swabs were taken from the azithromycin group and 563 from the placebo group, with similar numbers of swabs taken at 12 months and 24 months. In both groups at baseline, carriage of S pneumoniae was greater than 85% and the proportion of strains resistant to macrolides was 28%. At the 12-month follow-up, macrolide resistance was higher in the azithromycin group (36·9%, 95% CI 32·5–41·2) than in the placebo group (21·6%, 17·7–25·4; OR 2·26, 95% CI 1·46–3·49; p=0·0002). At 24 months, macrolide resistance remained higher in the azithromycin group (43·9%, 39·2–48·5) compared with placebo (32·8%, 28·5–37·1; OR 1·66, 1·15–2·40; p=0·0069). Interpretation These findings support previous evidence from trachoma MDA programmes and suggest that monitoring of macrolide resistance should remain a key component of azithromycin interventions for reducing child mortality. Funding Bill & Melinda Gates Foundation.
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Seleem MA, Wood NA, Brinkworth AJ, Manam S, Carabeo RA, Murthy AK, Ouellette SP, Conda-Sheridan M. In Vitro and In Vivo Activity of (Trifluoromethyl)pyridines as Anti- Chlamydia trachomatis Agents. ACS Infect Dis 2022; 8:227-241. [PMID: 34935346 PMCID: PMC9516413 DOI: 10.1021/acsinfecdis.1c00553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Chlamydia trachomatis is the leading pathogen in sexually transmitted bacterial infections across the globe. The development of a selective treatment against this pathogen could be an attractive therapeutic option that will reduce the overuse of broad-spectrum antibiotics. Previously, we reported some sulfonylpyridine-based compounds that showed selectivity against C. trachomatis. Here, we describe a set of related compounds that display enhanced anti-chlamydial potency when compared to our early leads. We found that the active molecules are bactericidal and have no impact on Staphylococcus aureus or Escherichia coli strains. Importantly, the molecules were not toxic to mammalian cells. Furthermore, a combination of molecule 20 (the most active molecule) and azithromycin at subinhibitory concentrations acted synergistically to inhibit chlamydial growth. Molecule 20 also eradicated Chlamydia in a 3D infection model and accelerated the recovery of Chlamydia-infected mice. This work presents compounds that could be further developed to be used alone or in combination with existing treatment regimens against chlamydial infections.
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Affiliation(s)
- Mohamed A. Seleem
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198, United States
| | - Nicholas A. Wood
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198, United States
| | - Amanda J. Brinkworth
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198, United States
| | - Srikanth Manam
- Department of Pathology and Population Medicine, Midwestern University, Glendale, Arizona 85308, United States
| | - Rey A. Carabeo
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198, United States
| | - Ashlesh K. Murthy
- Department of Pathology and Population Medicine, Midwestern University, Glendale, Arizona 85308, United States
| | - Scot P. Ouellette
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198, United States
| | - Martin Conda-Sheridan
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198, United States
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3
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Borel N, Sauer-Durand AM, Hartel M, Kuratli J, Vaupel P, Scherr N, Pluschke G. wIRA: hyperthermia as a treatment option for intracellular bacteria, with special focus on Chlamydiae and Mycobacteria. Int J Hyperthermia 2020; 37:373-383. [PMID: 32319834 DOI: 10.1080/02656736.2020.1751312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The emergence of antibiotic-resistant bacteria in the last century is alarming and calls for alternative, nonchemical treatment strategies. Thermal medicine uses heat for the treatment of infectious diseases but its use in facultative and obligate intracellular bacteria remains poorly studied. In this review, we summarize previous research on reducing the infectious burden of Mycobacterium ulcerans and Chlamydia trachomatis by using water-filtered infrared A-radiation (wIRA), a special form of heat radiation with high tissue penetration and low thermal load on the skin surface. Mycobacterium ulcerans is a thermosensitive bacterium causing chronic necrotizing skin disease. Therefore, previous data on wIRA-induced improvement of wound healing and reduction of wound infections is summarized first. Then, pathogenesis and treatment of infections with M. ulcerans causing Buruli ulcer and of those with C. trachomatis infecting the ocular conjunctiva and resulting in blinding trachoma are discussed. Both bacteria cause neglected tropical diseases and have similar geographical distributions. Results of previous in vitro and in vivo studies using wIRA on M. ulcerans and C. trachomatis infections are presented. Finally, technical aspects of using wIRA in patients are critically reviewed and open questions driving future research are highlighted. In conclusion, wIRA is a promising tool for reducing infectious burden due to intracellular bacteria such as M. ulcerans and C. trachomatis.
