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Role of randomised clinical trials in public health: distribution of mass antibiotics for trachoma control
In this issue, Wright et al1 discuss the role of randomised clinical trials (RCTs) in public health. They suggest that not all decisions can be based on evidence from RCTs, and they use the distribution of mass antibiotics for trachoma control as an example. The authors refer to several reports in which the prevalence of infection was dramatically lower after mass azithromycin distributions, but which had no control groups for comparison.2–5 They contend that a large RCT which randomised communities to different treatment strategies would be too difficult, too expensive and too unethical to conduct, and that treatment recommendations are needed immediately to prevent blindness.
The particular example that the authors choose is an interesting one. Antibiotics are clearly effective in eliminating chlamydia.6–8 Infection has stayed low for months, if not years, after a single community-wide antibiotic distribution.2–4 But the long-term efficacy of mass treatment had not been rigorously shown in a group-randomised trial, at least not in time for a Cochrane Collaboration report on the topic (most recently updated in 2005).9,10 The report highlighted the fact that many studies have been uncontrolled and non-blinded. For an outcome, several have relied on clinical activity, which has never been shown to be a particularly good marker for ocular chlamydial infection.11–13 Those trials that did randomise by group typically included far too few …
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