You highlight the MORDOR I trial (13.5% mortality reduction) but later note that AVENIR (Niger) and CHAT (Burkina Faso) found no significant benefit for infants, and CHAT even suggested possible harm in some subgroups. How do you reconcile these conflicting results in your final conclusions? Should WHO’s blanket recommendation for under-1-year-olds be revisited based on newer evidence?
You mention that in Nigeria, ~46 million practice open defecation and that azithromycin residues could contaminate water, but you cite a 2017 effluent study for resistance levels. Do you have more recent or region-specific data linking MDA programs to measurable environmental AMR increases? This seems like a strong claim with relatively sparse up-to-date evidence in the text.
You state the mechanism of azithromycin’s mortality reduction is “largely unknown” and may involve anti-inflammatory or microbiome effects. Yet much of the policy push assumes infectious disease reduction. Isn’t it problematic to scale an intervention whose primary mechanism isn’t understood, especially given the AMR risks?