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Mass Drug Administration of Antibiotics: Reaching Clinical and Community Equipoise

Guest edited by Anthony So and Matthew DeCamp

A thematic series in Infectious Diseases of Poverty

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Mass drug administration (MDA) of antibiotics—i.e., empirically administering drugs that fight bacterial infections to an entire at-risk community or population—raises challenging and relatively unexplored issues at the intersection of public health, research, and clinical ethics. MDA has the potential to reduce the burden of, or even eradicate, infectious diseases and reduce childhood mortality globally. At the same time, MDA raises some of the most vexing and seemingly intractable problems in bioethics, such as how to weigh near-term gains against longer-term, but less certain consequences (e.g., decreased childhood mortality now versus risks of obesity or antibiotic resistance later), how to fairly distribute benefits and risks between individuals, communities, and whole societies (e.g., near-term benefits for the target population vs. diminished, community-wide effectiveness of that antibiotic for otherwise treatable conditions), and what we owe future generations.

At present, however, there has been no comprehensive assessment of these bioethical issues, little is empirically known regarding how decisionmakers have approached them in the real world, and funders, governmental agencies, institutional review boards (IRBs), investigators, and others lack guidance for how to weigh potentially competing ethical claims. In 2020, the World Health Organization released guidelines for consideration of the use of MDA of azithromycin in young children living in sub-Saharan African settings with high infant and under-five mortality rates, and where other interventions to reduce childhood mortality could be strengthened. With an update of these guidelines suggested in 2-3 years with additional evidence of the benefits and consequences of MDA of antibiotics, a holistic approach to these issues within and between communities is needed.

This thematic series will consist of articles covering a range of ethical issues presented by MDA of antibiotics including, but not limited to, the clinical benefits and risks of MDA, potential effects of MDA on the microbiome, environmental and ecological impacts of MDA, MDA clinical trial design, and antibiotic resistance spillover between communities secondary to MDA. The series is intended to help guide the future consideration, research design, and implementation of MDA for the control of infectious diseases and reduction in childhood mortality. 

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