The Effect of Mass Azithromycin Distribution on Childhood Mortality: Beliefs and Estimates of Efficacy

Craig W. See F.I. Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California

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Kieran S. O'Brien F.I. Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California

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Jeremy D. Keenan F.I. Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California

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Nicole E. Stoller F.I. Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California

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Bruce D. Gaynor F.I. Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California

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Travis C. Porco F.I. Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California

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Thomas M. Lietman F.I. Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California

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A cluster-randomized trial demonstrated that mass oral azithromycin distribution reduced childhood mortality 49.6% (Trachoma Amelioration in Northern Amhara [TANA]). The relative risk of childhood mortality was then estimated using two approaches: an expert survey and a Bayesian analysis. The survey asked public health experts to estimate the true effect of mass azithromycin distribution on childhood mortality. The Bayesian estimation used the TANA study's results and prior estimates of the efficacy of other effective population-level interventions. The experts believed mass azithromycin reduces childhood mortality (relative risk = 0.83, 95% credible intervals [CrI] = 0.70–1.00). The Bayesian analysis estimated a relative risk of 0.71 (95% CrI = 0.39–0.93). Both estimates suggest that azithromycin may have a true mortality benefit, though of a smaller magnitude than found in the single available trial. Prior information about nonantibiotic, population-level interventions may have informed the expert's opinions. Additional trials are needed to confirm a mortality benefit from mass azithromycin.

Author Notes

* Address correspondence to Thomas M. Lietman, F.I. Proctor Foundation, Medical Sciences, University of California, 513 Parnassus Avenue, 3rd Floor, S334, San Francisco, CA 94143-0412. E-mail: tom.lietman@ucsf.edu

Financial support: This study was supported by funding from the Bill & Melinda Gates Foundation (OP1032340), the National Eye Institute-National Institutes of Health (U10 EY016214), Research to Prevent Blindness, and That Man May See.

Authors' addresses: Craig W. See, Kieran S. O'Brien, Jeremy D. Keenan, Nicole E. Stoller, Bruce D. Gaynor, Travis C. Porco, and Thomas M. Lietman, F.I. Proctor Foundation, Medical Sciences, University of California, San Francisco, CA, E-mails: craig.see@gmail.com, kieran.obrien@ucsf.edu, jeremy.keenan@ucsf.edu, nicole.stoller@ucsf.edu, bruce.gaynor@ucsf.edu, travis.porco@ucsf.edu, and tom.lietman@ucsf.edu.

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