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Most evidence supporting screening for undernutrition is for children aged 6-59 months. However, the highest risk of mortality and highest incidence of wasting occurs in the first 6 months of life. We evaluated relationships between neonatal anthropometric indicators, including birth weight, weight-for-age -score (WAZ), weight-for-length Z-score (WLZ), length-for-age -score (LAZ) and mid-upper arm circumference (MUAC) and mortality and growth at 6 months of age among infants in Burkina Faso. Data arose from a randomised controlled trial evaluating neonatal azithromycin administration for the prevention of child mortality. We evaluated relationships between baseline anthropometric measures and mortality, wasting (WLZ < -2), stunting (LAZ < -2) and underweight (WAZ < -2) at 6 months of age were estimated using logistic regression models adjusted for the child's age and sex. Five regions of Burkina Faso. Infants aged 8-27 d followed until 6 months of age. Of 21 832 infants enrolled in the trial, 7·9 % were low birth weight (<2500 g), 13·3 % were wasted, 7·7 % were stunted and 7·4 % were underweight at enrolment. All anthropometric deficits were associated with mortality by 6 months of age, with WAZ the strongest predictor (WAZ < -2 to ≥ -3 at enrolment . WAZ ≥ -2: adjusted OR, 3·91, 95 % CI, 2·21, 6·56). Low WAZ was also associated with wasting, stunting, and underweight at 6 months. Interventions for identifying infants at highest risk of mortality and growth failure should consider WAZ as part of their screening protocol.

Background Low birthweight is a major contributor to infant mortality. We evaluated the association between antenatal care (ANC) attendance and low birthweight among newborns in 5 regions of Burkina Faso. Methods We utilized data from the baseline assessment of a randomized controlled trial evaluating azithromycin distribution during the neonatal period for prevention of infant mortality. Neonates were eligible for the trial if the weighed at least 2500 g at enrollment and were 8–27 days of age. Data on ANC attendance and birthweight was extracted from each child’s carnet de santé , a government-issued health card on which pregnancy and birth-related data are recorded. We used linear and logistic regression models adjusting for potentially confounding variables to evaluate the relationship between ANC attendance (as total number of visits and ≥ 4 antenatal care visits) and birthweight (continuously and categorized into < 2500 g versus ≥2500 g). Results Data from 21,223 births were included in the analysis. The median number of ANC visits was 4 (interquartile range 3 to 5) and 69% of mothers attended at least 4 visits. Mean birthweight was 2998 g (standard deviation 423) and 8.1% of infants were low birthweight (< 2500 g). Birthweight was 63 g (95% CI 46 to 81 g, P  < 0.001) higher in newborns born to mothers who had attended ≥4 ANC visits versus < 4 visits. The odds of low birthweight among infants born to mothers with ≥4 ANC visits was 0.71 (95% CI 0.63 to 0.79, P  < 0.001) times the odds of low birthweight among infants born to mothers who attended < 4 ANC visits. Conclusions We observed a statistically significant association between ANC attendance and birthweight, although absolute differences were small. Improving access to ANC for all women may help improve birth outcomes. Trial registration The parent trial is registered at clinicaltrials.gov: NCT03682653 ; first registered 24 September 2018.

