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DeBoer MD, Platts-Mills JA, Elwood SE, Scharf RJ, McDermid JM, Wanjuhi AW, Jatosh S, Katengu S, Parpia TC, Rogawski McQuade ET, Gratz J, Svensen E, Swann JR, Donowitz JR, Mdoe P, Kivuyo S, Houpt ER, Mduma E. Effect of scheduled antimicrobial and nicotinamide treatment on linear growth in children in rural Tanzania: A factorial randomized, double-blind, placebo-controlled trial. PLoS Med 2021; 18:e1003617. [PMID: 34582462 PMCID: PMC8478246 DOI: 10.1371/journal.pmed.1003617] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/09/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Stunting among children in low-resource settings is associated with enteric pathogen carriage and micronutrient deficiencies. Our goal was to test whether administration of scheduled antimicrobials and daily nicotinamide improved linear growth in a region with a high prevalence of stunting and enteric pathogen carriage. METHODS AND FINDINGS We performed a randomized, 2 × 2 factorial, double-blind, placebo-controlled trial in the area around Haydom, Tanzania. Mother-child dyads were enrolled by age 14 days and followed with monthly home visits and every 3-month anthropometry assessments through 18 months. Those randomized to the antimicrobial arm received 2 medications (versus corresponding placebos): azithromycin (single dose of 20 mg/kg) at months 6, 9, 12, and 15 and nitazoxanide (3-day course of 100 mg twice daily) at months 12 and 15. Those randomized to nicotinamide arm received daily nicotinamide to the mother (250 mg pills months 0 to 6) and to the child (100 mg sachets months 6 to 18). Primary outcome was length-for-age z-score (LAZ) at 18 months in the modified intention-to-treat group. Between September 5, 2017 and August 31, 2018, 1,188 children were randomized, of whom 1,084 (n = 277 placebo/placebo, 273 antimicrobial/placebo, 274 placebo/nicotinamide, and 260 antimicrobial/nicotinamide) were included in the modified intention-to-treat analysis. The study was suspended for a 3-month period by the Tanzanian National Institute for Medical Research (NIMR) because of concerns related to the timing of laboratory testing and the total number of serious adverse events (SAEs); this resulted in some participants receiving their final study assessment late. There was a high prevalence of stunting overall (533/1,084, 49.2%). Mean 18-month LAZ did not differ between groups for either intervention (mean LAZ with 95% confidence interval [CI]: antimicrobial: -2.05 CI -2.13, -1.96, placebo: -2.05 CI -2.14, -1.97; mean difference: 0.01 CI -0.13, 0.11, p = 0.91; nicotinamide: -2.06 CI -2.13, -1.95, placebo: -2.04 CI -2.14, -1.98, mean difference 0.03 CI -0.15, 0.09, p = 0.66). There was no difference in LAZ for either intervention after adjusting for possible confounders (baseline LAZ, age in days at 18-month measurement, ward, hospital birth, birth month, years of maternal education, socioeconomic status (SES) quartile category, sex, whether the mother was a member of the Datoga tribe, and mother's height). Adverse events (AEs) and SAEs were overall similar between treatment groups for both the nicotinamide and antimicrobial interventions. Key limitations include the absence of laboratory measures of pathogen carriage and nicotinamide metabolism to provide context for the negative findings. CONCLUSIONS In this study, we observed that neither scheduled administration of azithromycin and nitazoxanide nor daily provision of nicotinamide was associated with improved growth in this resource-poor setting with a high force of enteric infections. Further research remains critical to identify interventions toward improved early childhood growth in challenging conditions. TRIAL REGISTRATION ClinicalTrials.gov NCT03268902.
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Affiliation(s)
- Mark D. DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
- * E-mail:
| | - James A. Platts-Mills
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Sarah E. Elwood
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Rebecca J. Scharf
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Joann M. McDermid
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Anne W. Wanjuhi
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Samwel Jatosh
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Siphael Katengu
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Tarina C. Parpia
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Elizabeth T. Rogawski McQuade
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Jean Gratz
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | | | - Jonathan R. Swann
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Jeffrey R. Donowitz
- Division of Infectious Disease, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Paschal Mdoe
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Sokoine Kivuyo
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Eric R. Houpt
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
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Parpia TC, Elwood SE, Scharf RJ, McDermid JM, Wanjuhi AW, Rogawski McQuade ET, Gratz J, Svensen E, Swann JR, Donowitz JR, Jatosh S, Katengu S, Mdoe P, Kivuyo S, Houpt ER, DeBoer MD, Mduma E, Platts-Mills JA. Baseline Characteristics of Study Participants in the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) Trial. Am J Trop Med Hyg 2020; 103:1397-1404. [PMID: 32783799 PMCID: PMC7543831 DOI: 10.4269/ajtmh.19-0918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Recurrent enteric infections and micronutrient deficiencies, including deficiencies in the tryptophan–kynurenine–niacin pathway, have been associated with environmental enteric dysfunction, potentially contributing to poor child growth and development. We are conducting a randomized, placebo-controlled, 2 × 2 factorial interventional trial in a rural population in Haydom, Tanzania, to determine the effect of 1) antimicrobials (azithromycin and nitazoxanide) and/or 2) nicotinamide, a niacin vitamer, on attained length at 18 months. Mother/infant dyads were enrolled within 14 days of the infant’s birth from September 2017 to September 2018, with the follow-up to be completed in February 2020. Here, we describe the baseline characteristics of the study cohort, risk factors for low enrollment weight, and neonatal adverse events (AEs). Risk factors for a low enrollment weight included being a firstborn child (−0.54 difference in weight-for-age z-score [WAZ] versus other children, 95% CI: −0.71, −0.37), lower socioeconomic status (−0.28, 95% CI: −0.43, −0.12 difference in WAZ), and birth during the preharvest season (November to March) (−0.22, 95% CI: −0.33, −0.11 difference in WAZ). The most common neonatal serious AEs were respiratory tract infections and neonatal sepsis (2.2 and 1.4 events per 100 child-months, respectively). The study cohort represents a high-risk population for whom interventions to improve child growth and development are urgently needed. Further analyses are needed to understand the persistent impacts of seasonal malnutrition and the interactions between seasonality, socioeconomic status, and the study interventions.
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Affiliation(s)
- Tarina C Parpia
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Sarah E Elwood
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Rebecca J Scharf
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Joann M McDermid
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Anne W Wanjuhi
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | | | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | | | - Jonathan R Swann
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Jeffrey R Donowitz
- Division of Infectious Disease, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Samwel Jatosh
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Siphael Katengu
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Paschal Mdoe
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Sokoine Kivuyo
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
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