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Affiliation(s)
- Nicole Borel
- Infection Pathology Unit, Department of Pathobiology, Vetsuisse Faculty and Center for Applied Biotechnology and Molecular Medicine (CABMM), Institute of Veterinary Pathology, University of Zurich, Zurich, Switzerland
| | | | - Mark Hartel
- Clinic for Visceral Surgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jasmin Kuratli
- Infection Pathology Unit, Department of Pathobiology, Vetsuisse Faculty and Center for Applied Biotechnology and Molecular Medicine (CABMM), Institute of Veterinary Pathology, University of Zurich, Zurich, Switzerland
| | - Peter Vaupel
- Department of Radiation Oncology, Medical Center, University of Freiburg, Freiburg i.B, Germany
| | - Nicole Scherr
- Molecular Immunology Unit, Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Gerd Pluschke
- Molecular Immunology Unit, Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland
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Gupta H, Galatas B, Chidimatembue A, Huijben S, Cisteró P, Matambisso G, Nhamussua L, Simone W, Bassat Q, Ménard D, Ringwald P, Rabinovich NR, Alonso PL, Saúte F, Aide P, Mayor A. Effect of mass dihydroartemisinin-piperaquine administration in southern Mozambique on the carriage of molecular markers of antimalarial resistance. PLoS One 2020; 15:e0240174. [PMID: 33075062 PMCID: PMC7571678 DOI: 10.1371/journal.pone.0240174] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/21/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mass drug administration (MDA) can rapidly reduce the burden of Plasmodium falciparum (Pf). However, concerns remain about its contribution to select for antimalarial drug resistance. METHODS We used Sanger sequencing and real-time PCR to determine the proportion of molecular markers associated with antimalarial resistance (k13, pfpm2, pfmdr1 and pfcrt) in Pf isolates collected before (n = 99) and after (n = 112) the implementation of two monthly MDA rounds with dihydroartemisinin-piperaquine (DHAp) for two consecutive years in Magude district of Southern Mozambique. RESULTS None of the k13 polymorphisms associated with artemisinin resistance were observed in the Pf isolates analyzed. The proportion of Pf isolates with multiple copies of pfpm2, an amplification associated with piperaquine resistance, was similar in pre- (4.9%) and post-MDA groups (3.4%; p = 1.000). No statistically significant differences were observed between pre- and post-MDA groups in the proportion of Pf isolates neither with mutations in pfcrt and pfmdr1 genes, nor with the carriage of pfmdr1 multiple copies (p>0.05). CONCLUSIONS This study does not show any evidence of increased frequency of molecular makers of antimalarial resistance after MDA with DHAp in southern Mozambique where markers of antimalarial resistance were absent or low at the beginning of the intervention.
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Affiliation(s)
- Himanshu Gupta
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Beatriz Galatas
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | | | - Silvie Huijben
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Pau Cisteró
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | | | - Lidia Nhamussua
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Wilson Simone
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Quique Bassat
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
- ICREA, Pg. Lluís Companys, Barcelona, Spain
- Spanish Consortium for Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
| | - Didier Ménard
- Institut Pasteur, Paris, France
- INSERM U1201, Paris, France
- CNRS ERL9195, Paris, France
| | - Pascal Ringwald
- World Health Organization (WHO), Global Malaria Programme, Geneva, Switzerland
| | - N. Regina Rabinovich
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Pedro L. Alonso
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Francisco Saúte
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Pedro Aide
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
- National Institute of Health, Ministry of Health, Manhica, Mozambique
| | - Alfredo Mayor
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
- ICREA, Pg. Lluís Companys, Barcelona, Spain
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5
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Gladstone RA, Bojang E, Hart J, Harding-Esch EM, Mabey D, Sillah A, Bailey RL, Burr SE, Roca A, Bentley SD, Holland MJ. Mass drug administration with azithromycin for trachoma elimination and the population structure of Streptococcus pneumoniae in the nasopharynx. Clin Microbiol Infect 2020; 27:864-870. [PMID: 32750538 PMCID: PMC8203556 DOI: 10.1016/j.cmi.2020.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/23/2020] [Accepted: 07/25/2020] [Indexed: 11/18/2022]
Abstract
Objective Mass drug administration (MDA) with azithromycin for trachoma elimination reduces nasopharyngeal carriage of Streptococcus pneumoniae in the short term. We evaluated S. pneumoniae carried in the nasopharynx before and after a round of azithromycin MDA to determine whether MDA was associated with changes in pneumococcal population structure and resistance. Methods We analysed 514 pneumococcal whole genomes randomly selected from nasopharyngeal samples collected in two Gambian villages that received three annual rounds of MDA for trachoma elimination. The 514 samples represented 293 participants, of which 75% were children aged 0–9 years, isolated during three cross-sectional surveys (CSSs) conducted before the third round of MDA (CSS-1) and at 1 (CSS-2) and 6 (CSS-3) months after MDA. Bayesian Analysis of Population Structure (BAPS) was used to cluster related isolates by capturing variation in the core genome. Serotype and multilocus sequence type were inferred from the genotype. Antimicrobial resistance determinants were identified from assemblies, including known macrolide resistance genes. Results Twenty-seven BAPS clusters were assigned. These consisted of 81 sequence types (STs). Two BAPS clusters not observed in CSS-1 (n = 109) or CSS-2 (n = 69), increased in frequency in CSS-3 (n = 126); BAPS20 (8.73%, p 0.016) and BAPS22 (7.14%, p 0.032) but were not associated with antimicrobial resistance. Macrolide resistance within BAPS17 increased after treatment (CSS-1 n = 0/6, CSS-2/3 n = 5/5, p 0.002) and was carried on a mobile transposable element that also conferred resistance to tetracycline. Discussion Limited changes in pneumococcal population structure were observed after the third round of MDA, suggesting treatment had little effect on the circulating lineages. An increase in macrolide resistance within one BAPS highlights the need for antimicrobial resistance surveillance in treated villages.
