EMBARGOED FOR RELEASE: 3 P.M. (CT) TUESDAY, MAY 15, 2012
Media Advisory: To contact corresponding author Junfeng (Jim) Zhang, Ph.D., call Alison Trinidad at 323-442-3941 or email alison.trinidad@usc.edu; to contact corresponding author Tong Zhu, Ph.D., email tzhu@pku.edu.cn. To contact editorial co-author Francesca Dominici, Ph.D., call Todd Datz at 617-432-8413 or email tdatz@hsph.harvard.edu.

CHICAGO – During the 2008 Beijing Olympics, changes in air pollution were associated with changes in biomarkers of systemic inflammation and thrombosis (formation of blood clot) as well as measures of cardiovascular physiology in healthy young persons, according to a study in the May 16 issue of JAMA, a theme issue on Global Health.

“Air pollution is a risk factor for cardiovascular diseases (CVD), but the mechanisms by which air pollution leads to CVD is not well understood. Hypothesized mechanisms with associated biomarkers include systemic inflammation and thrombosis or endothelial [thin layer of cells that line the heart and certain vessels and cavities within the body] dysfunction,” according to background information in the article. “As a condition for hosting the 2008 Olympic Games, the Chinese government agreed to temporarily and substantially improve air quality in Beijing for the Olympics and subsequent Paralympics. This provided a unique opportunity to use a quasi-experimental design in which exposures and biomarkers were measured at baseline (pre-Olympics), following a change in pollution (during-Olympics), and then repeated after an expected return to baseline (post-Olympics).”

David Q. Rich, Sc.D., of the University of Rochester, New York, and colleagues conducted a study to determine whether markers related to CVD pathophysiological pathways (biomarkers for systemic inflammation and thrombosis, heart rate, and blood pressure) are sensitive to changes in air pollution. The researchers measured environmental air pollutants daily and also measured various biomarkers and other measures (heart rate, blood pressure) in 125 healthy young adults before, during, and after the 2008 Olympics (June 2-October 30). The biomarkers measured included those associated with systemic inflammation (fibrinogen, C-reactive protein [CRP], white blood cell [WBC] count) and thrombosis or endothelial dysfunction (platelet activation markers P-selectin [sCD62P] and soluble CD40 ligand [sCD40L] as well as the adhesive endothelial glycoprotein von Willebrand factor).

Concentrations of particulate and gaseous pollutants decreased substantially (-13 percent to -60 percent) from the pre-Olympic period to the during-Olympic period. There were reductions in the average concentration of sulfur dioxide (-60 percent), carbon monoxide (-48 percent), nitrogen dioxide (-43 percent), elemental carbon (-36 percent), PM2.5 (-27 percent), organic carbon (-22 percent), and sulfate (-13 percent) from the pre-Olympic to the during-Olympic period. “In contrast, ozone concentrations increased (24 percent). Pollutant concentrations generally increased substantially from the during- to post-Olympic period for all the pollutants (21 percent to 197 percent) except ozone (-61 percent) and sulfate (-47 percent),” the authors write.

The researchers observed statistically significant improvements in SCD62P levels (by -34.0 percent), and von Willebrand factor (by -13.1 percent). Changes in the other outcomes were not statistically significant after adjustments for multiple comparisons. In the post-Olympic period when pollutant concentrations increased, most outcomes approximated pre-Olympic levels, but only sCD62P and systolic blood pressure were significantly worsened from the during-Olympic period. “The fraction of above-detection-limit values for CRP was reduced from 55 percent in the pre-Olympic period to 46 percent in the during-Olympic period and reduced further to 36 percent in the post-Olympic period. Interquartile range increases in pollutant concentrations were consistently associated with statistically significant increases in fibrinogen, von Willebrand factor, heart rate, sCD62P, and SCD40L concentrations.”

