Effect of Mass Distribution of Azithromycin for Trachoma Control on Overall Mortality in Ethiopian Children A Randomized Trial

Context Mass oral azithromycin distribution to affected communities is a cornerstone of the World Health Organization's trachoma elimination program. Antibiotics are provided to target the ocular strains of chlamydia that cause trachoma, but may also be efficacious against respiratory disease, diarrhea, and malaria-frequent causes of childhood mortality in trachoma-endemic areas. Objective To compare mortality rates of participants aged 1 to 9 years in treated communities with those in untreated communities. Design, Setting, and Participants We conducted a cluster-randomized clinical trial of mass azithromycin administration for trachoma control. Forty-eight communities (known as subkebeles) were randomized into 1 of 3 treatment schedules (annual treatment of all residents [15 902 participants], biannual treatment of all residents [17 288 participants], or quarterly treatment of children only [14 716 participants]) or into 1 group for which treatment was delayed by 1 year (control, 18 498 participants). Twelve subkebeles were randomized to each of the 4 schedules with all children in each of the 3 communities being eligible for treatment. The trial was conducted in a field setting in rural Ethiopia, May 2006 to May 2007. Interventions A single dose of oral azithromycin (adults, 1 g; children, 20 mg/kg) was administered for treatment of ocular Chlamydia trachomatis infection. Antibiotic coverage levels for children aged 1 to 9 years exceeded 80% at all visits. Main Outcome Measure The main outcome measure was the community-specific mortality risk for children aged 1 to 9 years over the course of 1 year. Mortality was measured by enumerative census at baseline and again after 1 year. Comparison of the risk of mortality was a prespecified outcome for the clinical trial. Results The odds ratio for childhood mortality in the intervention communities was 0.51 (95% confidence interval, 0.29-0.90; P=.02; clustered logistic regression) compared with the control group. In the treated communities, the estimated overall mortality rate during this period for children aged 1 to 9 years in the untreated group was 8.3 per 1000 person-years (95% confidence interval, 5.3-13.1), while among the treated communities, the estimated overall mortality rate was 4.1 per 1000 person-years (95% confidence interval, 3.0-5.7) for children aged 1 to 9 years. Conclusion In a trachoma-endemic area, mass distribution of oral azithromycin was associated with reduced mortality in children. Trial Registration clinicaltrials.gov Identifier: NCT00322972 JAMA. 2009;302(9):962-968 www.jama.com