The MORDOR II trial: mass azithromycin distribution decreases childhood mortality in Niger

1. Mass, twice-yearly administration of azithromycin to children between 1 and 59 months of age in communities in Niger previously not administered azithromycin significantly reduced childhood mortality rates.

2. Communities given azithromycin for a third year, after receiving it the previous 2 years, had no significant change in childhood mortality rates.

Evidence Rating Level: 1 (Excellent)  

Study Rundown: A prior, related tria lMORDOR I showed that twice-yearly azithromycin administration to children in various African countries reduced childhood mortality significantly. There was possibility that if administration were continued, antibiotic resistance could develop and reduce the efficacy of treatment. There was also the potential for increased efficacy through reduction of sensitive bacteria in the community. The MORDOR II (Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance) trial evaluated childhood mortality in various Niger communities who had and had not received azithromycin the previous 2 years. Childhood mortality rates in communities who had and had not previously received azithromycin were similar. In communities not previously administered azithromycin notable reductions in childhood mortality rates were observed.

This study provides additional follow-up to suggest continual community antibiotic treatment in certain countries may reduce childhood mortality rates. It is limited in scope of study to community level data and by a single country sample as opposed to multiple countries in the previous associated trial. Long term effects will also need to be evaluated prior to considering wider administration schemes.

Click to read the study in NEJM

Relevant Reading: Re-emergence of yaws after single mass azithromycin treatment followed by targeted treatment: a longitudinal study

In-Depth [prospective cohort]: This prospective cohort trial was conducted from 2017 to 2018. Communities (n=594) identified in Niger for study inclusion were already identified from the MORDOR I trial. All children age 1 to 59 months and weighing at least 3800g were eligible for treatment with azithromycin. Twice yearly dosing for one year of 20mg of azithromycin per kg of body weight was given. Mortality rates were established via community census data collected during the study. Approximately 92% of the target population in the communities received azithromycin. Mortality rates per 1000 person-years were comparable between communities who had received azithromycin for the first time (24.0, 95% confidence interval [CI], 22.1 to 26.3) and the prior 2 years (23.3 deaths, 95% CI, 21.4 to 25.5). The first year of treatment did not show a greater mortality reduction effect compared to the third year of treatment (P=0.55). In communities not previously receiving azithromycin a significant childhood mortality reduction of 13.3% was observed (95% CI, 5.8 to 20.2; P = 0.007). There was no significant difference in mortality rates between the first two years of treatment and the third year in communities already administered azithromycin (−3.6%; 95% CI, −12.3 to 4.5; P = 0.50). No serious adverse events were determined to be caused by azithromycin.

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