“Although these findings are of uncertain clinical significance, this study provides quasi-experimental, mechanistic data to support the argument that air pollution may be a global risk factor for CVD.”
(JAMA. 2012;307[19]:2068-2078. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: China’s Air Quality Dilemma – Reconciling Economic Growth With Environmental Protection

Francesca Dominici, Ph.D., and Murray A. Mittleman, M.D., Dr.P.H., of the Harvard School of Public Health, Boston, write in an accompanying editorial that “China’s dilemma, like many countries with emerging industries, is how to reconcile rapid economic growth with environmental protection.”

“In recent decades, China has achieved industrialization and urbanization. However, China has been much less successful in maintaining the quality of urban air. Several factors challenge the implementation of air pollution controls in China: heavy reliance on coal as a main heating system, especially in subsidized housing; lack of political incentives for trading slower growth for less pollution; economic factors: most Chinese factories and power plants run on extremely thin margins and fines for polluting are generally lower than the cost of controlling emissions; and economic transformation of the landscape, from ubiquitous construction sites to the rapid expansion of the nation’s vehicle fleet. If air pollution in China and other Asian nations cannot be controlled, it could spread to other continents. A recent study by Lin et al provides compelling evidence that Asian emissions may account for as much as 20 percent of ground-level pollution in the United States. Clean air is a shared global resource. It is in the common interest to maintain air quality for the promotion of global health.”
(JAMA. 2012;307[19]:2100-2102. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

# # #

EMBARGOED FOR RELEASE: 3 P.M. (CT) TUESDAY, MAY 15, 2012

Media Advisory: To contact Eran Bendavid, M.D., M.S., call Ruthann Richter at 650-725-8047 or email richter1@stanford.edu. To contact editorial author Ezekiel J. Emanuel, M.D., Ph.D., call Holly Auer at 215-349-5659 or email holly.auer@uphs.upenn.edu.

CHICAGO – Between 2004 and 2008, all-cause adult mortality declined more in African countries in which the AIDS relief program PEPFAR operated more intensively, according to a study in the May 16 issue of JAMA, a theme issue on Global Health.

“The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries,” according to background information in the article. PEPFAR has targeted the rapidly expanding human immunodeficiency virus (HIV) epidemic with a coordinated effort to increase HIV treatment, prevention, and care. PEPFAR scaled up the delivery of expanded antiretroviral therapy (ART) and supported large-scale prevention efforts. The initiative’s effect on all-cause adult mortality has not been known.

Eran Bendavid, M.D., M.S., of Stanford University, Stanford, Calif., and colleagues examined the relationship between PEPFAR’s implementation and trends in adult mortality. Using person-level data from the Demographic and Health Surveys (DHS), the researchers conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1,000 adults between 15 and 59 years old) and PEPFAR activities. Across countries, adult mortality was compared in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with adult mortality in 18 African nonfocus countries from 1998 to 2008.

The study included data on 1,538,612 African adults collected from 41 surveys conducted in 27 countries between 1998 and 2008. During this time period, 60,303 deaths were captured in the DHS used in this study. Analysis of the data indicated relatively greater mortality declines among adults living in focus countries between 2004 and 2008, with mortality in the focus countries declining from 8.30 per 1,000 adults in 2003 to 4.10 per 1,000 in 2008. The mortality trends in nonfocus countries did not show a similar decline during the study period (from 8.5 in 2003 to 6.9 in 2008). After adjustments for country-level and personal characteristics, the odds of all-cause death was lower in the focus countries.

The authors also examined district-level data for Tanzania and Rwanda.  High and low PEPFAR activity districts had similar populations, but program intensity was significantly different between the groups. Adults in Tanzania living in the regions with above-median (midpoint) PEPFAR intensity had a lower odds of mortality compared with adults living in regions with below-median intensity; in Rwanda, the similar comparison also revealed a lower odds of mortality for adults living in the regions with above-median PEPFAR intensity.

The researchers also found that, using the results for each focus country and generalizing to the size of each country’s adult population, an estimated total of 740,914 all-cause adult deaths were averted between 2004 and 2008 in association with PEPFAR. In comparison, PEPFAR was associated with an estimated 631,338 HIV-specific deaths averted during the same period.

