TY - JOUR
T1 - Ethical challenges in mass drug administration for reducing childhood mortality
T2 - a qualitative study
AU - Alasmar, Ahmed
AU - Kong, Alex C.
AU - So, Anthony D.
AU - DeCamp, Matthew
N1 - Funding Information:
This work was supported under a Greenwall Foundation grant on the “Mass Administration of Antibiotics: Reaching Clinical and Community Equipoise” as part of the Making a Difference in Real-World Bioethics Dilemmas program. The Greenwall Foundation did not have a role in the design of the study, collection, analysis, and interpretation of data nor in writing the manuscript.
Publisher Copyright:
© 2022, The Author(s).
PY - 2022/12
Y1 - 2022/12
N2 - Background: Mass drug administration (MDA) of medications to entire at-risk communities or populations has shown promise in the control and elimination of global infectious diseases. MDA of the broad-spectrum antibiotic azithromycin has demonstrated the potential to reduce childhood mortality in children at risk of premature death in some global settings. However, MDA of antibiotics raises complex ethical challenges, including weighing near-term benefits against longer-term risks—particularly the development of antimicrobial resistance that could diminish antibiotic effectiveness for current or future generations. The aim of this study was to understand how key actors involved in MDA perceive the ethical challenges of MDA. Methods: We conducted 35 semi-structured interviews from December 2020–February 2022 with investigators, funders, bioethicists, research ethics committee members, industry representatives, and others from both high-income countries (HICs) and low- and middle-income countries (LMICs). Interview participants were identified via one of seven MDA studies purposively chosen to represent diversity in terms of use of the antibiotic azithromycin; use of a primary mortality endpoint; and whether the study occurred in a high child mortality country. Data were analyzed using constructivist grounded theory methodology. Results: The most frequently discussed ethical challenges related to meaningful community engagement, how to weigh risks and benefits, and the need to target MDA We developed a concept map of how participants considered ethical issues in MDA for child mortality; it emphasizes MDA’s place alongside other public health interventions, empowerment, and equity. Concerns over an ethical double standard in weighing risks and benefits emerged as a unifying theme, albeit one that participants interpreted in radically different ways. Some thought MDA for reducing child mortality was ethically obligatory; others suggested it was impermissible. Conclusions: Ethical challenges raised by MDA of antibiotics for childhood mortality—which span socio-cultural issues, the environment, and effects on future generations—require consideration beyond traditional clinical trial review. The appropriate role of MDA also requires attention to concerns over ethical double standards and power dynamics in global health that affect how we view antibiotic use in HICs versus LMICs. Our findings suggest the need to develop additional, comprehensive guidance on managing ethical challenges in MDA. Graphical Abstract: [Figure not available: see fulltext.]
AB - Background: Mass drug administration (MDA) of medications to entire at-risk communities or populations has shown promise in the control and elimination of global infectious diseases. MDA of the broad-spectrum antibiotic azithromycin has demonstrated the potential to reduce childhood mortality in children at risk of premature death in some global settings. However, MDA of antibiotics raises complex ethical challenges, including weighing near-term benefits against longer-term risks—particularly the development of antimicrobial resistance that could diminish antibiotic effectiveness for current or future generations. The aim of this study was to understand how key actors involved in MDA perceive the ethical challenges of MDA. Methods: We conducted 35 semi-structured interviews from December 2020–February 2022 with investigators, funders, bioethicists, research ethics committee members, industry representatives, and others from both high-income countries (HICs) and low- and middle-income countries (LMICs). Interview participants were identified via one of seven MDA studies purposively chosen to represent diversity in terms of use of the antibiotic azithromycin; use of a primary mortality endpoint; and whether the study occurred in a high child mortality country. Data were analyzed using constructivist grounded theory methodology. Results: The most frequently discussed ethical challenges related to meaningful community engagement, how to weigh risks and benefits, and the need to target MDA We developed a concept map of how participants considered ethical issues in MDA for child mortality; it emphasizes MDA’s place alongside other public health interventions, empowerment, and equity. Concerns over an ethical double standard in weighing risks and benefits emerged as a unifying theme, albeit one that participants interpreted in radically different ways. Some thought MDA for reducing child mortality was ethically obligatory; others suggested it was impermissible. Conclusions: Ethical challenges raised by MDA of antibiotics for childhood mortality—which span socio-cultural issues, the environment, and effects on future generations—require consideration beyond traditional clinical trial review. The appropriate role of MDA also requires attention to concerns over ethical double standards and power dynamics in global health that affect how we view antibiotic use in HICs versus LMICs. Our findings suggest the need to develop additional, comprehensive guidance on managing ethical challenges in MDA. Graphical Abstract: [Figure not available: see fulltext.]
KW - Antimicrobial resistance
KW - Child mortality
KW - Decolonizing global health
KW - Ethics
KW - Global health equity
KW - Mass drug administration
UR - http://www.scopus.com/inward/record.url?scp=85138168783&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85138168783&partnerID=8YFLogxK
U2 - 10.1186/s40249-022-01023-6
DO - 10.1186/s40249-022-01023-6
M3 - Article
C2 - 36114588
AN - SCOPUS:85138168783
SN - 2095-5162
VL - 11
JO - Infectious Diseases of Poverty
JF - Infectious Diseases of Poverty
IS - 1
M1 - 99
ER -