In 2023, the World Health Organization (WHO) revised its guidelines for management of severe acute malnutrition (SAM). The revised guidelines include a focus on infants at risk of poor growth and development. The guideline identifies evaluation of routine antibiotics for these infants as a priority research area. We pooled data from two large randomized controlled trials evaluating azithromycin for prevention of infant mortality in Burkina Faso to assess whether azithromycin reduces mortality or wasting in this subgroup. Infants in the two trials were 1-12 weeks of age at enrollment. Infants were considered at risk of poor risk of growth and development per WHO: underweight (weight-for-age Z-score, WAZ < -2), wasted (weight-for-length Z-score, WLZ < -2), or MUAC < 11.0 cm among infants ≥6 weeks of age. Infants were randomized to a single oral (20 mg/kg) dose of azithromycin or matching placebo and were followed until 6 months of age. We evaluated vital status, underweight (WAZ < -2), wasting (WLZ < -2), and stunting (length-for-age Z-score, LAZ) at 6 months among infants at risk of poor growth and development based on WHO single measurement criteria. A total of 54,709 infants were enrolled in the two trials. Of these, 9,728 were at risk of poor growth and development based on baseline WAZ (N = 5,385), WLZ (N = 6,022), or MUAC (N = 1,541). We found no evidence of a difference in mortality (1.3% vs 1.1%, odds ratio, OR, 1.19, 95% confidence interval, CI, 0.82 to 1.72) or wasting (20.6% vs 20.2%, OR 1.03, 95% CI 0.92 to 1.14) at 6 months among infants receiving azithromycin versus placebo. In infants aged 1-12 weeks at risk of poor growth and development, we do not have evidence that single dose azithromycin reduces mortality or improves growth outcomes. ClinicalTrials.gov NCT03682654 and NCT03676764.

Antibiotic use during early infancy has been linked to childhood obesity in high-income countries. We evaluated whether a single oral dose of azithromycin administered during infant-well visits led to changes in infant growth outcomes at 6 months of age in a setting with a high prevalence of undernutrition in rural Burkina Faso. Infants were enrolled from September 25, 2019, until October 22, 2022, in a randomized controlled trial designed to evaluate the efficacy of a single oral dose of azithromycin (20 mg/kg) compared to placebo when administered during well-child visits for prevention of infant mortality. The trial found no evidence of a difference in the primary endpoint. This paper presents prespecified secondary anthropometric endpoints including weight gain (g/day), height change (mm/day), weight-for-age Z-score (WAZ), weight-for-length Z-score (WLZ), length-for-age Z-score (LAZ), and mid-upper arm circumference (MUAC). Infants were eligible for the trial if they were between 5 and 12 weeks of age, able to orally feed, and their families were planning to remain in the study area for the duration of the study. Anthropometric measurements were collected at enrollment (5 to 12 weeks of age) and 6 months of age. Among 32,877 infants enrolled in the trial, 27,298 (83%) were followed and had valid anthropometric measurements at 6 months of age. We found no evidence of a difference in weight gain (mean difference 0.03 g/day, 95% confidence interval (CI) -0.12 to 0.18), height change (mean difference 0.004 mm/day, 95% CI -0.05 to 0.06), WAZ (mean difference -0.004 SD, 95% CI -0.03 to 0.02), WLZ (mean difference 0.001 SD, 95% CI -0.03 to 0.03), LAZ (mean difference -0.005 SD, 95% CI -0.03 to 0.02), or MUAC (mean difference 0.01 cm, 95% CI -0.01 to 0.04). The primary limitation of the trial was that measurements were only collected at enrollment and 6 months of age, precluding assessment of shorter-term or long-term changes in growth. Single-dose azithromycin does not appear to affect weight and height outcomes when administered during early infancy. ClinicalTrials.gov NCT03676764.

IntroductionAmoxicillin is recommended for children with uncomplicated severe acute malnutrition (SAM). However, some trials have shown no difference in amoxicillin for nutritional recovery in children with SAM compared with placebo. In addition, amoxicillin treatment requires two times per day dosing for 7 days, which may influence adherence. Azithromycin is a broad-spectrum antibiotic that can be provided as a single dose and has reduced mortality in children aged 1–59 months when provided by mass drug administration. The AMOUR trial is designed to assess amoxicillin, azithromycin and placebo as part of outpatient treatment of uncomplicated SAM.Methods and analysisThis double-masked randomised controlled trial will enrol 3000 children over 3 years in an individually randomised 1:1:1 allocation to azithromycin, amoxicillin or placebo arms and follow them for 12 months. Children eligible to enrol in the study will be aged 6–59 months and have uncomplicated non-oedematous SAM as defined by weight-for-height Z-score <−3 SD and/or mid-upper arm circumference <115 mm. Additionally, the children must not have received antibiotics in the past 7 days and have not received nutritional programme treatment for SAM in the 2 weeks before enrolling in the study. Each participant will receive a 7-day course of treatment or placebo based on the arm they were randomised to; 1 dose of azithromycin plus placebo for consistency in the number of doses, 7 days of amoxicillin or 7 days of placebo, with the first dose directly observed in all arms. The primary endpoint outcome will be weight gain defined by g/kg/day at 8 weeks. Mortality and relapse will be assessed at 8 weeks and 3 months, 6 months, 9 months and 12 months.Ethics and disseminationEthical approval was obtained from the Institutional Review Board at the University of California, San Francisco (Protocol 23–39411) and the Comité d’Ethique pour la Recherche en Santé in Ouagadougou, Burkina Faso (Protocol 2024-01-08). The results of this study will be disseminated to the Ministry of Health, community stakeholders and via peer-reviewed publications and academic conferences.Trial registration numberNCT06010719.