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Affiliation(s)
| | - Ebrima Bojang
- Medical Research Council Unit The Gambia at LSHTM, Fajara, Banjul, Gambia
| | - John Hart
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | | | - David Mabey
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Ansumana Sillah
- National Eye Health Programme, Ministry of Health and Social Welfare, Kanifing, Gambia
| | - Robin L Bailey
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Sarah E Burr
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Anna Roca
- Medical Research Council Unit The Gambia at LSHTM, Fajara, Banjul, Gambia; London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | | | - Martin J Holland
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK.
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6
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Ansah D, Weaver J, Munoz B, Bloch EM, Coles CL, Lietman T, West SK. A Cross-Sectional Study of the Availability of Azithromycin in Local Pharmacies and Associated Antibiotic Resistance in Communities in Kilosa District, Tanzania. Am J Trop Med Hyg 2020; 100:1105-1109. [PMID: 30915951 DOI: 10.4269/ajtmh.18-0747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Mass drug administration (MDA) for trachoma control using azithromycin has generated concern for the development of resistant organisms. However, the contribution from azithromycin available in local pharmacies has not been studied. In Kilosa district, Tanzania, MDA stopped over 4 years ago, and this study sought to determine the availability of azithromycin in local pharmacies and correlate it with azithromycin resistance in children born after MDA. A cross-sectional survey was conducted in 644 randomly selected hamlets in Kilosa district, in which the presence of a pharmacy and the availability of azithromycin and erythromycin were determined. In 30 randomly selected hamlets, a random sample of 60 children less than 5 years were tested for azithromycin-resistant Streptococcus pneumoniae (Spn) and Escherichia coli (Ec), from nasopharyngeal and rectal swabs, based on disk diffusion criteria. Only 26.6% of hamlets had a pharmacy. Azithromycin and erythromycin were available in 30.8% and 89.1% of pharmacies closest to the hamlets, respectively. In the 30 communities tested for resistance, the overall prevalence of azithromycin-resistant Spn isolates was 14%. Six of seven (87%) hamlets where azithromycin was available had resistant Spn, compared with 14 of 23 (61%) hamlets without availability. Similarly, six of seven (87%) hamlets where azithromycin was available had resistant Ec isolates compared with 21 of 23 (70%) hamlets without availability. However, the differences were not statistically significant (P = 0.46 and 0.49, respectively). The availability of azithromycin in pharmacies in the district was limited, and a strong correlation with azithromycin-resistant Spn or Ec was not observed.
