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Dulli L, Touré F, Mama AD, Evens E, Murray K, Djè NN, Koné S, Sadate-Ngatchou P, Bovary A, Eichleay M, Jean-Baptiste M, Méité A. Feasibility and acceptability of integrating mass distribution of azithromycin to children 1-11 months into a trachoma mass drug administration campaign to reduce child mortality in Côte d'Ivoire. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003426. [PMID: 38985785 PMCID: PMC11236188 DOI: 10.1371/journal.pgph.0003426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/10/2024] [Indexed: 07/12/2024]
Abstract
Evidence suggests that bi-annual mass drug administration (MDA) of single-dose azithromycin to 1-11 month-old children reduces child mortality in high child-mortality settings. Several countries conduct annual MDAs to distribute azithromycin to individuals ages 6 months and older to prevent trachoma infection. This study examined the feasibility and acceptability of reaching 1-11 months-old children during a trachoma MDA in Côte d'Ivoire by extending azithromycin distribution to infants 1-5 months old during the campaign. In November 2020, the study piloted single-dose azithromycin for 1-5 month-olds during a trachoma MDA in one health district. Monitoring data included the number of children reached and occurrences of adverse drug reactions. Feasibility, the extent to which the target population received the intervention (coverage), was assessed through a population-based, household survey with parents/caregivers of eligible children conducted after the MDA. Acceptability was explored through in-depth interviews (IDIs) with parents/caregivers of eligible children, focus group discussions (FGDs) with community drug distributors (CDDs), and IDIs with their supervisors. CDD FGDs and supervisor IDIs also documented implementation challenges and recommendations for scale-up. 1,735 1-5 month-olds received azithromycin during the pilot activity (estimated population coverage of 90.2%). Adverse drug reactions were reported for 1% (n = 18) infants; all were mild and self-limited. The post-MDA coverage survey interviewed 267 parents/caregivers; survey-based intervention coverage was 95.4% of 1-5 month-olds. Qualitative data revealed high intervention acceptability among parents, CDDs, and supervisors. Implementation challenges included the need to weigh babies to calculate dosage for 1-5 month-olds and the need to obtain written informed consent from parents to provide the drug to 1-5 month-olds. CDDs also indicated the need for more information on azithromycin and possible side effects during training. Delivering azithromycin to younger infants appears acceptable to parents and implementers; >90% coverage indicates feasibility to integrate into a trachoma MDA. (Clinicaltrials.gov ID number: NCT04617626).
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Affiliation(s)
- Lisa Dulli
- Global Health and Population Business Unit, FHI 360, Durham, North Carolina, United States of America
| | - Fatoumata Touré
- Global Health and Population Business Unit, FHI 360, Abidjan, Côte d'Ivoire
| | - Adam Djima Mama
- The Côte d'Ivoire National Neglected Tropical Diseases Program (Programme National de Lutte contre les Maladies Tropicales Négligées à Chimiothérapie Préventive), Abidjan, Côte d'Ivoire
| | - Emily Evens
- Global Health and Population Business Unit, FHI 360, Durham, North Carolina, United States of America
| | - Kate Murray
- Global Health and Population Business Unit, FHI 360, Durham, North Carolina, United States of America
| | - Norbert N'goran Djè
- The Côte d'Ivoire National Neglected Tropical Diseases Program (Programme National de Lutte contre les Maladies Tropicales Négligées à Chimiothérapie Préventive), Abidjan, Côte d'Ivoire
| | - Stéphane Koné
- Global Health and Population Business Unit, FHI 360, Abidjan, Côte d'Ivoire
| | - Pat Sadate-Ngatchou
- Global Health and Population Business Unit, FHI 360, Durham, North Carolina, United States of America
| | - Anoma Bovary
- The Côte d'Ivoire National Neglected Tropical Diseases Program (Programme National de Lutte contre les Maladies Tropicales Négligées à Chimiothérapie Préventive), Abidjan, Côte d'Ivoire
| | - Marga Eichleay
- Global Health and Population Business Unit, FHI 360, Durham, North Carolina, United States of America
| | - Milenka Jean-Baptiste
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Aboulaye Méité
- The Côte d'Ivoire National Neglected Tropical Diseases Program (Programme National de Lutte contre les Maladies Tropicales Négligées à Chimiothérapie Préventive), Abidjan, Côte d'Ivoire
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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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Sanders AM, Makoy S, Deathe AR, Ohidor S, Jesudason TC, Nute AW, Odongi P, Boniface L, Abuba S, Delahaut AS, Sebit W, Niquette J, Callahan EK, Walker DG, Nash SD. Cost and community acceptability of enhanced antibiotic distribution approaches for trachoma in the Republic of South Sudan: enhancing the A in SAFE (ETAS) study protocol. BMC Ophthalmol 2023; 23:51. [PMID: 36747194 PMCID: PMC9900535 DOI: 10.1186/s12886-023-02783-x] [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: 04/18/2022] [Accepted: 01/13/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The World Health Organization targeted trachoma for global elimination as a public health problem by 2030. Reaching elimination thresholds by the year 2030 in the Republic of South Sudan will be a considerable challenge, as the country currently has many counties considered hyper-endemic (> 30% trachomatous inflammation-follicular [TF]) that have yet to receive interventions. Evidence from randomized trials, modeling, and population-based surveys suggests that enhancements may be needed to the standard-of-care annual mass drug administration (MDA) to reach elimination thresholds in a timely manner within highly endemic areas. We describe a protocol for a study to determine the cost and community acceptability of enhanced antibiotic strategies for trachoma in South Sudan. METHODS The Enhancing the A in SAFE (ETAS) study is a community randomized intervention costing and community acceptability study. Following a population-based trachoma prevalence survey in 1 county, 30 communities will be randomized 1:1 to receive 1 of 2 enhanced MDA interventions, with the remaining communities receiving standard-of-care annual MDA. The first intervention strategy will consist of a community-wide MDA followed by 2 rounds of targeted treatment to children ages 6 months to 9 years, 2 weeks and 4 weeks after the community MDA. The second strategy will consist of a community-wide biannual MDA approximately 6 to 8 months apart. The costing analysis will use a payer perspective and identify the total cost of the enhanced interventions and annual MDA. Community acceptability will be assessed through MDA coverage monitoring and mixed-methods research involving community stakeholders. A second trachoma-specific survey will be conducted 12 months following the original survey. DISCUSSION ETAS has received ethical clearance and is expected to be conducted between 2022 and 2023. Results will be shared through subsequent manuscripts. The study's results will provide information to trachoma programs on whether enhanced interventions are affordable and acceptable to communities. These results will further help in the design of future trachoma-specific antibiotic efficacy trials. Enhanced MDA approaches could help countries recover from delays caused by conflict or humanitarian emergencies and could also assist countries such as South Sudan in reaching trachoma elimination as a public health problem by 2030. TRIAL REGISTRATION This trial was registered on December 1st, 2022 (clinicaltrails.org: NCT05634759).
