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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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4
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St Jean DT, Rogawski McQuade ET, Edwards JK, Thompson P, Thomas J, Becker-Dreps S. Effect of early life antibiotic use on serologic responses to oral rotavirus vaccine in the MAL-ED birth cohort study. Vaccine 2022; 40:2580-2587. [PMID: 35341645 PMCID: PMC9045361 DOI: 10.1016/j.vaccine.2022.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/06/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Oral rotavirus vaccine efficacy is lower in low- and middle-income countries (LMICs) than in high-income countries. The degree to which antibiotic use impacts rotavirus vaccine immunogenicity in LMICs is unknown. Using data from a multisite prospective birth cohort study of malnutrition and enteric disease, MAL-ED, we examined the effect of early life antibiotic use on the immune response to rotavirus vaccine. METHODS We assessed whether antibiotic use from birth up to 7 days following rotavirus vaccine series completion was associated with rotavirus seropositivity at 7 months of age in Brazil, Peru, and South Africa using a modified Poisson regression. We then used parametric g-computation to estimate the impact of hypothetical interventions that treated all children and alternatively prevented inappropriate antibiotic treatments on seropositivity. RESULTS Of 537 children, 178 (33%) received at least one antibiotic course during the exposure window. Probability of seropositivity was 40% higher among children who had at least one course of antibiotics compared with those with no antibiotic exposure (PR: 1.40, 95% CI: 1.04, 1.89). There was no significant difference by the number of antibiotic courses received or total duration of antibiotics. Treating all children with antibiotics would be associated with a 19% (95% CI: 18%, 21%) absolute increase in seropositivity at 7 months. In contrast, removing inappropriate antibiotics would result in a 4% absolute reduction (95% CI: -5%, -2%) in seropositivity. CONCLUSIONS Early life antibiotic use was associated with increased seropositivity. However, a hypothetical intervention to remove inappropriate antibiotics would have little effect on overall seropositivity. Further investigation into the underlying mechanisms of antibiotic use on the infant gut microbiome and immune response are needed.
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Affiliation(s)
- Denise T St Jean
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peyton Thompson
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James Thomas
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sylvia Becker-Dreps
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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6
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Pickering H, Hart JD, Burr S, Stabler R, Maleta K, Kalua K, Bailey RL, Holland MJ. Impact of azithromycin mass drug administration on the antibiotic-resistant gut microbiome in children: a randomized, controlled trial. Gut Pathog 2022; 14:5. [PMID: 34991704 PMCID: PMC8740015 DOI: 10.1186/s13099-021-00478-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/22/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Mass drug administration (MDA) with azithromycin is the primary strategy for global trachoma control efforts. Numerous studies have reported secondary effects of MDA with azithromycin, including reductions in childhood mortality, diarrhoeal disease and malaria. Most recently, the MORDOR clinical trial demonstrated that MDA led to an overall reduction in all-cause childhood mortality in targeted communities. There is however concern about the potential of increased antimicrobial resistance in treated communities. This study evaluated the impact of azithromycin MDA on the prevalence of gastrointestinal carriage of macrolide-resistant bacteria in communities within the MORDOR Malawi study, additionally profiling changes in the gut microbiome after treatment. For faecal metagenomics, 60 children were sampled prior to treatment and 122 children after four rounds of MDA, half receiving azithromycin and half placebo. RESULTS The proportion of bacteria carrying macrolide resistance increased after azithromycin treatment. Diversity and global community structure of the gut was minimally impacted by treatment, however abundance of several species was altered by treatment. Notably, the putative human enteropathogen Escherichia albertii was more abundant after treatment. CONCLUSIONS MDA with azithromycin increased carriage of macrolide-resistant bacteria, but had limited impact on clinically relevant bacteria. However, increased abundance of enteropathogenic Escherichia species after treatment requires further, higher resolution investigation. Future studies should focus on the number of treatments and administration schedule to ensure clinical benefits continue to outweigh costs in antimicrobial resistance carriage. Trial registration ClinicalTrial.gov, NCT02047981. Registered January 29th 2014, https://clinicaltrials.gov/ct2/show/NCT02047981.