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Affiliation(s)
- Derick Ansah
- Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jerusha Weaver
- Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Beatriz Munoz
- Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christian L Coles
- Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Thomas Lietman
- Proctor Foundation, University of California San Francisco, San Francisco, California
| | - Sheila K West
- Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland
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7
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Bojang A, Camara B, Jagne Cox I, Oluwalana C, Lette K, Usuf E, Bottomley C, Howden BP, D'Alessandro U, Roca A. Long-term Impact of Oral Azithromycin Taken by Gambian Women During Labor on Prevalence and Antibiotic Susceptibility of Streptococcus pneumoniae and Staphylococcus aureus in Their Infants: Follow-up of a Randomized Clinical Trial. Clin Infect Dis 2019; 67:1191-1197. [PMID: 29608659 PMCID: PMC6160601 DOI: 10.1093/cid/ciy254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/27/2018] [Indexed: 11/14/2022] Open
Abstract
Background Oral azithromycin given to women in labor decreases maternal and neonatal bacterial carriage but increases azithromycin-resistant bacteria during at least 4 weeks following the intervention. We assessed the prevalence of bacterial carriage and azithromycin resistance 12 months after treatment among study infants. Methods Nasopharyngeal swabs (NPSs) were collected between November 2014 and May 2015 from children aged 11-13 months whose mothers had received azithromycin or placebo during labor. Streptococcus pneumoniae and Staphylococcus aureus were isolated using conventional microbiological methods. Antibiotic susceptibility was determined by disk diffusion and confirmed by Etest or VITEK-2. Results NPSs were collected from 461 children. The prevalence of S. pneumoniae and S. aureus was similar between children from the azithromycin and placebo arms (85.0% vs 82.1%; odds ratio [OR], 1.23 [95% confidence interval {CI}, .73-2.08] for S. pneumoniae and 21.7% vs 21.3%; OR, 1.02 [95% CI, .64-1.64] for S. aureus). Prevalence of azithromycin-resistant S. pneumoniae was similar in both arms (1.8% vs 0.9% in children from the azithromycin and placebo arms, respectively; OR, 2.10 [95% CI, .30-23.38]); resistance to other antibiotics was also similar between arms. For S. aureus, there was no difference in azithromycin resistance between children in the azithromycin (3.1%) and placebo (2.6%) arms (OR, 1.22 [95% CI, .35-4.47]) or resistance to any other antibiotics. Conclusions The higher prevalence of S. aureus azithromycin resistance observed among women treated during labor and their babies 4 weeks after treatment had waned 12 months after delivery. Azithromycin intervention did not induce other antibiotic resistance to S. pneumoniae or S. aureus. Clinical Trials Registration NCT01800942.
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Affiliation(s)
- Abdoulie Bojang
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara
| | - Bully Camara
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara
| | - Isatou Jagne Cox
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara
| | - Claire Oluwalana
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara
| | - Kodou Lette
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara
| | - Effua Usuf
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Christian Bottomley
- Medical Research Council Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Benjamin P Howden
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, University of Melbourne, Doherty Institute for Infection and Immunity, Victoria, Australia
| | - Umberto D'Alessandro
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom.,Institute of Tropical Medicine, Antwerp, Belgium
| | - Anna Roca
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, United Kingdom
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8
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Keenan JD, Arzika AM, Maliki R, Boubacar N, Elh Adamou S, Moussa Ali M, Cook C, Lebas E, Lin Y, Ray KJ, O’Brien KS, Doan T, Oldenburg CE, Callahan EK, Emerson PM, Porco TC, Lietman TM. Longer-Term Assessment of Azithromycin for Reducing Childhood Mortality in Africa. N Engl J Med 2019; 380:2207-2214. [PMID: 31167050 PMCID: PMC6512890 DOI: 10.1056/nejmoa1817213] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The MORDOR I trial (Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance) showed that in Niger, mass administration of azithromycin twice a year for 2 years resulted in 18% lower postneonatal childhood mortality than administration of placebo. Whether this benefit could increase with each administration or wane owing to antibiotic resistance was unknown. METHODS In the Niger component of the MORDOR I trial, we randomly assigned 594 communities to four twice-yearly distributions of either azithromycin or placebo to children 1 to 59 months of age. In MORDOR II, all these communities received two additional open-label azithromycin distributions. All-cause mortality was assessed twice yearly by census workers who were unaware of participants' original assignments. RESULTS In the MORDOR II trial, the mean (±SD) azithromycin coverage was 91.3±7.2% in the communities that received twice-yearly azithromycin for the first time (i.e., had received placebo for 2 years in MORDOR I) and 92.0±6.6% in communities that received azithromycin for the third year (i.e., had received azithromycin for 2 years in MORDOR I). In MORDOR II, mortality was 24.0 per 1000 person-years (95% confidence interval [CI], 22.1 to 26.3) in communities that had originally received placebo in the first year and 23.3 per 1000 person-years (95% CI, 21.4 to 25.5) in those that had originally received azithromycin in the first year, with no significant difference between groups (P = 0.55). In communities that had originally received placebo, mortality decreased by 13.3% (95% CI, 5.8 to 20.2) when the communities received azithromycin (P = 0.007). In communities that had originally received azithromycin and continued receiving it for an additional year, the difference in mortality between the third year and the first 2 years was not significant (-3.6%; 95% CI, -12.3 to 4.5; P = 0.50). CONCLUSIONS We found no evidence that the effect of mass administration of azithromycin on childhood mortality in Niger waned in the third year of treatment. Childhood mortality decreased when communities that had originally received placebo received azithromycin. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT02047981.).