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Affiliation(s)
| | - Samuel Makoy
- Ministry of Health, Juba, Republic of South Sudan
| | - Andrew R. Deathe
- grid.418694.60000 0001 2291 4696The Carter Center, Atlanta, GA USA
| | | | | | - Andrew W. Nute
- grid.418694.60000 0001 2291 4696The Carter Center, Atlanta, GA USA
| | | | | | - Stella Abuba
- The Carter Center, Juba, Republic of South Sudan
| | | | - Wilson Sebit
- Ministry of Health, Juba, Republic of South Sudan
| | | | | | | | - Scott D. Nash
- grid.418694.60000 0001 2291 4696The Carter Center, Atlanta, GA USA
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O'Brien KS, Arzika AM, Maliki R, Amza A, Manzo F, Mankara AK, Lebas E, Cook C, Oldenburg CE, Porco TC, Arnold BF, Bertozzi S, Keenan JD, Lietman TM. Azithromycin distribution and childhood mortality in compliance-related subgroups in Niger: complier average causal effect and spillovers in a cluster-randomized, placebo-controlled trial. Int J Epidemiol 2022; 51:1775-1784. [PMID: 34508582 DOI: 10.1093/ije/dyab198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Biannual azithromycin distribution to children 1-59 months old reduced all-cause mortality by 18% [incidence rate ratio (IRR) 0.82, 95% confidence interval (CI): 0.74, 0.90] in an intention-to-treat analysis of a randomized controlled trial in Niger. Estimation of the effect in compliance-related subgroups can support decision making around implementation of this intervention in programmatic settings. METHODS The cluster-randomized, placebo-controlled design of the original trial enabled unbiased estimation of the effect of azithromycin on mortality rates in two subgroups: (i) treated children (complier average causal effect analysis); and (ii) untreated children (spillover effect analysis), using negative binomial regression. RESULTS In Niger, 594 eligible communities were randomized to biannual azithromycin or placebo distribution and were followed from December 2014 to August 2017, with a mean treatment coverage of 90% [standard deviation (SD) 10%] in both arms. Subgroup analyses included 2581 deaths among treated children and 245 deaths among untreated children. Among treated children, the incidence rate ratio comparing mortality in azithromycin communities to placebo communities was 0.80 (95% CI: 0.72, 0.88), with mortality rates (deaths per 1000 person-years at risk) of 16.6 in azithromycin communities and 20.9 in placebo communities. Among untreated children, the incidence rate ratio was 0.91 (95% CI: 0.69, 1.21), with rates of 33.6 in azithromycin communities and 34.4 in placebo communities. CONCLUSIONS As expected, this analysis suggested similar efficacy among treated children compared with the intention-to-treat analysis. Though the results were consistent with a small spillover benefit to untreated children, this trial was underpowered to detect spillovers.
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Affiliation(s)
- Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.,School of Public Health, University of California, Berkeley, CA, USA
| | | | | | - Abdou Amza
- Programme National de Santé Oculaire, Niamey, Niger
| | | | | | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA
| | - Catherine Cook
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA
| | - Catherine E Oldenburg
- 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
| | - Travis 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.,Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Stefano Bertozzi
- School of Public Health, University of California, Berkeley, CA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Instituto Nacional de Salud Pública, Cuernavaca, MOR, México
| | - 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 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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Hu H, Arzika AM, Sie A, Abdou A, Maliki R, Mankara AK, Outtara M, Bountogo M, Boudo V, Yago-Wienne F, Bamba I, Knirsch C, Emerson P, Hooper PJ, Lebas E, Brogdon J, Nyatigo F, Oldenburg CE, Lietman TM, O'Brien KS. Simplified dosing of oral azithromycin for children 1-11 months old in child survival programmes: age-based and height-based dosing protocols. BMJ Glob Health 2022; 7:bmjgh-2022-009801. [PMID: 36253018 PMCID: PMC9577904 DOI: 10.1136/bmjgh-2022-009801] [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: 06/03/2022] [Accepted: 09/24/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND To facilitate mass distribution of azithromycin, trachoma control programmes use height instead of weight to determine dose for children 6 months to 15 years old. WHO has recommended azithromycin distribution to children 1-11 months old to reduce mortality in high mortality settings under carefully monitored conditions. Weight was used to determine dose in children 1-5 months old in studies of azithromycin distribution for child survival, but a simplified approach using age or height for all aged 1-11 months old could increase programme efficiency in real-world settings. METHODS This secondary analysis used data from two cluster randomised trials of azithromycin distribution for child mortality in Niger and Burkina Faso. An exhaustive search algorithm was developed to determine the optimal dose for different age groups, using tolerance limits of 10-20 mg/kg for children 1-2 months old and 15-30 mg/kg for children 3-11 months old. Height-based dosing was evaluated against the existing trachoma dosing pole and with a similar exhaustive search. RESULTS The optimal two-tiered age-based approach suggested a dose of 80 mg (2 mL) for children 1-2 months old and 160 mg (4 mL) for children 3-11 months old. Under this schedule, 89%-93% of children would have received doses within tolerance limits in both study populations. Accuracy was 93%-94% with a three-tiered approach, which resulted in doses of 80 mg (2 mL), 120 mg (3 mL) and 160 mg (4 mL) for children 1-2, 3-4 and 5-11 months old, respectively. For children 1-5 months old, the existing height pole would result in 70% of doses within tolerance limits. The optimisation identified height-based dosing options with 95% accuracy, although this would require changes to the existing dosing pole as well as additional training to measure infants lying flat. CONCLUSIONS Overall, an age-based approach with two age tiers resulted in high accuracy while considering both concerns about overdosing in this young population and simplicity of field operations.