“In conclusion, we provide new evidence suggesting that reductions in all- cause adult mortality were greater in PEPFAR’s focus countries relative to the nonfocus countries over the time period from 2004 through 2008. Our analysis suggests an association of PEPFAR with these improvements in population health,” the authors write.

(JAMA. 2012;307[19]:2060-2067. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Please Note: For this study, there will be multimedia content available, including the JAMA Report video, embedded and downloadable video, audio files, text, documents, and related links. This content will be available at 3 p.m. CT Tuesday, May 15 at this link.

Editorial: PEPFAR and Maximizing the Effects of Global Health Assistance

In an accompanying editorial, Ezekiel J. Emanuel, M.D., Ph.D., of the University of Pennsylvania, Philadelphia, writes that the “article by Bendavid et al is welcome news in helping to document the even greater benefits of PEPFAR not only on HIV/AIDS but on overall mortality in countries.”

“However, the further question that must be asked by ethically responsible people and policy makers becomes: Is PEPFAR worth it? Many other global health programs are improving the health of poor people worldwide but are not funded anywhere near the level of PEPFAR. The fundamental ethical, economic, and policy question is not whether PEPFAR is doing good, but rather whether other programs would do even more good in terms of saving life and improving health. Clearly, besides treatment for HIV/AIDS, there are other highly effective and lower-cost interventions for the world’s poor.”

(JAMA. 2012;307[19]:2097-2099. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Emanuel reported receiving payment for speaking engagements unrelated to this work.

# # #

EMBARGOED FOR RELEASE: 3 P.M. (CT) TUESDAY, MAY 15, 2012

Media Advisory: To contact Lars Ake Persson, M.D., Ph.D., email lars-ake.persson@kbh.uu.se. To contact editorial co-author Robert E. Black, M.D., M.P.H., call Tim Parsons at 410-955-7619 or email tmparson@jhsph.edu.

 CHICAGO – Pregnant women in poor communities in Bangladesh who received multiple micronutrients, including iron and folic acid combined with early food supplementation, had substantially improved survival of their newborns, compared to women in a standard program that included usual food supplementation, according to a study in the May 16 issue of JAMA, a theme issue on Global Health.

“Maternal and child undernutrition is estimated to be the underlying cause of 3.5 million annual deaths and 35 percent of the total disease burden in children younger than 5 years. The potential long-term consequences of nutritional imbalance or insult in fetal or early life also include cognitive impairment and chronic diseases in adulthood. Effective child nutrition interventions are available to reduce stunting, prevent consequences of micronutrient deficiencies, and improve survival. The knowledge base is weaker regarding prenatal nutrition interventions of benefit for mother and offspring,” according to background information in the article. “The proportion of malnourished mothers and children remains high in many areas of the world, especially in South Asia, where more than one-quarter of newborns have a low weight.”

Lars Ake Persson, M.D., Ph.D., of Uppsala University, Uppsala, Sweden, and colleagues conducted a study (the MINIMat trial) to examine whether a prenatal multiple micronutrient supplementation (MMS), as well as an early invitation to a daily food supplementation, would increase maternal hemoglobin level at 30 weeks’ gestation, birth weight, and infant survival, and that a combination of these interventions (early invitation with MMS) would further improve these outcomes. The randomized trial, conducted in Matlab, Bangladesh, included 4,436 pregnant women who were recruited between November 2001 and October 2003, with follow-up until June 2009. One-third of the women were illiterate and one-fifth experienced occasional or constant deficit in their perceived income-expenditure status.

Participants were randomized into 6 groups; a double-masked supplementation with capsules of 30 mg of iron and 400 μg of folic acid, 60 mg of iron and 400 μg of folic acid, or MMS containing a daily allowance of 15 micronutrients, including 30 mg of iron and 400 μg of folic acid, was combined with food supplementation randomized to either early invitation (9 weeks’ gestation) or usual invitation (20 weeks’ gestation).

