MORDOR II Burkina Faso: Longitudinal Trial

Study Overview
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Brief Summary
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Globally, childhood mortality has shown a promising downward trend in recent years, however, many sub-Saharan countries still have relatively high child mortality rates. In previous studies within Niger, Tanzania, and Malawi, mass azithromycin treatment to children aged 1-59 months old effectively reduced all-cause childhood mortality. A similar study will be conducted in Burkina Faso to replicate the results of mass azithromycin treatment. The investigators propose an individually randomized placebo-controlled trial alongside the MORDOR II Burkina Faso trial to evaluate the effect of a single dose of azithromycin (20 mg/kg) on potential mediators of the effect of azithromycin on all-cause mortality. Many questions surround the mechanism behind azithromycin's effect on reducing childhood mortality. Further questions exist regarding antibiotic resistance and how mass antibiotic administration can impact intestinal microflora. The goal of this study is to demonstrate the changes in the gut microbiome after antibiotic administration and to measure the growth of children after receiving a single dose of azithromycin. Additionally we will measure resistance markers, inflammatory markers, and IgA-bound bacteria. We hypothesize that a single dose of azithromycin will lead to a significant increase in child growth and that the gut microbiome will be significantly different in children who received azithromycin compared to those who received placebo. Objectives: . To determine the effect of a single dose of azithromycin for children aged 8 days-59 months on longitudinal changes in the intestinal microbiome over a 6-month period. We hypothesize that a single dose of azithromycin will result in a significant difference in the intestinal microbiome within the treatment group compared to the placebo group after a 6-month period within children ages 8 days-59 months. . To determine the effect of a single dose of azithromycin for children aged 8 days-59 months on child growth over a 6-month period. We hypothesize that a single dose of azithromycin will increase child growth over a 6-month period in children aged 8 days-59 months. . To determine the effect of a single dose of azithromycin for children aged 8 days to 59 months on the presence of macrolide genetic resistance determinants within the first two weeks post-treatment. The investigators hypothesize that a single dose of azithromycin will increase the presence of macrolide resistance determinants over a 2 week period in children aged 8 days to 59 months. The study will be conducted in Nouna Town in northwestern Burkina Faso.

Detailed Description
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The investigators' previous MORDOR I research demonstrated a significant reduction in all-cause child mortality after biannual mass azithromycin distribution. In three sub-Saharan Africa countries, (including Niger, Tanzania, and Malawi) mass azithromycin treatment over 2 years resulted in a 14% reduction in child mortality. Moreover, 1 in 5-6 deaths were shown to be averted within Niger alone1. Similar findings were demonstrated in a previous study for trachoma control in Ethiopia with mass azithromycin distribution. This study in rural Ethiopia noted a nearly 50% decrease in all-cause childhood mortality5. However, neither of these studies evaluated the longitudinal impact azithromycin has on the gut microbiome. The MORDOR II trial in Burkina Faso will further evaluate the efficacy of biannual azithromycin treatment. The under-5 child mortality rate in Burkina Faso is approximately 110 per 1,000 live births. Major causes of child mortality in this area are infectious mostly due to malaria, diarrhea, and upper respiratory tract infections. In addition, malnutrition contributes to a high burden of child mortality and morbidity within this region as well. By treating underlying conditions, the use of routine antibiotic treatment could reduce diverse health outcomes leading to morbidity and mortality. The investigative team proposes to conduct this study alongside the MORDOR II trial in the town of Nouna where a majority of childhood deaths are attributable to infectious causes and malnutrition. The World Health Organization is considering adopting the presumptive use of azithromycin and other antibiotics as a recommendation to reduce childhood mortality in areas with a high infectious disease burden2. Many questions remain unanswered surrounding the use of mass antibiotic treatment in areas with high child morbidity and mortality. This study will add to the current knowledge of mass azithromycin distribution from our previous MORDOR I research. The investigators propose to evaluate how azithromycin will impact childhood growth and to assess the changes that occur in the intestinal microbiome following a single dose of azithromycin treatment. The goal is to contribute more scientific literature that could assist future guidelines regarding antibiotic use. The role of antibiotics on child growth is unclear. Recent studies indicate that antibiotic use could impact child growth, but a previous study in Niger failed to find a statistically significant correlation between antibiotic treatment with azithromycin and stunting, underweight, or MUAC of pre-school aged children. Longitudinal studies have been recommended to further investigate the role of antibiotics on child growth6. Meanwhile some studies suggest antibiotics may create modifications in the gut microbiota impacting nutrient absorption and weight gain7.The investigative team proposes to measure child growth through anthropometric measurements longitudinally over a 6-month period to see if azithromycin treatment impacts child development. We hypothesize that children receiving a dose of azithromycin will have more growth and development in terms of height, weight, and mid-upper arm circumference compared to children who receive placebo. The investigators propose a longitudinal study designed to improve our knowledge about the changes in the intestinal microbiome following the course of a single dose of antibiotic in a setting with high childhood mortality and morbidity. More specifically, we propose to follow 500 children for a 6-month time period that are between the ages of 8 days old and 59 months old. Children in this age bracket are at the highest risk for mortality from infectious causes, and furthermore, they are at the highest risk for malnutrition. This group of children would receive the greatest benefit from this intervention. The causal changes in the microbiome are vastly understudied in regards to changes in the gut microbiome following a course of antibiotics. The investigators hypothesize that children receiving a dose of azithromycin will have a higher prevalence of pneumococcal resistance in nasopharyngeal samples, decreased bacterial diversity, and a higher likelihood of identification of bacterial resistance genes in stool and nasopharyngeal samples. A small group of 50 children (25 per arm) will be followed more intensely within the first 2 weeks of treatment to evaluate macrolide resistance. The investigators hypothesize that children receiving azithromycin will have a greater presence of macrolide genetic resistant determinants.