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Affiliation(s)
- Huiyu Hu
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
| | | | - Ali Sie
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | - Amza Abdou
- Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Ramatou Maliki
- Centre de Recherche et Interventions en Sante Publique, Niamey, Niger
| | | | | | | | - Valentin Boudo
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | | | - Issouf Bamba
- Helen Keller International, Ouagadougou, Burkina Faso
| | | | - Paul Emerson
- International Trachoma Initiative, Decatur, Georgia, USA
| | - PJ Hooper
- International Trachoma Initiative, Decatur, Georgia, USA
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
| | - Jessica Brogdon
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
| | - Fanice Nyatigo
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA,Department of Ophthalmology, University of California, San Francisco, California, USA,Institute for Global Health Sciences, University of California, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA,Department of Ophthalmology, University of California, San Francisco, California, USA,Institute for Global Health Sciences, University of California, San Francisco, California, USA
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA,Department of Ophthalmology, University of California, San Francisco, California, USA,Institute for Global Health Sciences, University of California, San Francisco, California, USA
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6
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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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7
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Arzika AM, Mindo-Panusis D, Abdou A, Kadri B, Nassirou B, Maliki R, Alsoudi AF, Zhang T, Cotter SY, Lebas E, O’Brien KS, Callahan EK, Bailey RL, West SK, Goodhew EB, Martin DL, Arnold BF, Porco TC, Lietman TM, Keenan JD. Effect of Biannual Mass Azithromycin Distributions to Preschool-Aged Children on Trachoma Prevalence in Niger: A Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2228244. [PMID: 35997979 PMCID: PMC9399865 DOI: 10.1001/jamanetworkopen.2022.28244] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Because transmission of ocular strains of Chlamydia trachomatis is greatest among preschool-aged children, limiting azithromycin distributions to this age group may conserve resources and result in less antimicrobial resistance, which is a potential advantage in areas with hypoendemic trachoma and limited resources. OBJECTIVE To determine the efficacy of mass azithromycin distributions to preschool-aged children as a strategy for trachoma elimination in areas with hypoendemic disease. DESIGN, SETTING, AND PARTICIPANTS In this cluster randomized clinical trial performed from November 23, 2014, until July 31, 2017, thirty rural communities in Niger were randomized at a 1:1 ratio to biannual mass distributions of either azithromycin or placebo to children aged 1 to 59 months. Participants and study personnel were masked to treatment allocation. Data analyses for trachoma outcomes were performed from October 19, 2021, through June 10, 2022. INTERVENTIONS Every 6 months, a single dose of either oral azithromycin (20 mg/kg using height-based approximation for children who could stand or weight calculation for small children) or oral placebo was provided to all children aged 1 to 59 months. MAIN OUTCOMES AND MEASURES Trachoma was a prespecified outcome of the trial, assessed as the community-level prevalence of trachomatous inflammation-follicular and trachomatous inflammation-intense through masked grading of conjunctival photographs from a random sample of 40 children per community each year during the 2-year study period. A secondary outcome was the seroprevalence of antibodies to C trachomatis antigens. RESULTS At baseline, 4726 children in 30 communities were included; 1695 children were enrolled in 15 azithromycin communities and 3031 children were enrolled in 15 placebo communities (mean [SD] proportions of boys, 51.8% [4.7%] vs 52.0% [4.2%]; mean [SD] age, 30.8 [2.8] vs 30.6 [2.6] months). The mean coverage of study drug for the 4 treatments was 79% (95% CI, 75%-83%) in the azithromycin group and 82% (95% CI, 79%-85%) in the placebo group. The mean prevalence of trachomatous inflammation-follicular at baseline was 1.9% (95% CI, 0.5%-3.5%) in the azithromycin group and 0.9% (95% CI, 0-1.9%) in the placebo group. At 24 months, trachomatous inflammation-follicular prevalence was 0.2% (95% CI, 0-0.5%) in the azithromycin group and 0.8% (95% CI, 0.2%-1.6%) in the placebo group (incidence rate ratio adjusted for baseline: 0.18 [95% CI, 0.01-1.20]; permutation P = .07). CONCLUSIONS AND RELEVANCE The findings of this trial do not show that biannual mass azithromycin distributions to preschool-aged children were more effective than placebo, although the underlying prevalence of trachoma was low. The sustained absence of trachoma even in the placebo group suggests that trachoma may have been eliminated as a public health problem in this part of Niger. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02048007.
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Affiliation(s)
- Ahmed M. Arzika
- The Carter Center, Niamey, Niger
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | | | - Amza Abdou
- Programme Nationale de Santé Oculaire, Niamey, Niger
| | | | | | - Ramatou Maliki
- The Carter Center, Niamey, Niger
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Amer F. Alsoudi
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Tianyi Zhang
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Sun Y. Cotter
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Robin L. Bailey
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sheila K. West
- Dana Center for Preventive Ophthalmology, The Johns Hopkins University, Baltimore, Maryland
| | - E. Brook Goodhew
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Diana L. Martin
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Benjamin F. Arnold
- 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 Ophthalmology, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Institute for Global Health Sciences, 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
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8
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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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9
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Abstract
Trachoma is a neglected tropical disease caused by infection with conjunctival strains of Chlamydia trachomatis. It can result in blindness. Pathophysiologically, trachoma is a disease complex composed of two linked chronic processes: a recurrent, generally subclinical infectious-inflammatory disease that mostly affects children, and a non-communicable, cicatricial and, owing to trichiasis, eventually blinding disease that supervenes in some individuals later in life. At least 150 infection episodes over an individual's lifetime are needed to precipitate trichiasis; thus, opportunity exists for a just global health system to intervene to prevent trachomatous blindness. Trachoma is found at highest prevalence in the poorest communities of low-income countries, particularly in sub-Saharan Africa; in June 2021, 1.8 million people worldwide were going blind from the disease. Blindness attributable to trachoma can appear in communities many years after conjunctival C. trachomatis transmission has waned or ceased; therefore, the two linked disease processes require distinct clinical and public health responses. Surgery is offered to individuals with trichiasis and antibiotic mass drug administration and interventions to stimulate facial cleanliness and environmental improvement are designed to reduce infection prevalence and transmission. Together, these interventions comprise the SAFE strategy, which is achieving considerable success. Although much work remains, a continuing public health problem from trachoma in the year 2030 will be difficult for the world to excuse.
