By Chioma Obinna

Nigeria has for long grappled with one of the highest infant mortality rates in the world — a stark indicator of the country’s maternal and child health challenges.

The World Bank, says Nigeria’s infant mortality rate stands at approximately 65 deaths per 1,000 live births, significantly higher than the global average and above the World Health Organisation threshold of 60 per 1,000 which signals urgent intervention.

In response, a promising initiative led by the Nigerian Institute of Medical Research, NIMR, in collaboration with the Federal Government, FG, has emerged, leveraging the antibiotic azithromycin to reduce deaths among children under five.

The  bold strategy follows the 2022 WHO guideline recommending mass administration of azithromycin in countries with infant mortality rates exceeding 60 per 1,000 live births as a complementary child survival tool.

Azithromycin, a broad-spectrum antibiotic traditionally used to combat neglected tropical diseases such as onchocerciasis and schistosomiasis prevalent in northern Nigeria and its neighbours, unexpectedly showed secondary benefits.

From data, communities receiving mass azithromycin treatment for these diseases also experienced declines in infant mortality.

Addressing journalists after a field trip to Kano on the ongoing study for the second implementation of the project titled: “Selective Antimicrobial Resistance Monitoring and Azithromycin Administration in Nigeria”, SARMAAN, the Director of Research at NIMR  and a Consultant Obstetrician-Gynaecologist, Professor Oliver Ezechi explained the genesis of the initiative.

“After years of using azithromycin for neglected tropical diseases, we noticed infant mortality in these areas dropped. That observation spurred NIMR to conduct focused research to validate these findings across Nigeria,” he said.

In line with WHO recommendation

Though the precise mechanisms remain under investigation, experts believe azithromycin helps by reducing bacterial infections such as respiratory tract infections and diarrheal diseases — two leading causes of child mortality in Nigeria.

Ezechi said WHO’s recommendation was clear: azithromycin was not to replace immunisation, nutrition, or other established child survival interventions but to be added as a complementary measure. This led to the creation of the SARMAAN project.

He explained that the SARMAAN (Selective Antimicrobial Resistance Monitoring and Azithromycin Administration in Nigeria) project began with a one-year pilot phase led by NIMR, supported by the Bill and Melinda Gates Foundation. Its focus was threefold: assess the safety of mass azithromycin administration, evaluate cost-effectiveness, and monitor antimicrobial resistance (AMR) risks.

“We wanted to ensure we don’t solve one problem only to create another through drug resistance. Our objective was clear — confirm safety, cost-effectiveness, and sustainable implementation,” Ezechi emphasised.

Rather than creating a parallel health programme, SARMAAN integrated azithromycin distribution into existing platforms like Nigeria’s National Immunisation Programme, ensuring synergy and sustainability.

The pilot phase took place in Kano, Jigawa, Sokoto, Kebbi, Abia, and Akwa Ibom states, carefully chosen for their diverse cultural, geographic, and epidemiologic profiles.  Despite initial resistance in one state, the project reached over 1.8 million children aged 1 to 59 months across selected local government areas.

Encouraging outcomes

After two years of biannual azithromycin distribution, SARMAAN reported encouraging outcomes, including a drop in infant mortality in participating communities.  Based on these promising results, the project scaled to 11 northern states with the highest infant mortality rates in its second phase, SARMAAN 2. This is about more than Nigeria. Our findings contribute to the global understanding of child survival, antimicrobial stewardship, and public health interventions.” A Research Fellow and Consultant Paediatrician at NIMR, Dr. Abideen Salako highlighted how SARMAAN unified multiple stakeholders.

“This aligns perfectly with NIMR’s vision of promoting national health through excellent research. We brought together the Federal Ministry of Health, international research partners like the University of Washington, Duke University, and community leaders.”

The project focused on research but also created jobs and empowered local communities through training and stipends for research assistants, strengthening grassroots ownership.

At the community level, the response has been overwhelmingly positive. Hussain Adamu, Head of the Korie Tsohuwa community in Kano State, remarked.

“When the health team introduced this, I was happy. Maternal and infant deaths have become rare. Parents appreciate the government’s support and want it to continue, especially to tackle malnutrition.

“Building on these successes, NIMR can continue to lead health research in Nigeria, securing a healthier future for millions of children,” Salako said.

Renewed hope

The SARMAAN sets a precedent for integrating innovative research-driven solutions into Nigeria’s public health landscape.

“Nigeria’s infant mortality rate remains a sobering challenge, but with innovative interventions like SARMAAN, there is renewed hope that one day, fewer children will die needlessly, and healthier childhoods will become the norm across the nation.”

However, the road to success has not been without hurdles, as outlined by  Dr. Folahanmi Akinsolu, a Public Health Research Fellow.

“Some policymakers still misunderstand the role of research in sustainable health solutions. We had to repeatedly advocate just to get buy-in. One state outright rejected the programme despite its high infant mortality rate,” Akinsolu said.

He said logistical problems abound: northern states often lack laboratory infrastructure, requiring costly transport of samples to Lagos for analysis. Security concerns have also endangered research staff in certain “no-go” areas.

“There is a shortage of skilled personnel too. Continuous training and supervision are crucial to ensure data quality,” Akinsolu added.He said despite these challenges, the team remains steadfast in reaching underserved populations to save lives.

Rigorous, ethical study on scale

Speaking during the ongoing sample collections for the second phase of the project in Kano, a consultant on SARMAAN 2 based in Kano, Dr Imam Wada Bello, who spoke to Vanguard elaborated on the scientific rigour and ethical framework of the ongoing four-year study.

“SARMAAN 2 is designed as a hybrid, mixed-methods study targeting states where infant mortality exceeds 60 per 1,000 live births and under-five mortality exceeds 80 per 1,000,” he explained.

The study covers over 6,000 households and 144,000 respondents across 24 local government areas in Kano alone. It includes detailed baseline data collection, periodic administration of azithromycin, and close monitoring for antimicrobial resistance.

Crucially, the study avoids denying treatment to any child, rather, adopting a stepwise rollout where all children eventually receive the drug, an approach that  upholds  beneficence.

Bello said azithromycin complements existing child survival measures such as immunisation, breastfeeding promotion, and deworming.

The mass administration targets common bacterial infections implicated in childhood deaths—pneumonia, diarrhoea, whooping cough, measles, among others.

“While immunisation covers many viral diseases, bacterial infections remain a significant threat. Diarrhea alone kills more children than many realize, stemming from multiple pathogens,” Bello said.

Preliminary data from pilot sites like Kura Local Government Area in Kano show promising results: low antimicrobial resistance levels and high community acceptance.

“The low AMR is very reassuring,” Bello noted. “Communities are voluntarily accepting the drug, which is a big success.”

The experts stated that if the ongoing study confirms the safety and effectiveness of mass azithromycin administration, Nigeria could adopt it as a national child survival strategy, alongside immunisation and nutrition programmes.