AVENIR: Azithromycin for Child Survival in Niger: Mortality and Resistance Trial
Study Details
Study Description
Brief Summary
The MORDOR trial found that biannual distribution of azithromycin to children 1-59 months old reduced child mortality. The World Health Organization (WHO) released conditional guidelines for this intervention, which include targeting azithromycin distributions to children 1-11 months of age in high mortality settings.Targeting treatment to children 1-11 months old could reduce antimicrobial resistance by limiting antibiotic distributions while treating children at the highest mortality risk. However, this targeted intervention has not yet been tested.
The AVENIR mortality/resistance trial aims to assess the efficacy of age-based targeting of biannual azithromycin distribution on mortality as well as determine the impact of age-based targeting on antimicrobial resistance.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
Phase 4 |
Detailed Description
In the Mortality/Resistance trial, 3,350 communities in the Dosso and Tahoua regions of Niger will be randomized to one of three arms: 1) azithro 1-11: biannual oral azithromycin to children 1-11 months old with biannual oral placebo to children 12-59 months old, 2) azithro 1-59: biannual oral azithromycin to children 1-59 months old, or 3) placebo: biannual oral placebo to children 1-59 months old. Interventions will be delivered biannually through a door-to-door census. Mortality will also be monitored through biannual census data collection, which will be used to adaptively allocate treatment assignments after the first year. Communities will retain an allocation for 4 distributions before being re-randomized.
Antimicrobial resistance will be monitored using cluster sampling of treated and untreated children and adults in the Dosso region.
To determine the costs of treating 1-11-month-old children only, an additional 80 communities in the Dosso region will be selected. These communities will be randomized in a 1:1 fashion to either receive 1) distribution of open-label azithromycin to children 1-11 months old with no intervention distribution to children 12-59 months old or 2) distribution of open-label azithromycin to children 1-59 months old.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Active Comparator: Azithro 1-11 Biannual weight- or height-based dose of oral azithromycin suspension to children 1-11 months old and oral placebo or no intervention to children 12-59 months old |
Drug: Azithromycin
Azithromycin will be administered as a directly observed dose in oral suspension form for children:
Single-dose of 20mg/kg in children (up to the maximum adult dose of 1g)
For children 1-11 months of age, weight or age-based dosing will be used
For children 12-59 months of age, height-based dosing will be used via height-stick approximation as currently performed by Niger's trachoma program
Other Names:
Other: Placebo
Placebo will be administered as a directly observed dose in oral suspension form for children:
Single-dose of 20mg/kg in children (up to the maximum adult dose of 1g)
For children 1-11 months of age, weight-based dosing will be used
For children 12-59 months of age, height-based dosing will be used via height-stick approximation as currently performed by Niger's trachoma program
|
| Active Comparator: Azithro 1-59 Biannual age, weight- or height-based dose of oral azithromycin suspension to children 1-59 months old |
Drug: Azithromycin
Azithromycin will be administered as a directly observed dose in oral suspension form for children:
Single-dose of 20mg/kg in children (up to the maximum adult dose of 1g)
For children 1-11 months of age, weight or age-based dosing will be used
For children 12-59 months of age, height-based dosing will be used via height-stick approximation as currently performed by Niger's trachoma program
Other Names:
|
| Placebo Comparator: Placebo Biannual weight- or height-based dose of oral placebo to children 1-59 months old |
Other: Placebo
Placebo will be administered as a directly observed dose in oral suspension form for children:
Single-dose of 20mg/kg in children (up to the maximum adult dose of 1g)
For children 1-11 months of age, weight-based dosing will be used
For children 12-59 months of age, height-based dosing will be used via height-stick approximation as currently performed by Niger's trachoma program
|
Outcome Measures
Primary Outcome Measures
- All-cause mortality (1-59 months old) [2.5 years from the first enrollment]
Mortality rate (deaths per 1,000 person-years at risk) among children 1-59 months of age, comparing the azithro 1-59 and placebo arms.
- All-cause mortality (1-11 months old) [2.5 years from the first enrollment]
Mortality rate (deaths per 1,000 person-years at risk) among children 1-11 months of age, comparing the azithro 1-11 and placebo arms.
- All-cause mortality (12-59 months old) [2.5 years from the first enrollment]
Mortality rate (deaths per 1,000 person-years at risk) among children 12-59 months of age with rates compared between azithro 1-11 and azithro 1-59 communities.
- Prevalence of resistance to macrolides - nasopharyngeal swabs (1-59 months old) [After 4 distributions (approximately 24 months)]
Prevalence of resistance to macrolides including those determinants known to be found in Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus from nasopharyngeal swabs in children 1-59 months old.
- Load of genetic determinants of resistance to macrolides - rectal swabs (1-59 months old) [After 4 distributions (approximately 24 months)]
Load of genetic determinants of resistance to macrolides including those determinants known to be found in Campylobacter spp, Salmonella spp, Shigella spp, and Escherichia coli from rectal swabs in children 1-59 months old, defined as read number per million base pairs, using DNA-seq (metagenomic deep sequencing)
Secondary Outcome Measures
- All-cause mortality (12-59 months old) [2.5 years from first enrollment]
Mortality rate (deaths per 1,000 person-years at risk) among children ages 12-59 months over 2.5 years, comparing the azithro 1-11 and placebo arms.