There were 3,625 live births out of 4,436 pregnancies. The average birth weight among 3,267 single-birth infants was 2,694 grams (5.9 lbs.). Overall, 31 percent of newborns weighed less than 2,500 g (5.5 lbs.). There was no significant difference in birth weight among treatment groups, and no main-effect differences between food groups or among micronutrient groups. The researchers found that infants in the early invitation with MMS group had a lower risk of death, with a mortality rate of 16.8 per 1,000 live births vs. 44.1 per 1,000 live births for usual invitation with 60 mg of iron and 400 μg of folic acid. The early invitation with MMS group had an under 5-year mortality rate of 18 per 1,000 live births (54 per 1,000 live births for usual invitation with 60 mg of iron and 400 μg of folic acid). Usual care invitation with MMS had the highest infant mortality rate (47.1 per 1,000 live births).

Adjusted maternal hemoglobin level at 30 weeks’ gestation was 115.0 g/L, with no significant differences among micronutrient groups. Women in the early invitation group had a small (0.9 g/L) but statistically significant lower hemoglobin level concentration than those in the usual invitation group.

“Scientists and policymakers have recommended replacing the current iron-folic acid supplements with MMS in the package of health and nutrition interventions delivered to pregnant women to improve size at birth and child growth and development. Other studies have questioned this view based on the limited size of the effect on birth weight and the absence of positive effect on fetal and neonatal survival. The MINIMat trial provides evidence that mortality of the offspring was reduced if multiple micronutrients were combined with a balanced protein-energy supplementation that began early in pregnancy,” the researchers conclude.

(JAMA. 2012;307[19]:2050-2059. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Food, Micronutrients, and Birth Outcomes

In an accompanying editorial, Parul Christian, Dr.P.H., M.Sc., and Robert E. Black, M.D., M.P.H., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, write that results from one country, such as in this study, “may not be applicable in other settings for a number of reasons, including variable maternal prepregnancy status, levels of macronutrient and micronutrient deficiencies, and antenatal [before birth] and delivery care availability.”

“Several nutrition programs in Asia and Africa have long targeted pregnant and lactating women in large-scale food supplementation programs, such as the one ongoing in Bangladesh when this trial was conducted. Coverage rates in these programs are known to be generally low and women are normally identified late in pregnancy. Further research on the timing of nutritional interventions including prior to and early and late in pregnancy is needed to examine their efficacy and safety both for survival and other long-term developmental consequences.”

(JAMA. 2012;307[19]:2094-2096. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

 # # #

Prevalence of Girl Child Marriage Decreases in South Asia

Girl child marriage (i.e., < 18 years of age) affects more than 10 million girls globally each year and is linked to maternal and infant morbidities (e.g., delivery complications, low birth weight) and an increased risk of death. Half (46 percent) of child marriages occur in South Asia. Anita Raj, Ph.D., M.S., of the

University of California, San Diego, and colleagues conducted a study to assess whether the prevalence of girl child marriage has changed over the past 2 decades in 4 South Asian nations (Bangladesh, India, Nepal, and Pakistan) with a girl child marriage prevalence of 20 percent or greater.

As reported in a Research Letter, the authors found that the prevalence of girl child marriage decreased in all countries from 1991-1994 to 2005-2007. Significant relative reductions occurred in marriage of girls prior to age 14 years across all 4 nations.  Little or no change over time was seen in marriage of 16- to 17-year-old adolescent girls for any nation except Bangladesh, where such marriages increased by 35.7 percent. “Reductions in girl child marriage in South Asia have occurred but are largely attributable to success delaying marriage among younger but not older adolescent girls. Improvements in education of girls and increasing rural to urban migration may have supported these reductions, but many schools graduate students at the 10th standard (about 15-16 years), maintaining vulnerability to early marriage for 16- to 17-year-old girls.”

