Predictors of non-participation in azithromycin mass drug administration to reduce mortality among children 1-11 months old in Niger: a coverage evaluation survey

The World Health Organization recommends biannual azithromycin mass drug administration (MDA) to infants aged 1-11 months to reduce mortality, following promising results from trials in West Africa. High coverage seen in well-resourced trials may decline as the intervention transitions to a real-world program. As a result, the most vulnerable children facing the highest risk of mortality may be missed. We aimed to identify predictors of non-participation in an azithromycin MDA program to inform programmatic delivery strategies to improve coverage. We conducted a coverage evaluation survey after azithromycin MDA to children aged 1-11 months in Nigers Tahoua region. Data collection teams visited households to assess caregiver-reported participation, reasons for participation and non-participation, and adverse events. Mixed effects logistic regression models were used to analyze community-, household-, and child-level predictors associated with non-participation in azithromycin MDA. Among 40 communities with 811 unique households and 871 children ages 2-12 months old included in analyses, 76% of eligible children received treatment based on caregiver report compared to 96% community health worker-reported coverage. The most frequently stated reasons for non-receipt of treatment were absence (34%), nobody coming to the house (31%), and not receiving enough information (17.2%). In an adjusted model, older children experienced higher odds of receiving treatment (aOR 1.22, 95% CI 1.15 - 1.30, P [≤] 0.0001), as did children living in more densely populated areas (aOR 1.15, 95% CI 1.04 - 1.28, P = 0.01). Adverse events were reported among 6.8% of children who received treatment, with fever being the most reported symptom. Strengthening community sensitization and preparation activities before MDA is essential to address common reasons for non-participation. Future research to understand why younger children and those living in sparsely populated communities were less likely to be included may help target specific interventions in these populations.