Abstract
.Mass azithromycin distribution has been shown to reduce all-cause mortality in preschool children in sub-Saharan Africa. However, substantial heterogeneity in the apparent effect has been noted across geographic settings, suggesting a greater relative benefit in higher mortality settings. Here, we evaluated the relationship between the underlying mortality rate and the efficacy of azithromycin for the prevention of child mortality using data from multiple sites in Ethiopia, Malawi, Niger, and Tanzania. Between regions, we find no strong evidence of effect modification of the efficacy of azithromycin distribution for the prevention of child mortality by the underlying mortality rate (P = 0.12), although a modest effect is consistent with our findings. Higher mortality settings could be prioritized, however, because of the larger number of deaths which could be averted with azithromycin distribution.
Highlights
IntroductionSmall trials of mass azithromycin distribution for trachoma control suggested that mass azithromycin may reduce postneonatal childhood mortality.[1,2,3] In the original primary analyses, the Trachoma Amelioration in northern Amhara (TANA) study demonstrated an odds ratio of 0.51 for mortality in the azithromycin treatment group (95% CI: 0.29–0.90), for an overall reduction in child mortality in communities receiving azithromycin compared with delayed azithromycin
In the original primary analyses, the Trachoma Amelioration in northern Amhara (TANA) study demonstrated an odds ratio of 0.51 for mortality in the azithromycin treatment group, for an overall reduction in child mortality in communities receiving azithromycin compared with delayed azithromycin
In the Niger component of the Partnership for the Rapid Elimination of Trachoma (PRET) study, biannual treatment of children led to a mortality rate ratio of 0.81, an overall reduction in child mortality compared with annual treatment of the entire community
Summary
Small trials of mass azithromycin distribution for trachoma control suggested that mass azithromycin may reduce postneonatal childhood mortality.[1,2,3] In the original primary analyses, the Trachoma Amelioration in northern Amhara (TANA) study demonstrated an odds ratio of 0.51 for mortality in the azithromycin treatment group (95% CI: 0.29–0.90), for an overall reduction in child mortality in communities receiving azithromycin compared with delayed azithromycin. Distribution of azithromycin for trachoma control has been shown to select for macrolide resistance in some organisms.[5,6,7,8] identifying areas which maximize the efficacy of azithromycin for prevention of child mortality could aid in limiting distributions to regions where it may be most effective, and limit antibiotic consumption. In both subgroup analyses of MORDOR and the pooled analysis,[9] effects appeared to be larger in areas with higher mortality. We assess the dependence of the efficacy of mass azithromycin distributions on the underlying childhood mortality rate in
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