(JAMA. 2012;307[19]:2027-2029. Available pre-embargo to the media at www.jamamedia.org)

A Framework Convention on Global Health – Health for All, Justice for All

In a Special Communication, Lawrence O. Gostin, J.D., of the Georgetown University Law Center, Washington, D.C., writes that “health inequalities represent perhaps the most consequential global health challenge and yet they persist despite increased funding and innovative programs.”

A global coalition of civil society and academics—the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI)— has formed an international campaign to advocate for a Framework Convention on Global Health (FCGH). Recently endorsed by the UN Secretary-General, the FCGH would re-imagine global governance for health. Mr. Gostin examines the key modalities of an FCGH to illustrate how it would improve health and reduce inequalities. “The modalities would include defining national responsibilities for the population’s health; defining international responsibilities for reliable, sustainable funding; setting global health priorities; coordinating fragmented activities; reshaping global governance for health; and providing strong global health leadership through the World Health Organization.”

(JAMA. 2012;307[19]:2087-2092. Available pre-embargo to the media at www.jamamedia.org)

Viewpoints in This Week’s JAMA

Primary Health Care in Low-Income Countries – Building on Recent Achievements

Jeffrey D. Sachs, Ph.D., of Columbia University, New York, discusses the advances and challenges of providing health care in low-income countries.

“The dozen years since the adoption of the Millennium Development Goals have been a period of great achievement and advances in public health in the poorest countries. The cynics and naysayers were proven wrong. Ancient scourges such as malaria and newer ones such as AIDS can be controlled, even in the poorest places. Now is the time to redouble efforts to ensure that the gains of the past decade are pushed forward to become lasting triumphs.”

(JAMA. 2012;307[19]:2031-2032. Available pre-embargo to the media at www.jamamedia.org)

Policy Making With Health Equity at Its Heart

Michael G. Marmot, F.R.C.P., of University College London, examines the importance of putting health equity – defined as the systematic inequalities in health between social groups that are deemed to be avoidable by reasonable means – at the heart of all policy making, nationally and globally.

“When governments cut social expenditures, the effect is greatest on those at the lower end of the social hierarchy, those who are most dependent on cash and in-kind government expenditures. It should be of the highest priority to ensure that government policies do not unfairly increase avoidable health inequalities. What applies to policies of governments should also apply to global decision making whether on trade, overseas development assistance, or financial flows—put health equity at the heart of all policy making.”

(JAMA. 2012;307[19]:2033-2034. Available pre-embargo to the media at www.jamamedia.org)

Achieving Equity in Global Health – So Near and Yet So Far

Zulfiqar A. Bhutta, F.R.C.P.C.H., Ph.D., of Aga Khan University, Karachi, Pakistan, and K. Srinath Reddy, M.D., D.M., (Card), of the Public Health Foundation of India, New Delhi, write that “few issues have generated as much passion and imagination over the last few decades as the challenge of global health. From major studies on the global burden of disease to the recognition of the global epidemic of human immunodeficiency virus, AIDS, and tuberculosis, health has been center stage of the global development debate.”

The authors discuss the needs of several major global health issues and cite initiatives that have experienced positive outcomes in certain areas of public health.

(JAMA. 2012;307[19]:2035-2036. Available pre-embargo to the media at www.jamamedia.org)

Noncommunicable Diseases – A Global Health Crisis in a New World Order

Shannon L. Marrero, B.A., of Brown University, Providence, R.I., and colleagues write that in September 2011, the United Nations General Assembly (UNGA) held a High-Level Meeting on the Prevention and Control of Non-communicable Diseases. It is only the second time in history that the UNGA convened a high-level meeting in response to a global health crisis. The authors discuss the outcomes and aftermath of the high-level meeting and affirm that the previously unrecognized non-communicable diseases (NCDs) epidemic has at last acquired a voice.

“The NCDs—cardiovascular disease, chronic respiratory disease, diabetes, and cancers—are the dominant public health challenge of the 21st century. Left unattended, NCDs compromise the Millennium Development Goals, thwart the eradication of poverty, and undercut economic growth.”

