In a nation where one in ten children dies before their fifth birthday, Nigeria’s child survival crisis remains among the worst in the world. But amid the grim statistics, a pioneering intervention by the Nigerian Institute of Medical Research (NIMR) is offering new hope. Through an ambitious, evidence-based programme known as SARMAAN (Safety and Antimicrobial Resistance of Mass Administration of Azithromycin in Nigeria), NIMR has taken a bold step to tackle infant mortality by administering azithromycin — a broad-spectrum antibiotic — to over four million infants.
At a recent media briefing, NIMR’s Director of Research and SARMAAN’s principal investigator, Prof. Oliver Ezechi, shared the project’s early findings. SARMAAN I, the first phase of the project, targeted children aged one to 11 months in six states — Kano, Kebbi, Jigawa, Sokoto, Abia, and Akwa Ibom — where infant death rates are dangerously high. By focusing on communities with elevated mortality burdens, the project aimed to identify whether routine azithromycin use could be a safe and scalable solution to saving young lives.
Azithromycin’s selection is not accidental. The World Health Organisation (WHO) recommends its periodic administration in high-risk regions to help reduce under-five deaths, especially in areas with limited access to quality healthcare. Yet the drug’s widespread use comes with a caveat: antimicrobial resistance (AMR). Critics have long feared that mass administration of antibiotics could breed resistant strains of bacteria, rendering treatments ineffective in the long run. SARMAAN I tackled this head-on by embedding rigorous AMR surveillance within the programme’s design. Through three population-based AMR testing cycles, NIMR found that resistance rates actually declined — from 41.1 per cent in the first cycle to 26.5 per cent in the third. This counterintuitive outcome not only challenged assumptions but provided a data-driven case for strategic antibiotic deployment under controlled and monitored conditions.
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The operational metrics of SARMAAN I also signal success. Coverage rates exceeded expectations, with Akwa Ibom achieving 99 per cent, followed closely by Kebbi, Sokoto, and Abia at 97 per cent. Kano and Jigawa trailed slightly at 94 per cent. According to Prof. Ezechi, these numbers were not accidental. Early and intentional engagement with community gatekeepers — particularly traditional and religious leaders — was key in achieving broad acceptance and compliance. On safety, the programme fared well. A remarkable 98 per cent of children experienced no adverse effects after receiving the antibiotic. The few reported cases — mostly mild vomiting and diarrhoea — were self-limiting and did not require further intervention. Such findings, according to Ezechi, reinforce azithromycin’s safety profile and suitability for broader preventive use in fragile health systems like Nigeria’s.
Buoyed by the success of SARMAAN I, NIMR has rolled out SARMAAN II. This expanded phase now targets children aged one to 59 months — nearly five times the initial age bracket — across seven states: Kano, Kaduna, Katsina, Kebbi, Sokoto, Jigawa, and Bauchi. With a target population of over nine million children, the scale is ambitious and logistically challenging. Yet, it reflects the growing confidence in the model’s efficacy.
According to Dr. Abideen Salako, a paediatrician and research fellow at NIMR, over 3.5 million doses of azithromycin have been administered under both SARMAAN I and II, spanning 96 local government areas. He highlighted ancillary benefits such as employment generation and strengthened community health systems. However, SARMAAN’s achievements have not come without hurdles. As public health specialist and NIMR research fellow Dr. Folahanmi Akinosolu explained, some state governments initially resisted participation, despite data showing high disease prevalence. It took persistent advocacy — sometimes up to six visits to the same officials — to secure buy-in. Beyond administrative reluctance, infrastructure deficits posed significant bottlenecks. With local laboratories unequipped to handle biological samples, researchers had to transport specimens to Lagos for processing. This not only inflated operational costs but introduced delays that could compromise time-sensitive analyses. Moreover, the project’s challenges underscore a broader systemic problem: the poor appreciation of research as a catalyst for national development. In many quarters, research is still perceived as abstract, elitist, or non-essential — a dangerous misconception in a country grappling with some of the world’s worst health indices.
