Recent research from UC San Francisco revealed that regularly administering a widely used antibiotic to children in Sub-Saharan Africa could significantly decrease deaths among those under five years old. In response, the World Health Organization (WHO) promptly recommended this treatment, but limited it only to infants aged 1 to 11 months.
New findings from UCSF indicate that it’s insufficient to only treat the youngest infants; the antibiotic should be given to all children up to five years of age to maximize its benefits. This extension of treatment can lead to a 14% reduction in child mortality in a region where one in ten children does not survive to age five.
WHO’s restriction of the antibiotic, azithromycin, was based on worries about potential antibiotic resistance if it were used more widely. However, the study highlights that treating older siblings is crucial, as it provides enhanced protection against respiratory infections and other severe illnesses for their younger siblings who are particularly at risk.
“The evidence is compelling,” stated Kieran S. O’Brien, PhD, MPH, the lead author and an epidemiologist with the Francis I. Proctor Foundation at UCSF. “By treating the older children, we can safeguard the younger ones, who are extremely vulnerable.”
The results of the study were published on August 21 in the New England Journal of Medicine.
Concerns about Antibiotic Resistance
Azithromycin is an antibiotic that targets a broad range of pathogens, including those that cause respiratory infections, diarrhea, and malaria, all of which are leading causes of childhood deaths in Sub-Saharan Africa.
The initial research conducted in 2018 involved nearly 200,000 children from three African countries: Niger, Malawi, and Tanzania. Participants received four doses of either azithromycin or a placebo over two years.
This intervention led to a nearly 14% overall decrease in mortality for children under five and a 25% reduction specifically for infants under five months old. In 2020, the WHO approved mass administration of azithromycin for children under one year of age. However, the earlier research did not prove that solely focusing on infants would meaningfully cut mortality rates.
The recent follow-up study, termed AVENIR (Azithromycin pour la Vie des Enfants au Niger; Implementation and Recherche), aimed to assess whether targeting only infants could yield similar results. This time, the study was conducted solely in Niger, a nation with higher childhood mortality rates than the other two countries included in the initial research.
The findings confirmed that significant reductions in under-five mortality were only achieved when all children were included in the treatment.
Infants Are at Risk from Home Exposure
The research highlighted that most infants had older siblings at home, who often interact outside with peers, raising the risk of transmitting infections to their younger, more susceptible siblings.
The authors recognized the valid concern regarding antibiotic resistance but emphasized that the intervention is targeted at a specific population for a limited time, and the potential for reducing mortality outweighs the risks.
Dr. Thomas M. Lietman, the senior author and an ophthalmologist at UCSF, hopes these findings will prompt WHO to expand its recommendations to include all children up to five years old.
“In medicine, we are taught to limit antibiotic use due to potential resistance; however, our findings suggest that organized usage can indeed lower childhood mortality,” explained Lietman, who was also the lead author on the initial study. “Why would we withhold a treatment that can decrease mortality by 14% in areas where 10% of children don’t reach their fifth birthday?”
