1
|
McPherson S, Geleta D, Tafese G, Tafese T, Behaksira S, Solomon H, Oljira B, Miecha H, Gemechu L, Debebe K, Kebede B, Gebre T, Kebede F, Seife F, Tadesse F, Mammo B, Aseffa A, Solomon AW, Mabey DCW, Marks M, Gadisa E. Perceptions and acceptability of co-administered albendazole, ivermectin and azithromycin mass drug administration, among the health workforce and recipient communities in Ethiopia. PLoS Negl Trop Dis 2023; 17:e0011332. [PMID: 37782675 PMCID: PMC10569502 DOI: 10.1371/journal.pntd.0011332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 10/12/2023] [Accepted: 08/30/2023] [Indexed: 10/04/2023] Open
Abstract
Several neglected tropical diseases (NTDs) employ mass drug administration (MDA) as part of their control or elimination strategies. This has historically required multiple distinct campaigns, each targeting one or more NTDs, representing a strain on both the recipient communities and the local health workforce implementing the distribution. We explored perceptions and attitudes surrounding combined MDA among these two groups of stakeholders. Our qualitative study was nested within a cluster randomized non-inferiority safety trial of combined ivermectin, albendazole and azithromycin MDA. Using semi-structured question guides, we conducted 16 key informant interviews with selected individuals involved in implementing MDA within the participating district. To better understand the perceptions of recipient communities, we also conducted four focus group discussions with key community groups. Individuals were selected from both the trial arm (integrated MDA) and the control arm (standard MDA) to provide a means of comparison and discussion. All interviews and focus group discussions were led by fluent Afaan oromo speakers. Interviewers transcribed and later translated all discussions into English. The study team synthesized and analyzed the results via a coding framework and software. Most respondents appreciated the time and effort saved via the co-administered MDA strategy but there were some misgivings amongst community beneficiaries surrounding pill burden. Both the implementing health work force members and beneficiaries reported refusals stemming from lack of understanding around the need for the new drug regimen as well as some mistrust of government officials among the youth. The house-to-house distribution method, adopted as a COVID-19 prevention strategy, was by far preferred by all beneficiaries over central-point MDA, and may have led to greater acceptability of co-administration. Our data demonstrate that a co-administration strategy for NTDs is acceptable to both communities and health staff.
Collapse
Affiliation(s)
- Scott McPherson
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- RTI International, Durham, North Carolina, United States of America
| | - Dereje Geleta
- College of Medicine and Health sciences, Hawassa University, Hawassa, Ethiopia
| | - Getinet Tafese
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | | | - Hiwot Solomon
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | | | - Hirpa Miecha
- Oromia regional Health Bureau, Addis Ababa, Ethiopia
| | - Lalisa Gemechu
- College of Medicine and Health sciences, Hawassa University, Hawassa, Ethiopia
| | - Kaleab Debebe
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Biruck Kebede
- RTI International, Durham, North Carolina, United States of America
| | - Teshome Gebre
- International Trachoma Initiative, Task Force for Global Health, Addis Ababa, Ethiopia
| | - Fikreab Kebede
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Fikre Seife
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Fentahun Tadesse
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Belete Mammo
- RTI International, Durham, North Carolina, United States of America
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Anthony W. Solomon
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - David C. W. Mabey
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Michael Marks
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | | |
Collapse
|
2
|
McPherson S, Solomon AW, Seife F, Solomon H, Gebre T, Mabey DCW, Marks M. Pharmacokinetics, feasibility and safety of co-administering azithromycin, albendazole, and ivermectin during mass drug administration: A review. PLoS Negl Trop Dis 2023; 17:e0011224. [PMID: 37315102 PMCID: PMC10298764 DOI: 10.1371/journal.pntd.0011224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/27/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Traditionally, health ministries implement mass drug administration programmes for each neglected tropical disease (NTD) as separate and distinct campaigns. Many NTDs have overlapping endemicity suggesting co-administration might improve programme reach and efficiency, helping accelerate progress towards 2030 targets. Safety data are required to support a recommendation to undertake co-administration. METHODOLOGY We aimed to compile and summarize existing data on co-administration of ivermectin, albendazole and azithromycin, including both data on pharmacokinetic interactions and data from previous experimental and observational studies conducted in NTD-endemic populations. We searched PubMed, Google Scholar, research and conference abstracts, gray literature, and national policy documents. We limited the publication language to English and used a search period from January 1st, 1995 through October 1st, 2022. Search terms were: azithromycin and ivermectin and albendazole, mass drug administration co-administration trials, integrated mass drug administration, mass drug administration safety, pharmacokinetic dynamics, and azithromycin and ivermectin and albendazole. We excluded papers if they did not include data on co-administration of azithromycin and both albendazole and ivermectin, or azithromycin with either albendazole or ivermectin alone. RESULTS We identified a total of 58 potentially relevant studies. Of these we identified 7 studies relevant to the research question and which met our inclusion criteria. Three papers analyzed pharmacokinetic and pharmacodynamic interactions. No study found evidence of clinically significant drug-drug interactions likely to impact safety or efficacy. Two papers and a conference presentation reported data on the safety of combinations of at least two of the drugs. A field study in Mali suggested the rates of adverse events were similar with combined or separate administration, but was underpowered. A further field study in Papua New Guinea used all three drugs as part of a four-drug regimen also including diethylcarbamazine; in this setting, co-administration appeared safe but there were issues with the consistency in how adverse events were recorded. CONCLUSION There are relatively limited data on the safety profile of co-administering ivermectin, albendazole and azithromycin as an integrated regimen for NTDs. Despite the limited amount of data, available evidence suggests that such a strategy is safe with an absence of clinically important drug-drug interactions, no serious adverse events reported and little evidence for an increase in mild adverse events. Integrated MDA may be a viable strategy for national NTD programmes.