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Affiliation(s)
- Jeremy D. Keenan
- Francis I Proctor Foundation, UCSF; Department of Ophthalmology, UCSF
| | | | | | | | | | | | | | | | - Ying Lin
- Francis I Proctor Foundation, UCSF
| | - Kathryn J. Ray
- Francis I Proctor Foundation, UCSF; Department of Epidemiology and
Biostatistics, UCSF
| | - Kieran S. O’Brien
- Francis I Proctor Foundation, UCSF; The University of California, Berkeley
School of Public Health
| | - Thuy Doan
- Francis I Proctor Foundation, UCSF; Department of Ophthalmology, UCSF
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, UCSF; Department of Ophthalmology, UCSF;
Department of Epidemiology and Biostatistics, UCSF; Institute for Global
Health Sciences, UCSF
| | | | | | - Travis C. Porco
- Francis I Proctor Foundation, UCSF; Department of Ophthalmology, UCSF;
Department of Epidemiology and Biostatistics, UCSF
| | - Thomas M. Lietman
- Corresponding Author Thomas M. Lietman, , 513 Parnassus Ave.,
Medical Sciences Building, Room S309, UCSF, San Francisco, CA 94143-0944
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9
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Tam CC, Offeddu V, Lim JM, Voo TC. One drug to treat them all: ethical implications of the MORDOR trial of mass antibiotic administration to reduce child mortality. J Glob Health 2019; 9:010305. [PMID: 30643634 PMCID: PMC6318831 DOI: 10.7189/jogh.09.010305] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Clarence C Tam
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Vittoria Offeddu
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Jane Mingjie Lim
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Teck Chuan Voo
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
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10
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Berkley JA. Mass antibiotic distribution to reduce mortality among preschool children? Arch Dis Child 2019; 104:227-228. [PMID: 30217861 PMCID: PMC7613555 DOI: 10.1136/archdischild-2018-315451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/13/2018] [Indexed: 11/03/2022]
Affiliation(s)
- James Alexander Berkley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
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O'Brien KS, Emerson P, Hooper PJ, Reingold AL, Dennis EG, Keenan JD, Lietman TM, Oldenburg CE. Antimicrobial resistance following mass azithromycin distribution for trachoma: a systematic review. THE LANCET. INFECTIOUS DISEASES 2019; 19:e14-e25. [PMID: 30292480 DOI: 10.1016/s1473-3099(18)30444-4] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/21/2018] [Accepted: 07/10/2018] [Indexed: 01/12/2023]
Abstract
Mass azithromycin distribution is a core component of trachoma control programmes and could reduce mortality in children younger than 5 years in some settings. In this systematic review we synthesise evidence on the emergence of antimicrobial resistance after mass azithromycin distribution. We searched electronic databases for publications up to June 14, 2018. We included studies of any type (excluding modelling studies, surveillance reports, and review articles) on community-wide distribution of oral azithromycin for the prevention and treatment of trachoma that assessed macrolide resistance, without restrictions to the type of organism. We extracted prevalence of resistance from published reports and requested unpublished data from authors of included studies. Of 213 identified studies, 19 met inclusion criteria (12 assessed Streptococcus pneumoniae) and were used for qualitative synthesis. Macrolide resistance after azithromycin distribution was reported in three of the five organisms studied. The lack of resistance in Chlamydia trachomatis suggests that azithromycin might remain effective for trachoma programmes, but evidence is scarce. As mass azithromycin distribution for trachoma continues and is considered for other indications, ongoing monitoring of antimicrobial resistance will be required.
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Affiliation(s)
- Kieran S O'Brien
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA; Division of Epidemiology, University of California, Berkeley, CA, USA
| | - Paul Emerson
- International Trachoma Initiative, Decatur, GA, USA
| | - P J Hooper
- International Trachoma Initiative, Decatur, GA, USA
| | - Arthur L Reingold
- Division of Epidemiology, University of California, Berkeley, CA, USA
| | - Elena G Dennis
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - Jeremy D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA; Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Thomas 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 & Biostatistics, University of California, San Francisco, CA, USA
| | - Catherine E Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA.
