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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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Adjunctive Azithromycin Prophylaxis for Prelabor Cesarean Birth. Obstet Gynecol 2023; 141:403-413. [PMID: 36649335 DOI: 10.1097/aog.0000000000005037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/17/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate maternal postoperative infections before and after addition of adjunctive azithromycin to standard antibiotic prophylaxis for prelabor cesarean births. METHODS We conducted a retrospective cohort study of patients with singleton gestations at more than 23 weeks of gestation who underwent prelabor cesarean birth at a single tertiary care center. Deliveries were categorized as those before implementation of 500 mg intravenous azithromycin in addition to standard preoperative cephalosporin antibiotic prophylaxis (pre-AZI group; January 2013-September 2015) and those after implementation of adjunctive azithromycin (post-AZI group; January 2016-December 2018). Cesarean births from October to December 2015 were excluded as a washout period. The primary outcome was a composite of postcesarean infections (endometritis, superficial or deep wound infections, intra-abdominal abscess, urinary tract infections). Secondary outcomes included composite components, other wound or postoperative complications, and select neonatal morbidities. Outcomes were compared between groups, and adjusted odds ratios (aORs) and 95% CIs were calculated using multivariable analysis. Propensity score matching was performed to assess the robustness our analysis. RESULTS Of 2,867 delivering patients included for analysis, 1,391 (48.5%) were in the pre-AZI group and 1,476 (51.5%) were in the post-AZI group. Patients in the post-AZI group were older and were more likely to have private insurance, use aspirin, and receive predelivery antibiotics within 2 weeks. There were significantly lower odds of composite infection after azithromycin implementation (3.3% vs 4.8%, aOR 0.60, 95% CI 0.40-0.89), driven by a reduction in wound infection odds (2.4% vs 3.5%, aOR 0.61, 95% CI 0.39-0.98). There were lower odds of other postpartum complications, including wound seroma (0.5% vs 0.9%, aOR 0.34, 95% CI 0.13-0.90) and dehiscence (0.5% vs 1.2%, aOR 0.32, 95% CI 0.13-0.79). There were no differences in select neonatal morbidities between groups. Of 1,138 matching sets in the propensity analysis, the primary outcome remained significantly lower in the post-AZI group (aOR 0.64, 95% CI 0.41-0.99). CONCLUSION Adopting adjunctive azithromycin for prelabor cesarean deliveries was associated with lower odds of postpartum infection.
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Brennhofer SA, Rogawski McQuade ET, Zhang J, Pholwat S, Stroup S, Platts-Mills JA, Liu J, Houpt ER. Effect of Biannual Azithromycin to Children under 5 Years on the Carriage of Respiratory Pathogens among Children Aged 7-11 Years. Am J Trop Med Hyg 2023; 108:428-432. [PMID: 36535258 PMCID: PMC9896336 DOI: 10.4269/ajtmh.22-0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/05/2022] [Indexed: 12/23/2022] Open
Abstract
In the MORDOR I trial, children under 5 years of age were randomized to receive biannual (every 6 months) azithromycin for 2 years in Niger, Malawi, and Tanzania. In 30 Nigerien communities, children aged 7-11 years, who were not enrolled in the MORDOR I trial to receive biannual azithromycin, were assessed for carriage of seven respiratory pathogens. We aimed to see whether there were effects on the carriage of these seven respiratory pathogens among 3,187 children aged 7-11 years living in the 30 communities via nasopharyngeal swabs collected at baseline (N = 1,066), as well as at year 1 (N = 1,019) and year 2 (N = 1,102)-each about 6 months after azithromycin or placebo treatment of children under age five. Most children were positive for Haemophilus influenzae (baseline: 83.8%; interquartile range [IQR]: 78.7-90.4) and Streptococcus pneumoniae (baseline: 82.9%; IQR: 74.2-86.8) at all time points regardless of treatment group. There were no differences in prevalence nor quantity of H. influenzae (prevalence ratio: 0.95; 95% CI: 0.90, 1.02), S. pneumoniae (prevalence ratio: 1.01; 95% CI: 0.96, 1.07), or any of the other respiratory pathogens in the treatment versus control groups at any time point. S. pneumoniae serotype 6AB (7.7%) and Neisseria meningitidis serotype W135 (24.9%) were the most prevalent serotypes detected among all positive S. pneumoniae and N. meningitidis samples, respectively. Biannual azithromycin did not reduce carriage of respiratory pathogens 6 months after the most recent round of biannual azithromycin among older nontreated children (aged 7-11 years) living in treatment communities.
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Affiliation(s)
- Stephanie A. Brennhofer
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia
| | - Elizabeth T. Rogawski McQuade
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia;,Address correspondence to Elizabeth T. Rogawski McQuade, Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322. E-mail:
| | - Jixian Zhang
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia
| | - Suporn Pholwat
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia
| | - Suzanne Stroup
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia
| | - James A. Platts-Mills
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia
| | - Jie Liu
- School of Public Health, Qingdao University, Qingdao, China
| | - Eric R. Houpt
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia
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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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Hart JD, Samikwa L, Meleke H, Burr SE, Cornick J, Kalua K, Bailey RL. Prevalence of nasopharyngeal Streptococcus pneumoniae carriage and resistance to macrolides in the setting of azithromycin mass drug administration: analysis from a cluster-randomised controlled trial in Malawi, 2015–17. THE LANCET MICROBE 2022; 3:e142-e150. [PMID: 35156069 PMCID: PMC8819720 DOI: 10.1016/s2666-5247(21)00279-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Azithromycin mass drug administration (MDA) could reduce child mortality. However, macrolide resistance, which has generally been reported to develop after whole-community MDA for trachoma control, is a concern, and it has less commonly been studied in the context of treating children to reduce mortality. Here, we report on macrolide resistance after biannual azithromycin MDA at the Malawi site of the MORDOR study. Methods In the MORDOR cluster-randomised trial in Malawi, 30 communities in Mangochi District were randomly selected. Communities were randomly assigned to receive azithromycin or placebo by simple randomisation without stratification. Children aged 1–59 months were administered azithromycin 20 mg/kg or placebo as an oral suspension biannually for a total of four treatments in 2015–17. 1200 children (40 children per community) were randomly selected for nasopharyngeal swabs at baseline, 12 months (6 months after the second treatment visit), and 24 months (6 months after the fourth treatment visit). Samples were processed to culture Streptococcus pneumoniae. The primary outcome was the proportion of S pneumoniae isolates exhibiting macrolide resistance at 12 months and 24 months, assessed in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT02048007. Findings At baseline, 3467 (76%) of 4541 eligible children in the azithromycin group and 3107 (72%) of 4308 eligible children in the placebo group were treated. 564 nasopharyngeal swabs were taken from the azithromycin group and 563 from the placebo group, with similar numbers of swabs taken at 12 months and 24 months. In both groups at baseline, carriage of S pneumoniae was greater than 85% and the proportion of strains resistant to macrolides was 28%. At the 12-month follow-up, macrolide resistance was higher in the azithromycin group (36·9%, 95% CI 32·5–41·2) than in the placebo group (21·6%, 17·7–25·4; OR 2·26, 95% CI 1·46–3·49; p=0·0002). At 24 months, macrolide resistance remained higher in the azithromycin group (43·9%, 39·2–48·5) compared with placebo (32·8%, 28·5–37·1; OR 1·66, 1·15–2·40; p=0·0069). Interpretation These findings support previous evidence from trachoma MDA programmes and suggest that monitoring of macrolide resistance should remain a key component of azithromycin interventions for reducing child mortality. Funding Bill & Melinda Gates Foundation.
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