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10
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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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11
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O’Brien KS, Sié A, Dah C, Ourohiré M, Ouedraogo M, Boudo V, Arzika A, Lebas E, Nyatigo F, Godwin W, Kelly JD, Arnold BF, Oldenburg CE. Comparing Azithromycin to Amoxicillin in the Management of Uncomplicated Severe Acute Malnutrition in Burkina Faso: A Pilot Randomized Trial. Am J Trop Med Hyg 2022; 106:930-938. [PMID: 35008055 PMCID: PMC8922483 DOI: 10.4269/ajtmh.21-1023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/12/2021] [Indexed: 11/07/2022] Open
Abstract
Azithromycin is a promising alternative to amoxicillin in the management of uncomplicated severe acute malnutrition (SAM) as it can be administered as a single dose and has efficacy against several pathogens causing infectious disease and mortality in children under 5. In this pilot trial, we aimed to establish the feasibility of a larger randomized controlled trial and provide preliminary evidence comparing the effect of azithromycin to amoxicillin on weight gain in children with uncomplicated SAM. We enrolled children 6-59 months old with uncomplicated SAM at six healthcare centers in Burkina Faso. Participants were randomized to a single dose of azithromycin or a 7-day course of amoxicillin and followed weekly until nutritional recovery and again at 8 weeks. Apart from antibiotics, participants received standard of care, which includes ready-to-use therapeutic food. Primary feasibility outcomes included enrollment potential, refusals, and loss to follow-up. The primary clinical outcome was weight gain (g/kg/day) over 8 weeks. Outcome assessors were masked. Between June and October 2020, 312 children were screened, 301 were enrolled with zero refusals, and 282 (93.6%) completed the 8-week visit. Average weight gain was 2.5 g/kg/day (standard deviation [SD] 2.0) in the azithromycin group and 2.6 (SD 1.7) in the amoxicillin group (mean difference -0.1, 95% CI -0.5 to 0.3, P = 0.63). Fewer adverse events were reported in the azithromycin group (risk ratio 0.50, 95% CI 0.31-0.82, P = 0.006). With strong enrollment and follow-up, a fully powered trial in this setting is feasible.
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Affiliation(s)
- Kieran S. O’Brien
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ahmed Arzika
- Centre de Recherche et Interventions en Santé Publique, Niamey, Niger
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Fanice Nyatigo
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - William Godwin
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - J. Daniel Kelly
- 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
| | - 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,Address correspondence to Catherine E. Oldenburg, Francis I. Proctor Foundation, University of California, San Francisco, 490 Illinois St., 2nd floor, San Francisco, CA 94158. E-mail:
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12
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Arzika AM, Maliki R, Ali MM, Alio MK, Abdou A, Cotter SY, Varnado NE, Lebas E, Cook C, Oldenburg CE, O’Brien KS, Callahan EK, Bailey RL, West SK, Porco TC, Lietman TM, Keenan JD. Effect of Mass Azithromycin Distributions on Childhood Growth in Niger: A Cluster-Randomized Trial. JAMA Netw Open 2021; 4:e2139351. [PMID: 34967883 PMCID: PMC8719241 DOI: 10.1001/jamanetworkopen.2021.39351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Mass azithromycin distributions may decrease childhood mortality, although the causal pathway is unclear. The potential for antibiotics to function as growth promoters may explain some of the mortality benefit. OBJECTIVE To investigate whether biannual mass azithromycin distributions are associated with increased childhood growth. DESIGN, SETTING, AND PARTICIPANTS This cluster-randomized trial was performed from December 2014 until March 2020 among 30 rural communities in Boboye and Loga departments in Niger, Africa, with populations from 200 to 2000 individuals. Communities were randomized in a 1:1 ratio to biannual mass distributions of azithromycin or placebo for children ages 1 to 59 months. Participants, field-workers, and study personnel were masked to treatment allocation. Height and weight changes from baseline to follow-up at 4 years were compared between groups. Data were analyzed from June through November 2021. INTERVENTIONS Participants received azithromycin at 20 mg/kg using height-based approximation or by weight for children unable to stand every 6 months at the participants' households. Placebo contained the vehicle of the azithromycin suspension. MAIN OUTCOMES AND MEASURES Longitudinal anthropometric assessments were performed on a random sample of children before the first treatment and then annually for 5 years. Height and weight were the prespecified primary outcomes. RESULTS Among 3936 children enrolled from 30 communities, baseline characteristics were similar between 1299 children in the azithromycin group and 2637 children in the placebo group (mean 48.2% [95% CI, 45.5% to 50.8%] girls vs 48.0% [95% CI, 45.7% to 50.3%] girls; mean age, 30.8 months [95% CI, 29.5 to 32.0 months] vs 30.6 months [95% CI, 29.2 to 31.6 months]). Baseline anthropometric assessments were performed among 2230 children, including 985 children in the azithromycin group and 1245 children in the placebo group, of whom follow-up measurements were available for 789 children (80.1%) and 1063 children (85.4%), respectively. At the prespecified 4-year follow-up visit, children in the azithromycin group gained a mean 6.7 cm (95% CI, 6.5 to 6.8 cm) in height and 1.7 kg (95% CI, 1.7 to 1.8 kg) in weight per year and children in the placebo group gained a mean 6.6 cm (95% CI, 6.4 to 6.7 cm) in height and 1.7 kg (95% CI, 1.7 to 1.8 kg) in weight per year. Height at 4 years was not statistically significantly different between groups when adjusted for baseline height (0.08 cm [95% CI, -0.12 to 0.28 cm] greater in the azithromycin group; P = .45), and neither was weight when adjusted for height and baseline weight (0.02 kg [95% CI, -0.10 to 0.06 kg] less in the azithromycin group; P = .64). However, among children in the shortest quartile of baseline height, azithromycin was associated with a 0.4 cm (95% CI, 0.1 to 0.7 cm) increase in height compared with placebo. CONCLUSIONS AND RELEVANCE This study did not find evidence of an association between mass azithromycin distributions and childhood growth, although subgroup analysis suggested some benefit for the shortest children. These findings suggest that the mortality benefit of mass azithromycin distributions is unlikely to be due solely to growth promotion. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02048007.