To examine how child mortality among children aged 1-59 months varies by asset-based wealth status in rural Burkina Faso, and to assess the interaction between mass azithromycin (AZ) distribution and wealth status on child mortality at both the household and community levels. We used data from a cluster-randomized trial and population census data on household characteristics and assets. A wealth index score for each household, used to classify the population by wealth, was generated using principal component analysis. We used the Relative Index of Inequality (RII), the Slope Index of Inequality (SII), and the concentration index to assess wealth-related inequalities in mortality, and the Gini Index to assess variability in child mortality across households and communities. Poisson regression models were used, with person-time at risk included as an offset, and robust standard error to estimate changes in mortality rates by wealth and treatment arm. Interaction was assessed on both the multiplicative and additive scales. Mortality declined with increasing wealth at both the household and community levels, with a significant gradient at the community level (RII = 1.17, 95% CI: 1.05-1.29; SII = 2.3 per 1,000 person-years, 95% CI: 0.2-4.4), reflecting higher mortality among the poorest. The effect of AZ did not vary significantly by wealth index, and changes in mortality rates across wealth levels were similar between the two treatment arms. There was no evidence of a statistically significant interaction between AZ and asset-based wealth on either the multiplicative or additive scale at the household or cluster level. Our findings demonstrate a wealth gradient in child mortality, with the highest mortality rates observed among households and communities in the lowest wealth quintiles. These disparities were consistent across both AZ-treated and placebo groups, suggesting that the role of AZ in health disparities may be limited to addressing gaps in treatment access rather than broader wealth-related disparities. While the study may have been underpowered to detect modest interaction effects, AZ appeared to offer similar benefits across economically diverse communities, with no evidence suggesting enhanced benefits for disadvantaged communities or for prioritizing treatment based on wealth status. Further work is needed to address the wealth-related disparities in child mortality in these communities. ClinicalTrials.gov NCT03676764.

