Mass drug administration of antibacterials: weighing the evidence regarding benefits and risks

Mass Azithromycin Distribution to Prevent Child Mortality in Burkina Faso: The CHAT Randomized Clinical Trial

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.

Temporal Trends in Phenotypic Macrolide and Nonmacrolide Resistance for Streptococcus pneumoniae Nasopharyngeal Samples Up to 36 Months after Mass Azithromycin Administration in a Cluster-Randomized Trial in Niger

Azithromycin mass drug administration decreases child mortality but also selects for antibiotic resistance. Herein, we evaluate macrolide resistance of nasopharyngeal Streptococcus pneumoniae after azithromycin MDA. In a cluster-randomized trial, children 1-59 months received azithromycin or placebo biannually. Fifteen villages from each arm were randomly selected for antimicrobial resistance testing, and 10-15 randomly selected swabs from enrolled children at each village were processed for S. pneumoniae isolation and resistance testing. The primary prespecified outcome was macrolide resistance fraction for azithromycin versus placebo villages at 36 months. Secondary non-prespecified outcomes were comparisons of azithromycin and placebo for: 1) macrolide resistance at 12, 24, and 36 months; 2) nonmacrolide resistance at 36 months; and 3) suspected-erm mutation. At 36 months, 423 swabs were obtained and 322 grew S. pneumoniae, (azithromycin: 146/202, placebo: 176/221). Mean resistance prevalence was non-significantly higher in treatment than placebo (mixed-effects model: 14.6% vs. 8.9%; OR = 2.0, 95% CI: 0.99-3.97). However, when all time points were evaluated, macrolide resistance prevalence was significantly higher in the azithromycin group (β = 0.102, 95% CI: 0.04-0.167). For all nonmacrolides, resistance prevalence at 36 months was not different between the two groups. Azithromycin and placebo were not different for suspected-erm mutation prevalence. Macrolide resistance was higher in the azithromycin group over all time points, but not at 36 months. Although this suggests resistance may not continue to increase after biannual MDA, more studies are needed to clarify when MDA can safely decrease mortality and morbidity in lower- and middle-income countries.

Prevalence of active trachoma infection and associated factors post-war resettled population in raya kobo districts, North East Ethiopia: A community-based cross-sectional study in 2022

Background

Active trachoma infection poses a serious threat to public health, particularly for those who live in an unprivileged area and has practiced open-field defecation. This study aimed to estimate the prevalence of active trachoma infection and associated factors in the post-war resettled population in Raya Kobo district, North East Ethiopia: a community-based cross-sectional study in 2022.

Methods

A community-based cross-sectional study was conducted among 602 participants randomly selected in 14 slum villages in Raya Kobo from February 16th to March 30th, 2023. After the data was collected using a semi-structured questionnaire and entered into Epi-data version 3.2. The study participants were chosen using a two-stage sampling process. Binary logistic regression was used to identify factors for active trachoma infection. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were claimed for the strength of association at p < 0.05.

Results

Overall, 602 (99.9%) study participants were included in the final analysis. At the end of the study period, 126 (20.9) participants developed active trachoma infection. On multivariable analysis, were aged ≥45 years (AOR = 7.9, 95% CI = 2.4-25.3), history of eye infection (AOR = 3.7, 95% CI = 2.4-10.4, p = 0.001), were poor wealth index (AOR = 9.2, 95% CI = 2.7-23.7), having separated kitchen (AOR = 4.05, 95% CI = 1.86-8.86), living with animals (AOR = 5.92, 95% CI = 2.31-14.7) and having got administration of mass-drug (AOR = 8.9, 95% CI = 2.36-33.6) were significant risk factors for active trachoma infection. Whereas, face washing practice regularly (AOR = 0.23, 95% CI = 0.127-0.43), and toilet availability (AOR = 0.35, 95% CI = 0.20-0.97) were preventive factors for active trachoma infection.

Conclusion

A significant prevalence of active trachoma infection was reported in the area as compared with previous findings and urgent clinical intervention, and the WHO critical SAFE strategies (surgery, antibiotics, facial cleanliness, and environmental improvement) implementation is highly needed in the area. In addition, healthcare providers should focus on information dissemination on proper latrine utilization, and washing the face regularly to prevent active trachoma infection is highly recommended.