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Affiliation(s)
- Ahmed M. Arzika
- Carter Center, Niamey, Niger
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Ramatou Maliki
- Carter Center, Niamey, Niger
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | | | - Mankara K. Alio
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Amza Abdou
- Programme National de Santé Oculaire, Niamey, Niger
| | - Sun Y. Cotter
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Nicole E. Varnado
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Catherine Cook
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Robin L. Bailey
- London School of Hygiene and Tropical Medicine, London, England
| | - Sheila K. West
- Dana Center for Preventive Ophthalmology, Johns Hopkins University, Baltimore, Maryland
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Institute for Global Health Sciences, 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
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Li D, Wang Y. Safety of azithromycin in pediatric infectious diseases: a clinical systematic review and meta-analysis. Transl Pediatr 2021; 10:2594-2601. [PMID: 34765483 PMCID: PMC8578745 DOI: 10.21037/tp-21-444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/13/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Azithromycin is a second-generation macrolide antibiotic which can be used in the treatment of diseases caused by sensitive bacterial infections. This article aimed to investigate the safety of azithromycin in the treatment of infectious diseases in children by meta-analysis. METHODS PubMed, Embase, and Cochrane were selected as the search database platforms. Randomized controlled trials (RCTs) published after 2010 were searched using the following keywords: "azithromycin", "children", "adverse event", "intravenous event", and "oral". Included studies were all clinical trials of azithromycin in the treatment of pediatric diseases. After inclusion/exclusion criteria screening and bias risk assessment, data were extracted from the included studies. RevMan 5.3.5 software was used for statistical analysis to obtain both forest and funnel plots. RESULTS A total of nine articles involving 3,597 pediatric patients were included in this study. The results of meta-analysis showed that the nine articles exhibited statistical heterogeneity (I2=70%; P=0.001), and thus, a random-effects model was used. The obtained statistic was [odds ratio (OR) =0.65; 95% confidence interval (CI): (0.43, 0.97)], the statistical effect value was Z=2.10, P=0.04, and the difference was statistically significant. After excluding one article, the remaining eight articles showed homogeneity (I2=12%; P=0.34). So, using fixed-effects model analysis, the statistic was [OR =0.79; 95% CI: (0.67, 0.94)], and the effect size value was Z=2.73, P=0.006. DISCUSSION Compared with other antibiotics, the clinical safety of azithromycin is relatively good, but care should be taken when the dosage is high in treating some disease.
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Affiliation(s)
- Dongjin Li
- Neonatal/Pediatric Department, Chengdu 363 Hospital, Southwest Medical University, Chengdu, China
| | - Yajun Wang
- Department of Pediatrics, Dujiangyan People's Hospital, Dujiangyan, China
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Sadilek A, Liu L, Nguyen D, Kamruzzaman M, Serghiou S, Rader B, Ingerman A, Mellem S, Kairouz P, Nsoesie EO, MacFarlane J, Vullikanti A, Marathe M, Eastham P, Brownstein JS, Arcas BAY, Howell MD, Hernandez J. Privacy-first health research with federated learning. NPJ Digit Med 2021; 4:132. [PMID: 34493770 PMCID: PMC8423792 DOI: 10.1038/s41746-021-00489-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/21/2021] [Indexed: 11/29/2022] Open
Abstract
Privacy protection is paramount in conducting health research. However, studies often rely on data stored in a centralized repository, where analysis is done with full access to the sensitive underlying content. Recent advances in federated learning enable building complex machine-learned models that are trained in a distributed fashion. These techniques facilitate the calculation of research study endpoints such that private data never leaves a given device or healthcare system. We show-on a diverse set of single and multi-site health studies-that federated models can achieve similar accuracy, precision, and generalizability, and lead to the same interpretation as standard centralized statistical models while achieving considerably stronger privacy protections and without significantly raising computational costs. This work is the first to apply modern and general federated learning methods that explicitly incorporate differential privacy to clinical and epidemiological research-across a spectrum of units of federation, model architectures, complexity of learning tasks and diseases. As a result, it enables health research participants to remain in control of their data and still contribute to advancing science-aspects that used to be at odds with each other.
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Affiliation(s)
| | | | - Dung Nguyen
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
- Department of Computer Science, University of Virginia, Charlottesville, VA, USA
| | - Methun Kamruzzaman
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
| | | | - Benjamin Rader
- Computational Epidemiology Lab, Boston Children's Hospital, Boston, MA, USA
- Department of Epidemiology, Boston University, Boston, MA, USA
| | | | | | | | | | | | - Anil Vullikanti
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
- Department of Computer Science, University of Virginia, Charlottesville, VA, USA
| | - Madhav Marathe
- Biocomplexity Institute, University of Virginia, Charlottesville, VA, USA
- Department of Computer Science, University of Virginia, Charlottesville, VA, USA
| | | | - John S Brownstein
- Computational Epidemiology Lab, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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15
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Amza A, Kadri B, Nassirou B, Arzika AM, Austin A, Nyatigo F, Lebas E, Arnold BF, Lietman TM, Oldenburg CE. Azithromycin Reduction to Reach Elimination of Trachoma (ARRET): study protocol for a cluster randomized trial of stopping mass azithromycin distribution for trachoma. BMC Ophthalmol 2021; 21:15. [PMID: 33407263 PMCID: PMC7789605 DOI: 10.1186/s12886-020-01776-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/17/2020] [Indexed: 12/23/2022] Open
Abstract
Background The World Health Organization (WHO) recommends annual mass azithromycin distribution until districts drop below 5% prevalence of trachomatous inflammation—follicular (TF). Districts with very low TF prevalence may have little or no transmission of the ocular strains of Chlamydia trachomatis that cause trachoma, and additional rounds of mass azithromycin distribution may not be useful. Here, we describe the protocol for a randomized controlled trial designed to evaluate whether mass azithromycin distribution can be stopped prior to the current WHO guidelines. Methods The Azithromycin Reduction to Reach Elimination of Trachoma (ARRET) study is a 1:1 community randomized non-inferiority trial designed to evaluate whether mass azithromycin distribution can be stopped in districts with baseline prevalence of TF under 20%. Communities in Maradi, Niger are randomized after baseline assessment either to continued annual mass azithromycin distribution or stopping annual azithromycin distribution over a 3-year period. We will compare the prevalence of ocular C. trachomatis (primary outcome), TF and other clinical signs of trachoma, and serologic markers of trachoma after 3 years. We hypothesize that stopping annual azithromycin distribution will be non-inferior to continued annual azithromycin distributions for all markers of trachoma prevalence and transmission. Discussion The results of this trial are anticipated to provide potentially guideline-changing evidence for when mass azithromycin distributions can be stopped in low TF prevalence areas. Trial registration number This study is registered at clinicaltrials.gov (NCT04185402). Registered December 4, 2019; prospectively registered pre-results.