Reduction in malaria case-fatality rate after implementation of an emergency plan for improved case management in the Bittou health district, Burkina FasoObjective. To observe the evolution in malaria case-fatality rate among children under 5 years of age receiving care at the Bittou district hospital (CMA) after an improvement of the care practices. The management team implemented an emergency plan in 2016 with 5 components: i) health facilities staff sensitization to enable rapid referral of severe malaria cases to CMA; ii) reorganization of CMA paediatric emergencies to make a physician as the mainpoint of contact; iii) ensuring availability of supplies for severe malaria case management, including the availability of blood; iv) daily medical check-ups of hospitalized patients; v) reinforcement of clinical staff skills at all peripheral health facilities. At the same time were introduced i) free care for children under 5 years; ii) municipality involvement to finance ambulance fuel for the referrals of patients; iii) free blood collection in professional schools and soldiers; iv) a free telephone line between the health structures; v) presence of 5 medical doctors at the CMA.Material and methods. Analysis of data collected from the statistical yearbooks of the Ministry of Health of Burkina Faso from 2014 to 2021.Results. The malaria case-fatality rate (CFR) in under-five in the Bittou health district (1.39% and 1.52% in 2014 and 2015) was higher than the average for all districts in this region (1.08%). After implementation of the emergency plan, the malaria CFR in Bittou declined to 0% in 2016 and 2017, 0.2% in 2018, 0% in 2019, 0.07% in 2020 and 0.05% in 2021. The same trend was observed at the CMA level with 2.94% and 2.59% in 2014 and 2015, 0% in 2016 and 2017, 0.38% in 2018, 0% in 2019, then 0.17% and 0.47% in 2020 and 2021.Conclusion. Malaria control remains a challenge in Burkina Faso. However, the improved malaria CFRs observed in Bittou show that effective involvement of health district teams could potentially contribute to substantial reductions in malaria case-fatality risk.Réduction de la létalité du paludisme après la mise en œuvre d’un plan d’urgence pour l’amélioration de la prise en charge des cas dans le district sanitaire de Bittou, Burkina FasoObjectif. Cette étude a pour objectif d’observer et de décrire la réduction de la létalité du paludisme chez les enfants de moins de 5 ans reçus dans le Centre médical avec antenne chirurgicale (CMA) de Bittou au Burkina Faso. Face à la létalité élevée du paludisme, l’équipe cadre du district a mis en place un plan d’urgence en 2016.Matériel et méthodes. Analyse des données collectées à partir des annuaires statistiques du ministère de la Santé du Burkina Faso de 2014 à 2021.Résultats. Le taux de létalité palustre des moins de 5 ans dans le district sanitaire de Bittou est passé de 1,39 % en 2014 et 1,52 % en 2015 à 0 % en 2016 et 2017, 0,2 % en 2018, 0 % en 2019, 0,07 % en 2020 et 0,05 % en 2021. La même tendance est observée au niveau du CMA avec 2,94 % et 2,59 % en 2014 et 2015, 0 % en 2016 et 2017, 0,38 % en 2018, 0 % en 2019, puis 0,17 % et 0,47 % en 2020 et 2021.Conclusion. La lutte contre le paludisme reste un défi au Burkina Faso. L’amélioration des taux de létalité observée à Bittou montre qu’une implication effective des équipes cadres des districts sanitaires peut contribuer à des réductions substantielles de la mortalité due au paludisme.

Background While Seasonal Malaria Chemoprevention (SMC) has been adopted as a malaria control strategy in regions with seasonal transmission, continued monitoring and evaluation of its effectiveness across diverse ecological, epidemiological, and healthcare settings remain critical for optimizing the intervention. This study aims to assess the ongoing population-level impact of SMC under routine programme conditions by evaluating rates of uncomplicated and severe malaria following four rounds of administration. Methods A pre-post analysis was conducted using real-world surveillance data from clinic visits in 285 villages in Nouna District, Burkina Faso, along with National Malaria Control Programme data on SMC administration. Estimates of the population used for person-time calculations were derived from a census conducted as part of a randomized controlled trial. Malaria rates for children under 5 were analyzed for each epidemiological week in 2021, for each health post in the study area. Negative binomial regression models were used, with person-time at risk used as an offset and standard errors clustered by health post, to obtain incidence rate ratios (IRRs) and rate differences. Changes in diagnoses were estimated from the administration weeks to each of the three weeks post- administration within the same population. Injury rates were used as a negative control outcome to assess potential unmeasured confounding. Results Although SMC was administered during peak malaria transmission weeks within each cycle, both uncomplicated and severe malaria rates remained high through December, following the fourth and final round of SMC. There was a substantial reduction in infection rates in the 3 weeks post SMC, with gradual increases in rates across the three weeks. The rates of uncomplicated and severe malaria per 1000 person-weeks in the administration weeks were 8.5 (95% CI 7.0 to 10.1) and 0.31 (95% CI 0.22 to 0.40), respectively. Uncomplicated malaria rates were lower by 41%, 95%CI (31–50%), 34% (23–43%) and 22% (12–31%) in the first, second and third weeks after administration, respectively. Severe malaria rates declined by 47% (21–64%), 47% (31–59%) and 34% (17–47%) in the three weeks post-administration. Injury rates, the negative control outcome, did not change significantly across the three weeks. Conclusion In programme settings, at the population level, SMC administration was associated with a substantial reduction in uncomplicated and severe malaria, though this effect was limited to the immediate weeks following administration. The gradual increase in malaria rates by the third week suggests a shorter duration of protection than previously observed. Extending the areas where 5 rounds of distribution occur may be necessary to effectively prevent malaria infections in regions with a longer transmission season. Regular evaluation of local malaria trends and impact of SMC can help further tailor and optimize SMC programmes for specific regional contexts.