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Affiliation(s)
| | - John D Hart
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Burr
- London School of Hygiene and Tropical Medicine, London, UK.,College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Ken Maleta
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Khumbo Kalua
- College of Medicine, University of Malawi, Blantyre, Malawi.,Blantyre Institute for Community Outreach, Blantyre, Malawi
| | - Robin L Bailey
- London School of Hygiene and Tropical Medicine, London, UK
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7
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Ahmed T, Chisti MJ, Rahman MW, Alam T, Ahmed D, Parvin I, Kabir MF, Sazawal S, Dhingra P, Dutta A, Deb S, Chouhan A, Sharma AK, Jaiswal VK, Dhingra U, Walson JL, Singa BO, Pavlinac PB, McGrath CJ, Nyabinda C, Deichsel EL, Anyango M, Kariuki KM, Rwigi D, Tornberg-Belanger SN, Kotloff KL, Sow SO, Tapia MD, Haidara FC, Mehta A, Coulibaly F, Badji H, Permala-Booth J, Tennant SM, Malle D, Bar-Zeev N, Dube Q, Freyne B, Cunliffe N, Ndeketa L, Witte D, Ndamala C, Cornick J, Qamar FN, Yousafzai MT, Qureshi S, Shakoor S, Thobani R, Hotwani A, Kabir F, Mohammed J, Manji K, Duggan CP, Kisenge R, Sudfeld CR, Kibwana U, Somji S, Bakari M, Msemwa C, Samma A, Bahl R, De Costa A, Simon J, Ashorn P. Effect of 3 Days of Oral Azithromycin on Young Children With Acute Diarrhea in Low-Resource Settings: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2136726. [PMID: 34913980 PMCID: PMC8678692 DOI: 10.1001/jamanetworkopen.2021.36726] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022] Open
Abstract
Importance World Health Organization (WHO) guidelines do not recommend routine antibiotic use for children with acute watery diarrhea. However, recent studies suggest that a significant proportion of such episodes have a bacterial cause and are associated with mortality and growth impairment, especially among children at high risk of diarrhea-associated mortality. Expanding antibiotic use among dehydrated or undernourished children may reduce diarrhea-associated mortality and improve growth. Objective To determine whether the addition of azithromycin to standard case management of acute nonbloody watery diarrhea for children aged 2 to 23 months who are dehydrated or undernourished could reduce mortality and improve linear growth. Design, Setting, and Participants The Antibiotics for Children with Diarrhea (ABCD) trial was a multicountry, randomized, double-blind, clinical trial among 8266 high-risk children aged 2 to 23 months presenting with acute nonbloody diarrhea. Participants were recruited between July 1, 2017, and July 10, 2019, from 36 outpatient hospital departments or community health centers in a mixture of urban and rural settings in Bangladesh, India, Kenya, Malawi, Mali, Pakistan, and Tanzania. Each participant was followed up for 180 days. Primary analysis included all randomized participants by intention to treat. Interventions Enrolled children were randomly assigned to receive either oral azithromycin, 10 mg/kg, or placebo once daily for 3 days in addition to standard WHO case management protocols for the management of acute watery diarrhea. Main Outcomes and Measures Primary outcomes included all-cause mortality up to 180 days after enrollment and linear growth faltering 90 days after enrollment. Results A total of 8266 children (4463 boys [54.0%]; mean [SD] age, 11.6 [5.3] months) were randomized. A total of 20 of 4133 children in the azithromycin group (0.5%) and 28 of 4135 children in the placebo group (0.7%) died (relative risk, 0.72; 95% CI, 0.40-1.27). The mean (SD) change in length-for-age z scores 90 days after enrollment was -0.16 (0.59) in the azithromycin group and -0.19 (0.60) in the placebo group (risk difference, 0.03; 95% CI, 0.01-0.06). Overall mortality was much lower than anticipated, and the trial was stopped for futility at the prespecified interim analysis. Conclusions and Relevance The study did not detect a survival benefit for children from the addition of azithromycin to standard WHO case management of acute watery diarrhea in low-resource settings. There was a small reduction in linear growth faltering in the azithromycin group, although the magnitude of this effect was not likely to be clinically significant. In low-resource settings, expansion of antibiotic use is not warranted. Adherence to current WHO case management protocols for watery diarrhea remains appropriate and should be encouraged. Trial Registration ClinicalTrials.gov Identifier: NCT03130114.