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Affiliation(s)
- Abdou Amza
- Programme National de Santé Oculaire, Ministere de la Santé Publique, Niamey, Niger
| | - Boubacar Kadri
- Programme National de Santé Oculaire, Ministere de la Santé Publique, Niamey, Niger
| | - Beido Nassirou
- Programme National de Santé Oculaire, Ministere de la Santé Publique, Niamey, Niger
| | - Ahmed M Arzika
- Centre de Recherche et d'Intervention en Santé Publique, Niamey, Niger
| | - Ariana Austin
- Francis I Proctor Foundation, University of California, San Francisco, USA
| | - Fanice Nyatigo
- Francis I Proctor Foundation, University of California, San Francisco, USA
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, USA
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, USA.,Department of Ophthalmology, University of California, 490 Illinois St, Floor 2, 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 St, Floor 2, San Francisco, CA, 94158, USA.,Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
| | - Catherine E Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, USA. .,Department of Ophthalmology, University of California, 490 Illinois St, Floor 2, San Francisco, CA, 94158, USA. .,Department of Epidemiology & Biostatistics, University of California, San Francisco, USA.
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16
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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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17
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O’Brien KS, Arzika AM, Maliki R, Manzo F, Mamkara AK, Lebas E, Cook C, Bailey RL, West SK, Oldenburg CE, Porco TC, Arnold B, Keenan JD, Lietman TM. Biannual azithromycin distribution and child mortality among malnourished children: A subgroup analysis of the MORDOR cluster-randomized trial in Niger. PLoS Med 2020; 17:e1003285. [PMID: 32931496 PMCID: PMC7491708 DOI: 10.1371/journal.pmed.1003285] [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: 04/13/2020] [Accepted: 08/10/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Biannual azithromycin distribution has been shown to reduce child mortality as well as increase antimicrobial resistance. Targeting distributions to vulnerable subgroups such as malnourished children is one approach to reaching those at the highest risk of mortality while limiting selection for resistance. The objective of this analysis was to assess whether the effect of azithromycin on mortality differs by nutritional status. METHODS AND FINDINGS A large simple trial randomized communities in Niger to receive biannual distributions of azithromycin or placebo to children 1-59 months old over a 2-year timeframe. In exploratory subgroup analyses, the effect of azithromycin distribution on child mortality was assessed for underweight subgroups using weight-for-age Z-score (WAZ) thresholds of -2 and -3. Modification of the effect of azithromycin on mortality by underweight status was examined on the additive and multiplicative scale. Between December 2014 and August 2017, 27,222 children 1-11 months of age from 593 communities had weight measured at their first study visit. Overall, the average age among included children was 4.7 months (interquartile range [IQR] 3-6), 49.5% were female, 23% had a WAZ < -2, and 10% had a WAZ < -3. This analysis included 523 deaths in communities assigned to azithromycin and 661 deaths in communities assigned to placebo. The mortality rate was lower in communities assigned to azithromycin than placebo overall, with larger reductions among children with lower WAZ: -12.6 deaths per 1,000 person-years (95% CI -18.5 to -6.9, P < 0.001) overall, -17.0 (95% CI -28.0 to -7.0, P = 0.001) among children with WAZ < -2, and -25.6 (95% CI -42.6 to -9.6, P = 0.003) among children with WAZ < -3. No statistically significant evidence of effect modification was demonstrated by WAZ subgroup on either the additive or multiplicative scale (WAZ < -2, additive: 95% CI -6.4 to 16.8, P = 0.34; WAZ < -2, multiplicative: 95% CI 0.8 to 1.4, P = 0.50, WAZ < -3, additive: 95% CI -2.2 to 31.1, P = 0.14; WAZ < -3, multiplicative: 95% CI 0.9 to 1.7, P = 0.26). The estimated number of deaths averted with azithromycin was 388 (95% CI 214 to 574) overall, 116 (95% CI 48 to 192) among children with WAZ < -2, and 76 (95% CI 27 to 127) among children with WAZ < -3. Limitations include the availability of a single weight measurement on only the youngest children and the lack of power to detect small effect sizes with this rare outcome. Despite the trial's large size, formal tests for effect modification did not reach statistical significance at the 95% confidence level. CONCLUSIONS Although mortality rates were higher in the underweight subgroups, this study was unable to demonstrate that nutritional status modified the effect of biannual azithromycin distribution on mortality. Even if the effect were greater among underweight children, a nontargeted intervention would result in the greatest absolute number of deaths averted. TRIAL REGISTRATION The MORDOR trial is registered at clinicaltrials.gov NCT02047981.
