Antibiotics and safety assurance
This article is adapted from two manuals, ‘Zithromax in the elimination of blinding trachoma. A program manager’s guide’, International Trachoma Initiative (ITI) and ‘Women and trachoma: Achieving gender equity in the implementation of SAFE’ The Carter Center.
Azithromycin dosing using height sticks
Height-based dosing is a generally accepted and reliable alternative to weight-based dosing for azithromycin, when used in mass drug administration (MDA) campaigns in trachoma-endemic countries.
Studies have shown that height can determine dose safely and effectively. Wooden dosing sticks are used to indicate the correct dose of azithromycin in number of tablets or millilitres of paediatric oral suspension (POS).
To use the height-dosing stick, the person is asked to stand erect, without shoes on a flat floor. The stick is placed vertically against their back, with the ground end touching the floor. The horizontal level at the top of the individual’s head indicates the number of tablets or POS to be dispensed. Adults or children with disorders that prevent full extension should be given the same dose as someone of similar age and build.
- 180cm long x 4cm wide x 1cm thick painted wooden stick for adults and children
- Make sure that the stick is vertical, not leaning to one side.
- Record in the register the number of tablets or amount of POS to be given
- From time to time, check the stick for bending or warping
If using a paper tape rather than a wooden stick, the tape should be fixed to a wall and the person can then stand next to the wall. Do not attempt to use a loose tape on its own as a measuring device.
Azithromycin is well tolerated with a low incidence of side effects. Communities undergoing treatment should be informed in advance that some people will have reactions. Encouraging families to eat breakfast on the day of treatment may help prevent stomach problems. Individuals who experience mild side effects should be reassured that their symptoms do not mean they should not take azithromycin in subsequent treatment rounds.
Serious adverse events
A serious adverse event is an adverse experience following drug treatment that results in one of the following:
- Life threatening condition
- Significant disability or incapacity
- Congenital anomaly or birth defect
Communities undergoing treatment should be informed about what to do if a serious adverse reaction to azithromycin happens, even though this is extremely uncommon.
If a serious adverse event does occur, community directed distribution team members should ensure that the people affected visit a nearby health institution for immediate care. They should also immediately report the event, in detail, to country programme managers who then report on the incident to the ITI within 48 hours.
Managing rumors and refusals
Initiating antibiotic distribution in a trachoma-endemic setting offers unique challenges. Few communities have experience of the concept of mass distribution of a medicine to treat a condition that affects only some members of the community.
Why should all members of a community take a medicine when not all of them are “sick”? Misunderstandings, political shenanigans and rumours have wreaked havoc on antibiotic distribution efforts in a number of settings. In most cases, the end result varies according to social and political divisions within communities. These divisions are often based upon gender roles and responsibilities.
If unfounded rumors arise that might keep individuals from receiving treatment or damage the reputation of the MDA campaign, it is important to first analyse the situation before moving quickly to respond.
- Clarify the extent of the rumor or misinformation - type of messages circulating, source, persons, or organizations spreading the rumors. Determine the motivation - lack of information, questioning of authority, religious opposition, or other.
- Be proactive in implementing ongoing activities and in increasing communication in advance of the MDA to prevent and limit rumors. Build ongoing relationships with communities (religious, social, media) and involve community leaders and stakeholders in planning and implementing health activities.
- Make communication and social mobilisation a continuous activity. Disseminate consistent messages to the community and take the time to deal with rumors as doing so will benefit the MDA campaign in the immediate and future perspective.
- An individual should never be forced to take a dose of azithromycin. As with the case of dealing with rumors, individuals should be educated in advance about the MDA campaign and the benefits of receiving azithromycin for the treatment of blinding trachoma.
- Programme staff should explain that because trachoma is easily transmitted from one person to another it is important to suppress transmission in addition to curing individuals by achieving a high rate of coverage of all residents in endemic communities. However, if an individual does not wish to take azithromycin their right to refuse must always be acknowledged and respected.
An experience from Egypt
Right before the distribution was to start, rumors erupted among villagers suggesting that the drug was going to blind people within three days and that deaths occurred in other villages—when, in fact, this was to be the first distribution. The distribution ended with 62% coverage, almost identical for preschool children, school-age children, and adult women (all 69%) but much less for adult men (48%). Refusals were generally family based rather than person based. Many men were away in the fields or working elsewhere when the teams were doing door-to-door distribution, and some women were unwilling to accept treatment without the agreement of the male head of household. When one family refused, this information spread quickly, and nearby families also refused.
Subsequent rounds focused on changing the time of distribution to make sure that men were present when teams visited. The second round of distribution succeeded in increasing coverage; however, coverage among adult men never reached more than 65%. The importance of understanding community perceptions and the role that gender plays in adoption of new technologies such as mass distribution cannot be underestimated.