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Affiliation(s)
- Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Muhammad Waliur Rahman
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmina Alam
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Dilruba Ahmed
- Laboratory Sciences and Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Irin Parvin
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Farhad Kabir
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sunil Sazawal
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | | | - Arup Dutta
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | - Saikat Deb
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | | | | | | | - Usha Dhingra
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | - Judd L Walson
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
- Department of Medicine (Allergy and Infectious Diseases), University of Washington, Seattle
| | - Benson O Singa
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - Emily L Deichsel
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | | | | | - Doreen Rwigi
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Karen L Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Samba O Sow
- Centre pour le Développement des Vaccins, Bamako, Mali
| | - Milagritos D Tapia
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Fadima Cheick Haidara
- Division of Advanced Primary Health Care Research and Clinical Trials, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Ashka Mehta
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Flanon Coulibaly
- Division of Advanced Primary Health Care Research and Clinical Trials, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Henry Badji
- Division of Clinical Microbiology and Molecular Biology, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Jasnehta Permala-Booth
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Sharon M Tennant
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Dramane Malle
- Division of Clinical Microbiology and Molecular Biology, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Naor Bar-Zeev
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Queen Dube
- Department of Pediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bridget Freyne
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Institute of Infection, Veterinary and Ecological Sciences, The University of Liverpool, Blantyre, Malawi
| | - Nigel Cunliffe
- National Institutes of Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
| | - Latif Ndeketa
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine, Blantyre, Malawi
| | - Desiree Witte
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Chifundo Ndamala
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Jennifer Cornick
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Institute of Infection, Veterinary and Ecological Sciences, The University of Liverpool, Blantyre, Malawi
| | - Farah Naz Qamar
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | | | - Shahida Qureshi
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Sadia Shakoor
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Rozina Thobani
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Furqan Kabir
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Jan Mohammed
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher P Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Upendo Kibwana
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohamed Bakari
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Cecylia Msemwa
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abraham Samma
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rajiv Bahl
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Ayesha De Costa
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Jonathon Simon
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Per Ashorn
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
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9
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Hart JD, Samikwa L, Sikina F, Kalua K, Keenan JD, Lietman TM, Burr SE, Bailey RL. Effects of Biannual Azithromycin Mass Drug Administration on Malaria in Malawian Children: A Cluster-Randomized Trial. Am J Trop Med Hyg 2020; 103:1329-1334. [PMID: 32342841 PMCID: PMC7470590 DOI: 10.4269/ajtmh.19-0619] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Reductions in malaria morbidity have been reported following azithromycin mass drug administration (MDA) for trachoma. The recent Macrolides Oraux pour Reduire les Deces avec un Oeil sur la Resistance (MORDOR) trial reported a reduction in child mortality following biannual azithromycin MDA. Here, we investigate the effects of azithromycin MDA on malaria at the MORDOR-Malawi study site. A cluster-randomized double-blind placebo-controlled trial, with 15 clusters per arm, was conducted. House-to-house census was updated biannually, and azithromycin or placebo syrup was distributed to children aged 1–59 months for a total of four biannual distributions. At baseline, 12-month, and 24-month follow-up visits, a random sample of 1,200 children was assessed for malaria with thick and thin blood smears and hemoglobin measurement. In the community-level analysis, there was no difference in the prevalence of parasitemia (1.0% lower in azithromycin-treated communities; 95% CI: −8.2 to 6.1), gametocytemia (0.7% lower in azithromycin-treated communities; 95% CI: −2.8 to 1.5), or anemia (1.7% lower in azithromycin-treated communities; 95% CI: −8.1 to 4.6) between placebo and azithromycin communities. Further interrogation of the data at the individual level, both per-protocol (including only those who received treatment 6 months previously) and by intention-to-treat, did not identify differences in parasitemia between treatment arms. In contrast to several previous reports, this study did not show an effect of azithromycin MDA on malaria parasitemia at the community or individual levels.
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Affiliation(s)
- John D Hart
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lyson Samikwa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Feston Sikina
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Khumbo Kalua
- Blantyre Institute for Community Outreach, Blantyre, Malawi
| | - Jeremy D Keenan
- Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Sarah E Burr
- College of Medicine, University of Malawi, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Robin L Bailey
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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