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Kuratli J, Pesch T, Marti H, Leonard CA, Blenn C, Torgerson P, Borel N. Water Filtered Infrared A and Visible Light (wIRA/VIS) Irradiation Reduces Chlamydia trachomatis Infectivity Independent of Targeted Cytokine Inhibition. Front Microbiol 2018; 9:2757. [PMID: 30524392 PMCID: PMC6262300 DOI: 10.3389/fmicb.2018.02757] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/29/2018] [Indexed: 11/13/2022] Open
Abstract
Chlamydia trachomatis is the major cause of infectious blindness and represents the most common bacterial sexually transmitted infection worldwide. Considering the potential side effects of antibiotic therapy and increasing threat of antibiotic resistance, alternative therapeutic strategies are needed. Previous studies showed that water filtered infrared A alone (wIRA) or in combination with visible light (wIRA/VIS) reduced C. trachomatis infectivity. Furthermore, wIRA/VIS irradiation led to secretion of pro-inflammatory cytokines similar to that observed upon C. trachomatis infection. We confirmed the results of previous studies, namely that cytokine secretion (IL-6, IL-8, and RANTES/CCL5) upon wIRA/VIS treatment, and the subsequent reduction of chlamydial infectivity, are independent of the addition of cycloheximide, a host protein synthesis inhibitor. Reproducible cytokine release upon irradiation indicated that cytokines might be involved in the anti-chlamydial mechanism of wIRA/VIS. This hypothesis was tested by inhibiting IL-6, IL-8, and RANTES secretion in C. trachomatis or mock-infected cells by gene silencing or pharmaceutical inhibition. Celastrol, a substance derived from Trypterygium wilfordii, used in traditional Chinese medicine and known for anti-cancer and anti-inflammatory effects, was used for IL-6 and IL-8 inhibition, while Maraviroc, a competitive CCR5 antagonist and anti-HIV drug, served as a RANTES/CCL5 inhibitor. HeLa cell cytotoxicity and impact on chlamydial morphology, size and inclusion number was evaluated upon increasing inhibitor concentration, and concentrations of 0.1 and 1 μM Celastrol and 10 and 20 μM Maraviroc were subsequently selected for irradiation experiments. Celastrol at any concentration reduced chlamydial infectivity, an effect only observed for 20 μM Maraviroc. Triple dose irradiation (24, 36, 40 hpi) significantly reduced chlamydial infectivity regardless of IL-6, IL-8, or RANTES/CCL5 gene silencing, Celastrol or Maraviroc treatment. Neither gene silencing nor pharmaceutical cytokine inhibition provoked the chlamydial stress response. The anti-chlamydial effect of wIRA/VIS is independent of cytokine inhibition under all conditions evaluated. Thus, factors other than host cell cytokines must be involved in the working mechanism of wIRA/VIS. This study gives a first insight into the working mechanism of wIRA/VIS in relation to an integral component of the host immune system and supports the potential of wIRA/VIS as a promising new tool for treatment in trachoma.
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Affiliation(s)
- Jasmin Kuratli
- Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Theresa Pesch
- Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Hanna Marti
- Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Cory Ann Leonard
- Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Christian Blenn
- Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Paul Torgerson
- Section of Veterinary Epidemiology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Nicole Borel
- Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
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Childhood Mortality After Mass Distribution of Azithromycin: A Secondary Analysis of the PRET Cluster-randomized Trial in Niger. Pediatr Infect Dis J 2018; 37:1082-1086. [PMID: 29561511 PMCID: PMC6138579 DOI: 10.1097/inf.0000000000001992] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mass distributions of azithromycin for trachoma have been associated with secondary benefits, including reductions in child mortality. METHODS In the Partnership for the Rapid Elimination of Trachoma cluster-randomized trial in Niger, 24 communities were randomized to annual treatment of everyone and 24 communities were randomized to biannual treatment of children under 12 for 3 years (clinicaltrials.gov, NCT00792922). Treatment was a single dose of directly observed oral azithromycin (20 mg/kg up to 1 g in adults). Vital status was assessed during annual census and monitoring visits. In this prespecified secondary analysis, we compared the mortality rate among children 6 months to less than 5 years of age by treatment arm using negative binomial regression. RESULTS Among children 6 months to less than 5 years of age, 404 deaths occurred during the study period. The mortality rate was 35.6 deaths per 1000 person-years (231 deaths, 95% CI: 30.9-40.9) in the annual arm and 29.0 deaths per 1000 person-years (173 deaths, 95% CI: 24.8-33.8) in the biannual arm. The mortality rate ratio comparing children in the biannual arm to the annual arm was 0.81 (95% CI: 0.66-1.00, P = 0.07; primary outcome). The mortality rate ratio comparing children who died from infectious causes in the biannual arm to the annual arm was 0.73 (95% CI: 0.57-0.94; P = 0.02). No adverse events were reported. CONCLUSIONS This secondary analysis of a cluster-randomized trial found a nonsignificant 19% decrease in mortality among children 6 months to less than 5 years of age who received biannual azithromycin compared with children who received annual azithromycin. This study was conducted in a high mortality, trachoma-endemic area; thus, results may be specific to this environment only. In addition, the trial was neither designed nor powered to detect a mortality effect, and we cannot rule out the possibility that mortality differences resulted from bias.
