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Federico CA, Heagerty PJ, Lantos J, O'Rourke P, Rahimzadeh V, Sugarman J, Weinfurt K, Wendler D, Wilfond BS, Magnus D. Ethical and epistemic issues in the design and conduct of pragmatic stepped-wedge cluster randomized clinical trials. Contemp Clin Trials 2022; 115:106703. [PMID: 35176501 PMCID: PMC9272561 DOI: 10.1016/j.cct.2022.106703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 11/27/2022]
Abstract
Stepped-wedge cluster randomized trial (SW-CRT) designs are increasingly employed in pragmatic research; they differ from traditional parallel cluster randomized trials in which an intervention is delivered to a subset of clusters, but not to all. In a SW-CRT, all clusters receive the intervention under investigation by the end of the study. This approach is thought to avoid ethical concerns about the denial of a desired intervention to participants in control groups. Such concerns have been cited in the literature as a primary motivation for choosing SW-CRT design, however SW-CRTs raise additional ethical concerns related to the delayed implementation of an intervention and consent. Yet, PCT investigators may choose SW-CRT designs simply because they are concerned that other study designs are infeasible. In this paper, we examine justifications for the use of SW-CRT study design, over other designs, by drawing on the experience of the National Institutes of Health's Health Care Systems Research Collaboratory (NIH Collaboratory) with five pragmatic SW-CRTs. We found that decisions to use SW-CRT design were justified by practical and epistemic reasons rather than ethical ones. These include concerns about feasibility, the heterogeneity of cluster characteristics, and the desire for simultaneous clinical evaluation and implementation. In this paper we compare the potential benefits of SW-CRTs against the ethical and epistemic challenges brought forth by the design and suggest that the choice of SW-CRT design must balance epistemic, feasibility and ethical justifications. Moreover, given their complexity, such studies need rigorous and informed ethical oversight.
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Affiliation(s)
- Carole A Federico
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98185, USA
| | - John Lantos
- Children's Mercy Hospital Bioethics Center, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | | | - Vasiliki Rahimzadeh
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Weinfurt
- Center for Health Measurement, Duke University, Durham, NC 27701, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD 20892, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98185, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA.
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2
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Cao L, Zhang L, Zhang X, Liu J, Jia MA, Zhang J, Liu J, Wang F. Types of Interferons and Their Expression in Plant Systems. J Interferon Cytokine Res 2022; 42:62-71. [PMID: 35171703 DOI: 10.1089/jir.2021.0148] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Interferons (IFNs) are divided into 3 types (type I, type II, and type III) on the basis of sequence homology and functional properties. Recombinant IFNs have been approved by regulatory agencies in many countries for clinical treatment of hepatitis B, hepatitis C, and other diseases; these IFNs are mainly produced in microorganisms and mammalian cell systems. However, there are serious obstacles to the production of recombinant IFNs in microorganism systems; for example, the recombinant IFN may have different glycosylation patterns from the native protein, be present in insoluble inclusion bodies, be contaminated with impurities such as endotoxins and nucleic acids, have a short half-life in human blood, and incur high production costs. Some medicinal proteins have been successfully expressed in plants and used in clinical applications, suggesting that plants may also be a good system for IFN expression. However, there are still many technical problems that need to be addressed before the clinical application of plant-expressed IFNs, such as increasing the amount of recombinant protein expression and ensuring that the IFN is modified with the correct type of glycosylation. In this article, we review the classification of IFNs, their roles in antiviral signal transduction pathways, their clinical applications, and their expression in plant systems.
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Affiliation(s)
- Linggai Cao
- Key Laboratory of Molecular Genetics, China National Tobacco Corporation, Guizhou Academy of Tobacco Science, Guiyang, China
| | - Lili Zhang
- Key Laboratory of Molecular Genetics, China National Tobacco Corporation, Guizhou Academy of Tobacco Science, Guiyang, China
| | - Xiaolian Zhang
- Key Laboratory of Molecular Genetics, China National Tobacco Corporation, Guizhou Academy of Tobacco Science, Guiyang, China
| | - Jia Liu
- School of Pharmaceutical Sciences (Shenzhen), Sun Yat-sen University, Shenzhen, China
| | - Meng-Ao Jia
- Key Laboratory of Molecular Genetics, China National Tobacco Corporation, Guizhou Academy of Tobacco Science, Guiyang, China
| | - Jishun Zhang
- Key Laboratory of Molecular Genetics, China National Tobacco Corporation, Guizhou Academy of Tobacco Science, Guiyang, China
| | - Jiemin Liu
- Guizhou Provincial People's Hospital, Guiyang, China
| | - Feng Wang
- Key Laboratory of Molecular Genetics, China National Tobacco Corporation, Guizhou Academy of Tobacco Science, Guiyang, China
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Lynch HF, Caplan A, Furlong P, Bateman-House A. Helpful Lessons and Cautionary Tales: How Should COVID-19 Drug Development and Access Inform Approaches to Non-Pandemic Diseases? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:4-19. [PMID: 34665689 DOI: 10.1080/15265161.2021.1974975] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
After witnessing extraordinary scientific and regulatory efforts to speed development of and access to new COVID-19 interventions, patients facing other serious diseases have begun to ask "where's our Operation Warp Speed?" and "why isn't Emergency Use Authorization an option for our health crises?" Although this pandemic bears a number of unique features, the response to COVID-19 offers translatable lessons, in both its successes and failures, for non-pandemic diseases. These include the importance of collaborating across sectors, supporting the highest-priority research efforts, adopting rigorous and innovative trial designs, and sharing reliable information quickly. In addition, the regulatory response to the pandemic demonstrates that lowering standards for marketing authorization can result in increased safety concerns, missed opportunities for research and treatment, and delays in determining what works. Accordingly, policymakers and patient advocates seeking to build on the COVID-19 experience for non-pandemic diseases with unmet treatment needs should focus their efforts on promoting robust and efficient research designs, improving access to clinical trials, and facilitating use of the Food and Drug Administration's existing Expanded Access pathway.
