Childhood Mortality in a Cohort Treated With Mass Azithromycin for Trachoma

Background. Mass azithromycin distributions are used to clear ocular strains of chlamydia that cause trachoma, but treatments may also affect respiratory infections, diarrhea, and malaria. Here, we monitor a large cohort in which almost 90% of individuals received azithromycin. We assess whether receiving treatment is associated with reduced all-cause and infectious childhood mortality. Methods. As part of a clinical trial for trachoma, a census was conducted in 24 communities in rural Ethiopia. All individuals >= 1 year of age were eligible for single-dose oral azithromycin, although antibiotic coverage was not universal. A follow-up census was performed 26 months after treatment to estimate all-cause mortality among children 1-5 years of age, and verbal autopsies were performed to identify infectious mortality. Results. The cohort included 35,052 individuals >= 1 year of age and 5507 children 1-5 years of age, of whom 4914 received a dose of azithromycin. All-cause mortality was significantly lower among those 1-5-year-old children who received azithromycin (odds ratio [OR] 5 0.35 [95% confidence interval {CI}, 0.17-0.74]), as was infectious mortality (OR = 0.20 [95% CI, 0.07-0.58]). When individuals were compared only with members of the same household, azithromycin treatment was still associated with reduced all-cause mortality in children 1-5 years of age (OR = 0.40 [95% CI, 0.16-0.96]), although this relationship was not statistically significant for infectious mortality (OR = 0.35 [95% CI, 0.10-1.28]). Conclusions. This study demonstrated an association between mass oral azithromycin treatment and reduced all-cause and infectious childhood mortality. This relationship could not be attributed to bias at the level of the household. Mass azithromycin distributions may have benefits unrelated to trachoma.