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Keenan JD, Bailey RL, West SK, Arzika AM, Hart J, Weaver J, Kalua K, Mrango Z, Ray KJ, Cook C, Lebas E, O'Brien KS, Emerson PM, Porco TC, Leitman TM. Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa. N Engl J Med 2018; 378:1583-1592. [PMID: 29694816 PMCID: PMC5849140 DOI: 10.1056/nejmoa1715474] [Citation(s) in RCA: 240] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We hypothesized that mass distribution of a broad-spectrum antibiotic agent to preschool children would reduce mortality in areas of sub-Saharan Africa that are currently far from meeting the Sustainable Development Goals of the United Nations. METHODS In this cluster-randomized trial, we assigned communities in Malawi, Niger, and Tanzania to four twice-yearly mass distributions of either oral azithromycin (approximately 20 mg per kilogram of body weight) or placebo. Children 1 to 59 months of age were identified in twice-yearly censuses and were offered participation in the trial. Vital status was determined at subsequent censuses. The primary outcome was aggregate all-cause mortality; country-specific rates were assessed in prespecified subgroup analyses. RESULTS A total of 1533 communities underwent randomization, 190,238 children were identified in the census at baseline, and 323,302 person-years were monitored. The mean (±SD) azithromycin and placebo coverage over the four twice-yearly distributions was 90.4±10.4%. The overall annual mortality rate was 14.6 deaths per 1000 person-years in communities that received azithromycin (9.1 in Malawi, 22.5 in Niger, and 5.4 in Tanzania) and 16.5 deaths per 1000 person-years in communities that received placebo (9.6 in Malawi, 27.5 in Niger, and 5.5 in Tanzania). Mortality was 13.5% lower overall (95% confidence interval [CI], 6.7 to 19.8) in communities that received azithromycin than in communities that received placebo (P<0.001); the rate was 5.7% lower in Malawi (95% CI, -9.7 to 18.9), 18.1% lower in Niger (95% CI, 10.0 to 25.5), and 3.4% lower in Tanzania (95% CI, -21.2 to 23.0). Children in the age group of 1 to 5 months had the greatest effect from azithromycin (24.9% lower mortality than that with placebo; 95% CI, 10.6 to 37.0). Serious adverse events occurring within a week after administration of the trial drug or placebo were uncommon, and the rate did not differ significantly between the groups. Evaluation of selection for antibiotic resistance is ongoing. CONCLUSIONS Among postneonatal, preschool children in sub-Saharan Africa, childhood mortality was lower in communities randomly assigned to mass distribution of azithromycin than in those assigned to placebo, with the largest effect seen in Niger. Any implementation of a policy of mass distribution would need to strongly consider the potential effect of such a strategy on antibiotic resistance. (Funded by the Bill and Melinda Gates Foundation; MORDOR ClinicalTrials.gov number, NCT02047981 .).
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Affiliation(s)
- Jeremy D Keenan
- Francis I Proctor Foundation, UCSF
- Department of Ophthalmology, UCSF
| | | | - Sheila K West
- The Dana Center, Johns Hopkins University School of
Medicine
| | | | - John Hart
- London School of Hygiene & Tropical
Medicine
| | - Jerusha Weaver
- The Dana Center, Johns Hopkins University School of
Medicine
| | - Khumbo Kalua
- Blantyre Institute for Community Outreach, Blantyre,
Malawi
- College of Medicine, University of Malawi, Blantyre,
Malawi
| | | | | | | | | | | | | | - Travis C Porco
- Francis I Proctor Foundation, UCSF
- Department of Ophthalmology, UCSF
- Department of Epidemiology and Biostatistics,
UCSF
- Institute for Global Health Sciences, UCSF
| | - Thomas M Leitman
- Francis I Proctor Foundation, UCSF
- Department of Ophthalmology, UCSF
- Department of Epidemiology and Biostatistics,
UCSF
- Institute for Global Health Sciences, UCSF
- Corresponding Author. Thomas M. Lietman,
, 513 Parnassus Ave., Medical Sciences
Building, Room S309, UCSF, San Francisco, CA 904143-0944
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Aqeel Y, Rodriguez R, Chatterjee A, Ingalls RR, Samuelson J. Killing of diverse eye pathogens (Acanthamoeba spp., Fusarium solani, and Chlamydia trachomatis) with alcohols. PLoS Negl Trop Dis 2017; 11:e0005382. [PMID: 28182670 PMCID: PMC5321442 DOI: 10.1371/journal.pntd.0005382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 02/22/2017] [Accepted: 02/02/2017] [Indexed: 12/18/2022] Open
Abstract