Background Many countries worldwide, particularly those in sub-Saharan Africa, suffer from malaria burden, both mortality and morbidity. Multiple funding agencies are investing to improve the health of populations. The aim of this study was to assess the impact of malaria funding on mortality and morbidity in children under 5 years of age over a 15-year period. Methods A retrospective study was conducted from 2009 to 2023 across the country. Analysis was based on a secondary analysis of routine data from health facilities via DHIS2. Financial data was assembled from the malaria programme and health accounts. Results Between 2009 and 2023, Burkina Faso’s population grew by 50.7%, from 15.2 to 22.9 million. Children under 5 represented 19.1% of the population in 2009 and 17.9% in 2023 and increased in number by 41.4%. In fifteen years, Burkina Faso invested USD13,545 million in the health sector, including 15.3% against malaria. These efforts yielded several benefits in health services including: the reduction of distance travelled by the population to health facilities from 7.2 to 6.0 km; the number of new contacts per capita for children under 5 per year increased from 0.8 to 2.1; the malaria case fatality rate decreased from 3.4% to 1.3% in children under 5. Stratified analysis identified three regions out of thirteen [Sahel (IRR = 4.1), Boucle du Mouhoun (IRR = 3.5) and Nord (IRR = 3.4), where the risk of malaria mortality was three times higher than in the Centre. Conclusion The study demonstrated the impact of funding on malaria morbidity and mortality, and diverse local risk of death from malaria in children under 5.

Objective To assess the benefits of Seasonal Malaria Chemoprevention (SMC)—the monthly administration of sulfadoxine-pyrimethamine and amodiaquine—beyond malaria prevention in real-world program settings. Methods We conducted a pre-post comparison of non-malarial diagnoses (pneumonia, diarrhea, acute malnutrition) and antibiotic prescription rates during SMC administration weeks versus a three-week post-intervention period in rural Burkina Faso. Data was obtained from clinic surveillance at 51 health facilities, a population-based census, and National Malaria Control Program data on SMC timing. Poisson regression models with person-weeks as an offset and standard errors clustered by health post estimated changes in rates. Interaction terms assessed variation across SMC cycles. Positive (malaria diagnoses, antimalarial prescriptions) and negative (injury) control outcomes were used to evaluate potential unmeasured confounding. Results Compared to administration weeks, modest declines were observed in pneumonia, diarrhea, and acute malnutrition diagnoses, as well as in antibiotic prescription rates during the post-SMC period. Absolute reductions were 0.7 (95% CI: 0.3–1.0), 0.2 (95% CI: 0.1–0.4), 0.05 (95% CI: 0.001–0.09), and 0.90 (95% CI: 0.4–1.4) per 1,000 person-weeks, respectively ( corresponding IRRs: 0.86 , 0.83 , 0.71 , and 0.88 ). Positive control outcomes also declined, with malaria diagnoses and antimalarial prescriptions decreasing by 3.7 (95% CI: 2.6–4.8) and 3.6 (95% CI: 2.5–4.7) per 1,000 person-weeks ( IRRs: 0.62 and 0.63 ). Injury rates (negative control) remained stable (0.02; 95% CI: −0.03 to 0.07). Reductions varied across SMC cycles and were most pronounced following the final round. Conclusion SMC may have additional benefits beyond malaria prevention, including reductions in common pediatric infections and subsequent routine antibiotic use. Clinical trial Not applicable.