[Personal View] Azithromycin mass drug administration: balancing survival benefits and risks in children

Childhood mortality remains a major public health challenge in low-income and middle-income countries, particularly in sub-Saharan Africa, despite major advances in universal sanitation and immunisations. Mass drug administration (MDA) of azithromycin, a broad-spectrum antibiotic, has shown promise in reducing under-5 mortality in high-risk regions, although its mechanism of protection remains largely unknown. In this Personal View, we analyse current evidence, potential effect of MDA on antimicrobial resistance, and relevant ethical principles, and propose priorities for future public health interventions.