Background Blindness is caused by eye pathogens that include a free-living protist (Acanthamoeba castellanii, A. byersi, and/or other Acanthamoeba spp.), a fungus (Fusarium solani), and a bacterium (Chlamydia trachomatis). Hand-eye contact is likely a contributor to the spread of these pathogens, and so hand washing with soap and water or alcohol–based hand sanitizers (when water is not available) might reduce their transmission. Recently we showed that ethanol and isopropanol in concentrations present in hand sanitizers kill walled cysts of Giardia and Entamoeba, causes of diarrhea and dysentery, respectively. The goal here was to determine whether these alcohols might kill infectious forms of representative eye pathogens (trophozoites and cysts of Acanthamoeba, conidia of F. solani, or elementary bodies of C. trachomatis). Methodology/Principal findings We found that treatment with 63% ethanol or 63% isopropanol kills >99% of Acanthamoeba trophozoites after 30 sec exposure, as shown by labeling with propidium iodide (PI) and failure to grow in culture. In contrast, Acanthamoeba cysts, which contain cellulose fibers in their wall, are relatively more resistant to these alcohols, particularly isopropanol. Depending upon the strain tested, 80 to 99% of Acanthamoeba cysts were killed by 63% ethanol after 2 min and 95 to 99% were killed by 80% ethanol after 30 sec, as shown by PI labeling and reduced rates of excystation in vitro. Both ethanol and isopropanol (63% for 30 sec) kill >99% of F. solani conidia, which have a wall of chitin and glucan fibrils, as demonstrated by PI labeling and colony counts on nutrient agar plates. Both ethanol and isopropanol (63% for 60 sec) inactivate 96 to 99% of elementary bodies of C. trachomatis, which have a wall of lipopolysaccharide but lack peptidoglycan, as measured by quantitative cultures to calculate inclusion forming units. Conclusions/Significance In summary, alcohols kill infectious forms of Acanthamoeba, F. solani, and C. trachomatis, although longer times and higher ethanol concentrations are necessary for Acanthamoeba cysts. These results suggest the possibility that expanded use of alcohol-based hand sanitizers in places where water is not easily available might reduce transmission of these important causes of blindness. Hand washing with soap and water is an important public health tool for reducing transmission of viruses, bacteria, fungi, and protists. Alcohol-based hand sanitizers, which are widely dispensed in hospitals and public places, kill many of these same pathogens. What is not known is how effectively the alcohol-based hand sanitizers kill protists, fungi, or bacteria that cause eye disease. Here we show ethanol and isopropanol penetrate the walls and kill a free-living protist (Acanthamoeba castellanii, A. byersi, and other Acanthamoeba spp.), and a fungus (Fusarium solani), each of which causes keratitis, as well as a bacterium (Chlamydia trachomatis) that causes trachoma. These results suggest the possible benefit of hand sanitizers in the prevention of these eye pathogens.
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Affiliation(s)
- Yousuf Aqeel
- Department of Molecular and Cell Biology, Boston University Goldman School of Dental Medicine, Boston, Massachusetts, United States of America
| | - Raquel Rodriguez
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
- Department of Microbiology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Aparajita Chatterjee
- Department of Molecular and Cell Biology, Boston University Goldman School of Dental Medicine, Boston, Massachusetts, United States of America
| | - Robin R. Ingalls
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
- Department of Microbiology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - John Samuelson
- Department of Molecular and Cell Biology, Boston University Goldman School of Dental Medicine, Boston, Massachusetts, United States of America
- Department of Microbiology, Boston University School of Medicine, Boston, Massachusetts, United States of America
- * E-mail:
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Opportunities for Integrated Control of Neglected Tropical Diseases That Affect the Skin. Trends Parasitol 2016; 32:843-854. [PMID: 27638231 DOI: 10.1016/j.pt.2016.08.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/04/2016] [Accepted: 08/05/2016] [Indexed: 11/23/2022]
Abstract
Many neglected tropical diseases (NTDs) affect the skin, causing considerable disability, stigma, and exacerbation of poverty. However, there has been relatively little investment into laboratory research, epidemiology, diagnostic tools or management strategies to control tropical skin disease. Integration may advance the control of skin disease across a range of domains, including mapping, diagnosis, clinical management, and community control measures such as mass drug administration. Examples of successful integration strategies include programs targeting scabies, impetigo, yaws, and diseases causing lymphoedema. Future strategies should build on these experiences and the experience of integration of other NTDs, strengthen existing health systems, and contribute toward the attainment of Universal Health Coverage. Strong partnerships and political support and will be necessary to achieve these goals.
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