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Costs, Coverage, and Acceptability of Azithromycin Mass Administration to Children 1-11 Versus 1-59 Months Old to
Ahmed M Arzika1, Ramatou Maliki1, Abdou Amza2
1Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger.
Insights
Expanding azithromycin mass drug administration (MDA) to include children aged 1-59 months is more cost-effective and preferred by communities. This approach, despite concerns about antimicrobial resistance, showed lower costs and higher acceptability than restricting MDA to infants aged 1-11 months.
Area of Science:
- Global Health
- Infectious Diseases
- Public Health Interventions
Background:
- Azithromycin mass drug administration (MDA) in children aged 1-59 months reduces child mortality.
- Current guidelines limit azithromycin MDA to 1-11-month-olds due to antimicrobial resistance concerns.
- Implementation trials are crucial for evaluating real-world effectiveness and feasibility of different MDA age groups.
Purpose of the Study:
- To compare implementation outcomes of azithromycin MDA for 1-59-month-olds versus 1-11-month-olds.
- To assess cost-effectiveness, coverage, acceptability, appropriateness, and feasibility of the two MDA approaches.
- To inform guidelines on optimizing azithromycin MDA strategies for child mortality reduction.
Main Methods:
- A cluster-randomized implementation trial conducted in rural Niger.
- Random assignment of communities to biannual azithromycin MDA for either 1-59-month-olds or 1-11-month-olds over one year.
- Primary outcome: community-level cost per dose delivered. Secondary outcomes: reach, acceptability, appropriateness, and feasibility.
Main Results:
- The 1-59-month arm had a significantly lower mean cost per dose delivered ($1.60 vs. $8.20).
- Treatment coverage exceeded 90% in both arms, with similar reach.
- Caregivers found the 1-59-month intervention more acceptable and appropriate; community groups strongly preferred it.
Conclusions:
- Including children aged 1-59 months in azithromycin MDA is more cost-effective and feasible than restricting to 1-11-month-olds.
- The broader age group demonstrated higher acceptability and appropriateness among participants and providers.
- Findings support revising guidelines to include younger children in azithromycin MDA programs to reduce child mortality.
Abstract:
Azithromycin mass drug administration (MDA) for 1- to 59-month-olds reduces child mortality. However, guidelines restrict eligibility to 1- to 11-month-olds because of concerns about antimicrobial resistance. This cluster-randomized implementation trial was conducted in parallel with a larger efficacy trial and compared implementation outcomes between these approaches. Rural communities in Niger were randomly assigned to receive biannual azithromycin MDA for either 1- to 59-month-olds or 1- to 11-month-olds over 1 year. The primary outcome was the community-level cost per dose delivered. Secondary outcomes included reach (coverage), as well as acceptability, appropriateness, and feasibility according to participants and providers. In November 2020, 40 eligible communities were randomly assigned to each arm, with 37 communities in the 1- to 59-month arm and 39 communities in the 1- to 11-month arm contributing to analyses. The mean cost per dose delivered was $6.50 lower (95% CI -$10.40 to -$3.70; P-value <0.001) in the 1- to 59-month arm ($1.60; 95% CI $1.00 to $2.30) compared with the 1- to 11-month arm ($8.20; 95% CI $7.60 to $8.80). Treatment coverage was similar by arm and exceeded 90% in both distributions. More caregivers in the 1- to 59-month arm found the intervention acceptable (mean difference 4.2%; 95% CI 0 to 8.4%; P-value 0.04) and appropriate (3.4%; 95% CI 0.1 to 6.8%; P-value 0.04) compared with the 1- to 11-month arm. When combining arms, all groups indicated that including 1- to 59-month-olds was more acceptable, appropriate, and feasible than restricting to 1- to 11-month-olds. No serious adverse events were reported. Overall, including 1- to 59-month-olds resulted in a lower cost per dose delivered than restricting to 1- to 11-month-olds. Community groups perceived both interventions to be acceptable, appropriate, and feasible, but they strongly preferred the 1- to 59-month treatment.
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