(JAMA. 2012;307[19]:2037-2038. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

 # # #

EMBARGOED FOR RELEASE: 3 P.M. (CT) TUESDAY, MAY 15, 2012
Media Advisory: To contact R. Matthew Chico, M.P.H., email Katie Steels at katie.steels@lshtm.ac.uk or call +44 (0)20-7927-2802.

CHICAGO – A review of studies reporting estimates of the prevalence of sexually transmitted infections/reproductive tract infections (STIs/RTIs) and malaria over the past 20 years suggests that a considerable burden of malaria and STIs/RTIs exists among pregnant women attending antenatal (before birth) facilities in sub-Saharan Africa, according to a review and meta-analysis of previous studies published in the May 16 issue of JAMA, a theme issue on Global Health.

“There are 880,000 stillbirths and 1.2 million neonatal deaths each year in sub-Saharan Africa. Low birth weight (< 2.5 kg [5.5 lbs.]), attributable to intrauterine growth retardation, preterm delivery, or both, is the leading risk factor for neonatal mortality. Intrauterine infection is implicated in stillbirth and is associated with 25 percent to 40 percent of preterm births. Sexually transmitted infections and reproductive tract infections and malaria are associated with adverse birth outcomes, but both may be mitigated with preventive or presumptive treatment or by repeated screening and treatment throughout the antenatal period. The extent to which either approach may be beneficial depends on the underlying prevalence of STIs/RTIs and malaria in pregnancy,” according to background information in the article.

R. Matthew Chico, M.P.H., of the London School of Hygiene and Tropical Medicine, London, and colleagues conducted a systematic review and meta-analysis to provide estimates for the dual prevalence of STIs/RTIs and malaria in pregnancy among women in sub-Saharan Africa. The researchers conducted a search for studies reporting malaria, syphilis, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, or bacterial vaginosis among pregnant women attending antenatal care facilities in sub-Saharan Africa. A total of 171 studies, which were conducted from 1990-2011, were identified that met inclusion criteria.

The studies included 340,904 women. The researchers found that the pooled prevalence estimates among studies in East and Southern Africa were: syphilis, 4.5 percent (n = 8,346 positive diagnoses), N gonorrhoeae, 3.7 percent (n = 626), C trachomatis, 6.9 percent (n = 350), T vaginalis, 29.1 percent (n = 5,502), bacterial vaginosis, 50.8 percent (n = 4,280), peripheral malaria, 32.0 percent (n = 11,688), and placental malaria, 25.8 percent (n = 1,388).

“West and Central Africa prevalence estimates were as follows: syphilis, 3.5 percent (n = 851), N gonorrhoeae, 2.7 percent (n = 73), C trachomatis, 6.1 percent (n = 357), T vaginalis, 17.8 percent (n = 822), bacterial vaginosis, 37.6 percent (n = 1,208), peripheral malaria, 38.2 percent (n = 12,242), and placental malaria, 39.9 percent (n = 4,658),” the authors write.

“The dual prevalence of malaria and STIs/RTIs is evident among pregnant women who attend antenatal facilities in sub-Saharan Africa. As malaria control and elimination efforts are brought to scale, the relative contribution of STIs/RTIs to adverse birth outcomes most likely will increase proportionately. Coinfection prevalence estimates for malaria and STIs/RTIs need to be established and routinely reported. Rigorous studies using molecular diagnostic methods are needed to characterize more accurately the prevalence of these infections and their clinical consequences. Clinical trials are needed to compare birth outcomes, operational feasibility/acceptability, and cost-effectiveness of intermittent preventive treatment during pregnancy (IPTp) with azithromycin-based combination therapy against an approach of integrated screening and treatment for malaria and STIs/RTIs,” the researchers conclude.
(JAMA. 2012;307[19]:2079-2086. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Mr. Chico reports having previously received funding as part of 2 studies co-financed by Pfizer and the Medicines for Malaria Venture that are investigating the use of azithromycin plus chloroquine in IPTp. No other disclosures were reported.

# # #