Collapse
Affiliation(s)
- Scott McPherson
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Anthony W. Solomon
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Global Neglected Tropical Diseases Programme, World Health Organization, Geneva, Switzerland
| | - Fikre Seife
- Federal Ministry of Health, Addis Ababa, Ethiopia
| | | | - Teshome Gebre
- International Trachoma Initiative, Task Force for Global Health, Addis Ababa, Ethiopia
| | - David C. W. Mabey
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Michael Marks
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom
- Division of Infection & Immunity, University College London, London, United Kingdom
| |
Collapse
|
3
|
McPherson S, Tafese G, Tafese T, Behaksra SW, Solomon H, Oljira B, Miecha H, Debebe KA, Kebede B, Gebre T, Kebede F, Seife F, Tadesse F, Mammo B, Aseffa A, Solomon AW, Mabey DC, Marks M, Gadisa E. Safety of integrated mass drug administration of azithromycin, albendazole and ivermectin versus standard treatment regimens: a cluster-randomised trial in Ethiopia. EClinicalMedicine 2023; 59:101984. [PMID: 37152362 PMCID: PMC10154979 DOI: 10.1016/j.eclinm.2023.101984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023] Open
Abstract
Background Neglected Tropical Disease (NTD) programs require separate and distinct drug regimens for treatment. This has required countries to undertake multiple independent mass drug administration (MDA) programmes, each targeting one or more diseases. The possibility of safely combining different drug regimens together in one MDA may offer several advantages to national programs. We conducted a study to assess the safety of combining ivermectin, albendazole and azithromycin in one integrated MDA. Methods We conducted an open-label, non-inferiority cluster-randomised trial comparing the frequency of adverse events in communities receiving co-administered ivermectin, albendazole and azithromycin to that in communities given albendazole and ivermectin MDA followed by azithromycin MDA after a two-week interval. The study took place in 58 gares (small administrative units) across two kebeles (sub-districts) in Kofele woreda (district) in the Oromia region of Ethiopia. We randomly assigned 29 gares to the combined treatment arm and 29 gares to the control arm. The study team revisited all individuals within 48 h and actively collected data on the occurrence of adverse events using a dedicated questionnaire and a pre-specified list of adverse events. The study team followed the same process in the control arm for the azithromycin distribution and again after the ivermectin plus albendazole distribution. Following this initial active surveillance, passive surveillance was undertaken for one week after the first visit. The primary outcome was the frequency of adverse events occurring following MDA. The study team determined that the safety of the combined MDA would be non-inferior to that of separate MDAs if the upper limit of the two-sided CI for the difference in rates was equal to or lower than 5%. The trial was registered with ClinicalTrials.gov, NCT03570814. Findings The study took place from December 2021 to January 2022. The combined MDA arm consisted of 7292 individuals who were eligible to participate, of whom 7068 received all three medications. The separate MDA arm consisted of 6219 eligible individuals of whom 6211 received ivermectin and albendazole and 4611 received azithromycin two weeks later. Overall, adverse events were reported by 197 (1.2%) of individuals. The most commonly reported adverse events included headache, gastrointestinal disturbance and dizziness. There were no serious adverse events in either arm. The cluster-level mean frequency of reported adverse events varied markedly between clusters, ranging from 0.1 to 10.4%. The cluster-level mean frequency of adverse events was 1.4% in the combined MDA arm and 1.2% following ivermectin and albendazole MDA (absolute difference 0.2%, 95% confidence interval [CI] -0.6% to +1.1%). This met the pre-defined 1.5% non-inferiority margin. For the combined MDA comparison to the stand-alone azithromycin MDA the absolute difference was -0.4% (1.4 versus 1.8%, 95% CI -0.8 to +1.5) which also met the pre-specified non-inferiority margin. Interpretation This study is the largest of its kind to date and demonstrates that the safety of combined MDA of azithromycin, ivermectin and albendazole is non-inferior to the safety of ivermectin-plus-albendazole MDA then azithromycin MDA conducted separately although we may not have been powered to detect very small differences between arms. Co-administration of these three medicines is safe and feasible in this setting and allows national programs to develop new strategies for integrated MDA programs. Funding Ivermectin (Mectizan) was donated by the Mectizan Donation Program, albendazole was donated by GlaxoSmithKline, and azithromycin (Zithromax®) was donated by Pfizer via the International Trachoma Initiative (ITI). The trial was funded by ITI using operational research funds from the Bill and Melinda Gates Foundation.