Official Title
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Gut and Azithromycin Mechanisms in Infants and Neonates

Conditions
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Child Growth, Diversity of Microbiome, Child Mortality, Resistance Bacterial

Intervention / Treatment
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* Drug: Azithromycin
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Between 8 days and 59 months old Primary residence within catchment area of study site Available for full 6 month study No known allergy to macrolides/azalides Appropriate written informed consent from at least one parent or guardian Able to feed orally Exclusion Criteria: <8 days old or >59 months Primary residence outside catchment area of study site Not available for full 6 month study Known allergy to macrolides/azalides No written informed consent from at least one parent or guardian Unable to feed orally

Ages Eligible for Study
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Minimum Age: 8 Days
Maximum Age: 59 Months

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Individually randomized placebo-controlled trail of azithromycin vs. placebo to establish the efficacy and safety of azithromycin.
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Azithromycin<br>A single dose of azithromycin will be administered to children between the ages of 8 days and 59 months old. | Drug: Azithromycin<br>* Zithromax® for oral suspension is supplied in bottles containing azithromycin dehydrate powder equivalent to 1200mg per bottle and the following inactive ingredients: sucrose; tribasic anhydrous sodium phosphate; hydroxypropyl cellulose; xanthan gum; FD&C Red #40; and flavoring including spray dried artificial cherry, crème de vanilla, and banana. After constitution, a 5mL suspension contains 200mg of azithromycin.<br>|
| Placebo Comparator: Placebo<br>A single dose of placebo will be administered to children between the ages of 8 days and 59 months old. | Drug: Placebo<br>* Oral suspension of placebo for azithromycin<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Intestinal Microbial Diversity | The primary outcome of the study was pre-specified as α-diversity (inverse Simpson's) at the genus level, expressed in effective number. The minimum of Simpson's index of diversity is 0, there is no maximum. Higher Simpson's index of diversity means more diverse. There are no subscales. | 6 months | 
| Macrolide Resistance | Presence of macrolide genetic resistance determinants measured using DNA-seq from rectal swabs from 450 children. Macrolide resistance is defined by resistance to erythromycin or clarithromycin. We compare the read numbers of macrolide resistance in each treatment group. A higher read number indicates more resistance. | 2 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Weight Over Time | WAZ. Weight will be measured at all follow-ups and weight-for-age z-scores will be calculated. Weight measured in kg. | 180 days post-treatment | 
| Change in Height Over Time | Height or length will be measured at all follow-ups and height-for-age z-scores will be calculated. | 180 days post-treatment | 
| Number of Participants With Infantile Hypertrophic Pyloric Stenosis |  | 6 months | 
| Mortality | Vital status will be assessed at all follow-up time points. Mortality will be defined as death within the study period. Date of death will be collected. | 180 days post-treatment | 
| Malaria Status | Number of Participants Positive for Malaria. Blood smears (thin and thick) for malaria will be collected at all follow-ups to determine malaria infection status. | 180 days post-treatment | 
| Adverse Events | Caregivers will be asked if the child has been taken to the health post since the last visit and why | 14 days post-treatment | 
| Genotypic Resistance | Total resistance read numbers in 12 classes: Aminoglycosides, Cationic antimicrobial peptides, Elfamycins, MLS, Metronidazole, Multi-drug resistance, Phenicol, Rifampin, Sulfonamides, Tetracyclines, Trimethoprim, and Beta-lactams. We compare the read numbers of macrolide resistance in each treatment group. A higher read number indicates more resistance. | 180 days post-treatment | 
| Inflammatory Marker Changes | Measured by C-reactive protein | 6 months | 
| IgA-bound Bacteria From Small Intestine Changes | Measured using BugFACS from whole blood and stool | 180 days post-treatment | 
| Nutritional Status | To be measured using mid-upper arm circumference | 180 days post-treatment | 
| Acute Modulation of the Gut Microbiome | Next generation sequencing | 2 weeks post-treatment | 
| L-1 Norm Distance on Bacterial Reads (Intestinal) | L-1 norm distance on bacterial reads (intestinal) from rectal swabs of 50 children. L1-norm distance on bacterial reads (intestinal) - L1 norm is equivalent to Shannon's diversity. Shannon's Alpha Diversity combines richness and diversity. Shannon's index of diversity (alpha diversity) measures both the number of species and the inequality between species abundances. A large value is given by the presence of many species with well balanced abundances. | 2 weeks post-treatment | 
| L-2 Norm Distance on Bacterial Reads (Intestinal) | L-2 norm distance on bacterial reads (intestinal) from rectal swabs of 450 children. L2-norm distance on bacterial reads (intestinal) - L2 norm is equivalent to Simpson's diversity. Simpson's Alpha Diversity were obtained at Baseline and Post-treatment in this study. The minimum of Simpson's index of diversity is 0, there is no maximum. Higher Simpson's index of diversity means more diverse. There are no subscales. | 2 weeks post-treatment | 
| Changes in Normalized Reads for Campylobacter Species | Reduce in normalized reads for Campylobacter species using DNA-seq from rectal swabs of 450 children. We compare the read numbers of Campylobacter species in each treatment group. Campylobacter is associated with disease. Reduction in Campylobacter species burden may reduce diarrhea-related mortality. | 2 weeks post-treatment | 
| Resistome | Chao1 total resistance gene determinant richness using DNA-seq from rectal swabs of 450 children. We calculated Chao1 total resistance gene determinant richness across arms. Species richness is the simplest measure of biodiversity and is just a count of the number of different species in a given area. | 2 weeks post-treatment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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azithromycin, mass drug administration, childhood mortality