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Affiliation(s)
- Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Division of Epidemiology, School of Public Health, University of California, Berkeley, California, United States of America
- * E-mail:
| | | | | | | | | | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Catherine Cook
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Robin L. Bailey
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sheila K. West
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
| | - Benjamin Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
| | - Jeremy D. Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
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18
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Booth R, Nyari S. Clinical comparison of five anti-chlamydial antibiotics in koalas (Phascolarctos cinereus). PLoS One 2020; 15:e0236758. [PMID: 32730301 PMCID: PMC7392309 DOI: 10.1371/journal.pone.0236758] [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: 04/14/2020] [Accepted: 07/12/2020] [Indexed: 11/27/2022] Open
Abstract
Chlamydiosis is the most significant infectious disease of koalas (Phascolarctos cinereus). It is primarily a systemic sexually transmitted disease caused by Chlamydia pecorum and was responsible for 46% of the 2348 koala admissions to Australia Zoo Wildlife Hospital between 2013 and 2017. Treatment of chlamydiosis in koalas is complicated by three major factors. Firstly, koalas rely on bacterial fermentation of their high fibre diet making antibiotic therapy a risk. Secondly, they possess efficient metabolic pathways for the excretion of plant toxins and potentially of therapeutic agents. Thirdly, wild koalas, often present to rehabilitation facilities with chronic and severe disease. Traditional anti-chlamydial antibiotics used in other species may cause fatal dysbiosis in koalas or be excreted before they can be effective. We compared five anti-chlamydial antibiotics, azithromycin, chloramphenicol, doxycycline, enrofloxacin and florfenicol, which were used to treat 86 wild koalas with chlamydiosis presented to Australia Zoo Wildlife Hospital under consistent conditions of nutrition, housing, husbandry and climate. Response to treatment was assessed by recovery from clinical signs, and clearance of detectable Chlamydia via quantitative PCR. Doxycycline was the most effective anti-chlamydial antibiotic of the five, producing a 97% cure rate, followed by chloramphenicol (81%), enrofloxacin (75%), florfenicol (66%) and azithromycin (25%). The long-acting injectable preparation of doxycycline was well tolerated by koalas when administered via the subcutaneous route, and the weekly dosing requirement is a major advantage when treating wild animals. These findings indicate that doxycycline is the current drug of choice for the treatment of chlamydiosis in koalas, with chloramphenicol being the best alternative.
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Affiliation(s)
- Rosemary Booth
- Australia Zoo Wildlife Hospital, Beerwah, Queensland, Australia
- * E-mail:
| | - Sharon Nyari
- Genecology Research Centre, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
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19
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Safety of azithromycin in pediatrics: a systematic review and meta-analysis. Eur J Clin Pharmacol 2020; 76:1709-1721. [PMID: 32681202 PMCID: PMC7661415 DOI: 10.1007/s00228-020-02956-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 07/06/2020] [Indexed: 02/07/2023]
Abstract
Purpose To evaluate the toxicity of azithromycin in neonates, infants, and children. Methods A systematic review was performed for relevant studies using Medline (Ovid), PubMed, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, and International Pharmaceutical Abstracts. We calculated the pooled incidence of adverse drug reactions (ADRs) associated with azithromycin based on prospective studies (RCTs and prospective cohort studies) and analyzed the risk difference (RD) of ADRs between azithromycin and placebo or other antibiotics using meta-analysis of RCTs. Results We included 133 studies with 4243 ADRs reported in 197,675 neonates, infants, and children who received azithromycin. The safety of azithromycin as MDA in pediatrics was poorly monitored. The main ADRs were diarrhea and vomiting. In prospective non-MDA studies, the most common toxicity was gastrointestinal ADRs (938/1967; 47.7%). The most serious toxicities were cardiac (prolonged QT or irregular heart beat) and idiopathic hypertrophic pyloric stenosis (IHPS). Compared with placebo, azithromycin did not show increased risk ADRs based on RCTs (risk difference − 0.17 to 0.07). The incidence of QT prolonged was higher in the medium-dosage group (10–30 mg/kg/day) than that of low-dosage group (≤ 10 mg/kg/day) (82.0% vs 1.2%). Conclusion The safety of azithromycin as MDA needs further evaluation. The most common ADRs are diarrhea and vomiting. The risk of the most serious uncommon ADRs (cardiac-prolonged QT and IHPS) is unknown. Electronic supplementary material The online version of this article (10.1007/s00228-020-02956-3) contains supplementary material, which is available to authorized users.
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20
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Keenan JD, Arzika AM, Maliki R, Elh Adamou S, Ibrahim F, Kiemago M, Galo NF, Lebas E, Cook C, Vanderschelden B, Bailey RL, West SK, Porco TC, Lietman TM. Cause-specific mortality of children younger than 5 years in communities receiving biannual mass azithromycin treatment in Niger: verbal autopsy results from a cluster-randomised controlled trial. LANCET GLOBAL HEALTH 2020; 8:e288-e295. [PMID: 31981558 PMCID: PMC7025321 DOI: 10.1016/s2214-109x(19)30540-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/31/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022]
Abstract
Background The Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) trial found that biannual mass distribution of azithromycin to children younger than 5 years in Niger reduced the primary outcome of all-cause mortality by 18%. We aimed to determine the causes of mortality among deceased children using verbal autopsy. Methods In this 2-year cluster-randomised controlled trial, 594 community clusters in Niger were randomly allocated (1:1 ratio) to receive biannual mass distributions of either oral azithromycin (approximately 20 mg per kg of bodyweight) or placebo targeted to children aged 1–59 months. Participants, study investigators, and field workers were masked to treatment allocation. Between Nov 23, 2014, and July 31, 2017, 3615 child deaths were recorded by use of biannual house-to-house censuses, and verbal autopsies were done between May 26, 2015, and May 17, 2018, to identify cause of death. Cause-specific mortality, as assessed by verbal autopsy, was a prespecified secondary outcome. This trial is completed and is registered with ClinicalTrials.gov, NCT02047981. Findings Between Nov 23, 2014, and July 31, 2017, 303 communities (n=40 375 children at baseline) in Niger received mass azithromycin and 291 communities (n=35 747 children at baseline) received placebo. Treatment coverage was 90·3% (SD 10·6) in the azithromycin group and 90·4% (10·1) in the placebo group. No communities were lost to follow-up. In total, 1727 child deaths in the azithromycin group and 1888 child deaths in the placebo group were reported from the population censuses. Of these, the cause of death for 1566 (90·7%) children in the azithromycin group and 1735 (91·9%) children in the placebo group were ascertained by verbal autopsy interviews. In the azithromycin group, 437 (27·9%) deaths were due to malaria, 252 (16·1%) deaths were due to pneumonia, and 234 (14·9%) deaths were due to diarrhoea. In the placebo group, 493 (28·4%) deaths were due to malaria, 275 (15·9%) deaths were due to pneumonia, and 251 (14·5%) deaths were due to diarrhoea. Relative to communities that received placebo, child mortality in communities that received azithromycin was lower for malaria (incidence rate ratio 0·78, 95% CI 0·66–0·92; p=0·0029), dysentery (0·65, 0·44–0·94; p=0·025), meningitis (0·67, 0·46–0·97; p=0·036), and pneumonia (0·83, 0·68–1·00; p=0·051). The distribution of causes of death did not differ significantly between the two study groups (p=0·98). Interpretation Mass azithromycin distribution resulted in approximately a third fewer deaths in children aged 1–59 months due to meningitis and dysentery, and a fifth fewer deaths due to malaria and pneumonia. The lack of difference in the distribution of causes of death between the azithromycin and placebo groups could be attributable to the broad spectrum of azithromycin activity and the study setting, in which most childhood deaths were due to infections. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Jeremy D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA; Department of Ophthalmology, University of California, San Francisco, CA, USA.
| | | | | | | | | | | | | | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - Catherine Cook
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | | | - Robin L Bailey
- London School of Hygiene & Tropical Medicine, London, UK
| | - Sheila K West
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Travis 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 & Biostatistics, University of California, San Francisco, CA, USA; Institute for Global Health Sciences, 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; Institute for Global Health Sciences, University of California, San Francisco, CA, USA
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21
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Sié A, Ouattara M, Bountogo M, Bagagnan C, Coulibaly B, Boudo V, Lebas E, Brogdon JM, Lin Y, Bärnighausen T, Porco TC, Doan T, Lietman TM, Oldenburg CE. A double-masked placebo-controlled trial of azithromycin to prevent child mortality in Burkina Faso, West Africa: Community Health with Azithromycin Trial (CHAT) study protocol. Trials 2019; 20:675. [PMID: 31801563 PMCID: PMC6894235 DOI: 10.1186/s13063-019-3855-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 10/25/2019] [Indexed: 01/20/2023] Open
Abstract
Background Biannual, mass azithromycin distribution has previously been shown to reduce all-cause child mortality in sub-Saharan Africa. Subgroup analysis suggested that the strongest effects were in the youngest children, leading to the hypothesis that targeting younger age groups might be an effective strategy to prevent mortality. We present the methods of two randomized controlled trials designed to evaluate mass and targeted azithromycin distribution for the prevention of child mortality in Burkina Faso, West Africa. Methods/design The Child Health with Azithromycin Treatment (CHAT) study consists of two nested, randomized controlled trials. In the first, communities are randomized in a 1:1 fashion to biannual, mass azithromycin distribution or placebo. The primary outcome is under-5 all-cause mortality measured at the community level. In the second, children attending primary healthcare facilities during the first 5–12 weeks of life for a healthy child visit (e.g., for vaccination) are randomized in a 1:1 fashion to a single orally administered dose of azithromycin or placebo. The primary outcome is all-cause mortality measured at 6 months of age. The trial commenced enrollment in August 2019. Discussion This study is expected to provide evidence on two health systems delivery approaches (mass and targeted treatment) for azithromycin to prevent all-cause child mortality. The results will inform global and national policies related to azithromycin for the prevention of child mortality. Trial registration ClinicalTrials.gov, ID: NCT03676764. Registered on 19 September 2018; prospectively registered pre results.
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Affiliation(s)
- Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | - Cheik Bagagnan
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA
| | - Jessica M Brogdon
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA
| | - Ying Lin
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg, Germany.,Africa Health Research Institute (AHRI), Somkhele, South Africa.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, 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
| | - Thuy Doan
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, 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
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, 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.
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22
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Sie A, Bountogo M, Nebie E, Ouattara M, Coulibaly B, Bagagnan C, Zabre P, Lebas E, Brogdon J, Godwin WW, Lin Y, Porco T, Doan T, Lietman TM, Oldenburg CE. Neonatal azithromycin administration to prevent infant mortality: study protocol for a randomised controlled trial. BMJ Open 2019; 9:e031162. [PMID: 31488494 PMCID: PMC6731835 DOI: 10.1136/bmjopen-2019-031162] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Biannual mass azithromycin distribution to children aged 1-59 months has been shown to reduce all-cause mortality. Children under 28 days of age were not treated in studies evaluating mass azithromycin distribution for child mortality due to concerns related to infantile hypertrophic pyloric stenosis (IHPS). Here, we report the design of a randomised controlled trial to evaluate the efficacy and safety of administration of a single dose of oral azithromycin during the neonatal period. METHODS AND ANALYSIS The Nouveaux-nés et Azithromycine: une Innovation dans le Traitement des Enfants (NAITRE) study is a double-masked randomised placebo-controlled trial designed to evaluate the efficacy of a single dose of azithromycin (20 mg/kg) for the prevention of child mortality. Newborns (n=21 712) aged 8-27 days weighing at least 2500 g are 1:1 randomised to a single, directly observed, oral dose of azithromycin or matching placebo. Participants are followed weekly for 3 weeks after treatment to screen for adverse events, including IHPS. The primary outcome is all-cause mortality at the 6-month study visit. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Boards at the University of California, San Francisco in San Francisco, USA (Protocol #18-25027) and the Comité National d'Ethique pour la Recherche in Ouagadougou, Burkina Faso (Protocol #2018-10-123). The findings of this trial will be presented at local, regional and international meetings and published in open access peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03682653; Pre-results.
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Affiliation(s)
- Ali Sie
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | | | - Eric Nebie
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | | | | | - Cheik Bagagnan
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | - Pascal Zabre
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Jessica Brogdon
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - William W Godwin
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Ying Lin
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Travis Porco
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States
| | - Thuy Doan
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States
| | - Catherine E Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States
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23
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Mass Administration of Azithromycin to Prevent Pre-school Childhood Mortality: Boon or Bane? Indian Pediatr 2019. [DOI: 10.1007/s13312-019-1633-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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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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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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