- All-cause mortality (1-11 months old ) [2.5 years from first enrollment]
Mortality rate (deaths per 1,000 person-years at risk) among children ages 1-11 months over 2.5 years, comparing the azithro 1-11 and azithro 1-59 arms.
- Mortality rate by subgroup: anthropometric indicators [Over 2.5 years]
Mortality rate compared by arm in subgroups based on weight in children 1-11 months
- Prevalence of resistance to macrolides from nasopharyngeal swabs and load of genetic determinants of resistance to macrolides from rectal swabs [After 4 distributions (approximately 24 months)]
Prevalence of resistance to macrolides from nasopharyngeal swabs and load of genetic determinants of resistance to macrolides from rectal swabs in: Children 7-12 years old at 24 months from baseline Caregivers/guardians of eligible children at 24 months from baseline
- Program costs [2.5 years]
Program costs as captured by routine administrative data collection during the study period and by micro-costing activities.
Eligibility Criteria
Criteria
- Intervention
At the community-level, eligibility includes:
Inclusion Criteria:
-
Location in Dosso, Tahoua, Maradi, Zinder, or Tillabéri regions
-
Population 250 to 2,499*
-
Distance > 5 km from district headquarters town
-
Distinguishable from neighboring communities
-
Verbal consent of community leader(s)
Exclusion criteria:
-
Inaccessible or unsafe for study team
-
"Quartier" designation on national census *Population size as estimated from the most recent national census or projections
At the individual-level, eligibility includes:
Inclusion criteria:
-
Age 1-59 months
-
Primary residence in a study community
-
Verbal consent of caregiver/guardian for study participation
-
Weight ≥ 3.0 kg (*no weight limits in communities using age-based dosing)
Exclusion criteria:
• Known allergy to macrolides
- Population-based sample collections
At the community-level, eligibility includes:
Inclusion Criteria:
-
Location in Dosso
-
Distinguishable from neighboring communities
-
Verbal consent of community leader(s)
Exclusion criteria:
-
Inaccessible or unsafe for the study team
-
Included in MORDOR trials
-
Not randomly selected
-
Received treatment prior to sample collection
At the individual-level, eligibility includes:
Inclusion Criteria:
-
Age 1-59 months or 7-12 years or caregiver/guardian of a child eligible for treatment
-
Primary residence in a study community selected for sample collections
-
Verbal consent of caregiver/guardian for study participation
Exclusion criteria:
• An individual is not on the list of randomly selected participants from the census
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Programme national de santé oculaire | Niamey | Niger |
Sponsors and Collaborators
- University of California, San Francisco
- Bill and Melinda Gates Foundation
- Ministry of Health, Niger
Investigators
- Principal Investigator: Tom M Lietman, MD, University of California, San Francisco
- Principal Investigator: Kieran S O'Brien, PhD, University of California, San Francisco
Study Documents (Full-Text)
None provided.More Information
Publications
- Doan T, Arzika AM, Hinterwirth A, Maliki R, Zhong L, Cummings S, Sarkar S, Chen C, Porco TC, Keenan JD, Lietman TM; MORDOR Study Group. Macrolide Resistance in MORDOR I - A Cluster-Randomized Trial in Niger. N Engl J Med. 2019 Jun 6;380(23):2271-2273. doi: 10.1056/NEJMc1901535.
- Keenan JD, Arzika AM, Maliki R, Boubacar N, Elh Adamou S, Moussa Ali M, Cook C, Lebas E, Lin Y, Ray KJ, O'Brien KS, Doan T, Oldenburg CE, Callahan EK, Emerson PM, Porco TC, Lietman TM. Longer-Term Assessment of Azithromycin for Reducing Childhood Mortality in Africa. N Engl J Med. 2019 Jun 6;380(23):2207-2214. doi: 10.1056/NEJMoa1817213.
- Keenan JD, Bailey RL, West SK, Arzika AM, Hart J, Weaver J, Kalua K, Mrango Z, Ray KJ, Cook C, Lebas E, O'Brien KS, Emerson PM, Porco TC, Lietman TM; MORDOR Study Group. Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa. N Engl J Med. 2018 Apr 26;378(17):1583-1592. doi: 10.1056/NEJMoa1715474.
- Oldenburg CE, Arzika AM, Maliki R, Lin Y, O'Brien KS, Keenan JD, Lietman TM, For The Mordor Study Group. Optimizing the Number of Child Deaths Averted with Mass Azithromycin Distribution. Am J Trop Med Hyg. 2020 Sep;103(3):1308-1310. doi: 10.4269/ajtmh.19-0328.
- WHO Guideline on Mass Drug Administration of Azithromycin to Children under Five Years of Age to Promote Child Survival [Internet]. Geneva: World Health Organization; 2020. No abstract available. Available from http://www.ncbi.nlm.nih.gov/books/NBK561641/
- 19-28387A