Collapse
Affiliation(s)
- Scott McPherson
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- RTI International, Research Triangle Park, NC, USA
| | - Getinet Tafese
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | | | - Hiwot Solomon
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | | | - Hirpa Miecha
- Oromia Regional Health Bureau, Addis Ababa, Ethiopia
| | | | | | | | - Fikreab Kebede
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Fikre Seife
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Fentahun Tadesse
- Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Belete Mammo
- RTI International, Research Triangle Park, NC, USA
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Anthony W. Solomon
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - David C.W. Mabey
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Michael Marks
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Hospital for Tropical Diseases, University College London Hospital, London, UK
- Division of Infection and Immunity, University College London, London, UK
| | | |
Collapse
|
4
|
Simpson H, Mengiste A, Mbonigaba JB, Kollie K, Nganda M, Dean L, Argaw D, Davey G, Semrau M. Research priorities to support the development of integrated national strategies to control skin-neglected tropical diseases. Trans R Soc Trop Med Hyg 2023; 117:132-138. [PMID: 36130404 PMCID: PMC9890312 DOI: 10.1093/trstmh/trac086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/04/2022] [Accepted: 08/25/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Skin-presenting neglected tropical diseases (skin-NTDs) impose large burdens on affected people, families and communities. The NTD Roadmap 2021-2030 presents a strategic plan to guide collaborative, multisectoral action to overcome these burdens, defining targets to control, eliminate and/or eradicate skin-NTDs by 2030. One of its targets is for 40 countries to adopt integrated skin-NTD strategies. Despite this high-level support for integration, only four countries were implementing integrated skin-NTD strategies in 2020. METHODS We hosted workshops at the 2021 annual meeting of the Coalition for Operational Research on NTDs, to discuss the operationalisation of Roadmap goals into national strategies and interventions for skin-NTD control. Speakers included NTD Programme Managers from NTD-endemic countries, technical experts and researchers of different aspects of skin-NTDs. RESULTS Challenges include community perceptions of interventions, demonstrating the cost-effectiveness of integrated care, availability and accessibility of community-based and primary healthcare services, the quality of data on skin-NTD morbidity and changes to operational structures required for integration. Research priorities included the identification of optimal case detection platforms, evaluation of integrated care, understanding the impacts of integration on community members and community health staff and development of point-of-care diagnostics. CONCLUSIONS The operational research priorities are intended to support the scale-up of integrated skin-NTDs programmes.
Collapse
Affiliation(s)
- Hope Simpson
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton BN1 9PX, UK.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Asrat Mengiste
- College of Health Sciences, Addis Ababa University, 2Q92+P2W, Addis Ababa, Ethiopia
| | - Jean Bosco Mbonigaba
- Rwanda Neglected Tropical Diseases Programme, Rwanda Biomedical Centre, Ministry of Health 23VV+3MM, Kigali, Rwanda
| | - Karsor Kollie
- Non Communicable and Neglected Tropical Disease Program in the Ministry of Health and Social Welfare, 8643+F7C, Monrovia, Liberia
| | - Motto Nganda
- Capacity Research Unit, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Laura Dean
- Capacity Research Unit, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Daniel Argaw
- Department of Control of Neglected Tropical Diseases, World Health Organization, 1211 Geneva, Switzerland
| | - Gail Davey
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton BN1 9PX, UK
| | - Maya Semrau
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton BN1 9PX, UK
| |
Collapse
|