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Debnath N, Thakur M, Khushboo, Negi NP, Gautam V, Kumar Yadav A, Kumar D. Insight of oral vaccines as an alternative approach to health and disease management: An innovative intuition and challenges. Biotechnol Bioeng 2021; 119:327-346. [PMID: 34755343 DOI: 10.1002/bit.27987] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 11/03/2021] [Indexed: 12/11/2022]
Abstract
Vaccination is the most suitable and persuasive healthcare program for the prohibition of various deadly diseases. However, the higher production cost and purification strategies are out of reach for the developing nations. In this scenario, development of edible vaccine turns out to be the most promising alternative for remodeling the pharmaceutical industry with reduced production and purification costs. Generally, oral route of vaccination is mostly preferred due to its safety, compliance, low manufacturing cost and most importantly the ability to induce immunity in both systemic and mucosal sites. Genetically modified microorganisms and plants could efficiently be used as vehicles for edible vaccines. Edible vaccines are supposed to reduce the risk associated with traditional vaccines. Currently, oral vaccines are available in the market for several viral and bacterial diseases like cholera, hepatitis B, malaria, rabies etc. Herein, the review focuses on the breakthrough events in the area of edible vaccines associated with dietary microbes and plants for better control over diseases.
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Affiliation(s)
- Nabendu Debnath
- Centre for Molecular Biology, Central University of Jammu, Samba, Jammu & Kashmir (UT), India
| | - Mony Thakur
- Department of Microbiology, Central University of Haryana, Mahendergarh, Haryana, India
| | - Khushboo
- Department of Biotechnology, Central University of Haryana, Mahendergarh, Haryana, India
| | - Neelam P Negi
- Department of Biotechnology, University Institute of Biotechnology, Chandigarh University, Mohali, Punjab, India
| | - Vibhav Gautam
- Centre of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ashok Kumar Yadav
- Centre for Molecular Biology, Central University of Jammu, Samba, Jammu & Kashmir (UT), India
| | - Deepak Kumar
- Department of Botany, Institute of Science, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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5
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Kazanjian P. Polio, AIDS, and Ebola: A Recurrent Ethical Dilemma. Clin Infect Dis 2021; 70:334-337. [PMID: 31339992 DOI: 10.1093/cid/ciz662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 07/17/2019] [Indexed: 11/14/2022] Open
Abstract
During the 2014 West African outbreak, a dilemma emerged about the ethics of conducting randomized placebo-controlled trials in the midst of a rapidly spreading, devastating epidemic for which there was no effective treatment. The dilemma has in fact has deep historic roots; it has appeared in several previous fearsome epidemics-during the poliomyelitis epidemic in the 1930s-1950s, and again during the AIDS epidemic in the1980s-1990s. Moreover, ethical and social questions characterizing each of these epidemics-the increased risks of withholding potentially life-saving drugs for people assigned to a control arm and the damaging effect on eroding community trust-were conceptualized beforehand in the 1925 novel Arrowsmith. A historical analysis both reaffirms that rigorous placebo-controlled trials remain indispensable tools in epidemic settings and also provides guidance on how to approach the ethical and social issues that will likely arise when these trials are carried out in future epidemic emergencies.
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Affiliation(s)
- Powel Kazanjian
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Michigan Medicine, Ann Arbor
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Hunt A, Saenz C, Littler K. The global forum on bioethics in research meeting, "ethics of alternative clinical trial designs and methods in low- and middle-income country research": emerging themes and outputs. Trials 2019; 20:701. [PMID: 31852514 PMCID: PMC6921436 DOI: 10.1186/s13063-019-3840-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Alternative clinical trial designs and methods are increasingly being used in place of the conventional individually randomised controlled trial (RCT) in high-income and in low-income and middle-income country (LMIC) research. These approaches - including adaptive, cluster-randomised and stepped-wedge designs and controlled human infection models - offer a number of potential advantages, including being more efficient and making the clinical trial process more socially acceptable. However, these designs and methods are generally not familiar to researchers, research ethics committees and regulators and their ethical implications have not received sufficient international attention from the bioethics, research, and policymaking communities working together. The ethics of alternative clinical trial designs and methods in LMIC research was chosen as a topic for the 2017 Global Forum on Bioethics in Research (GFBR). The meeting opened a global dialogue about this emerging issue in research ethics and gave voice to the LMIC perspective. It identified the need to take a multidisciplinary approach and to develop capacity amongst researchers and research ethics committees and regulators to propose, review and regulate these novel designs and methods. Building skills and infrastructure will empower researchers to choose from a broad range of designs and methods and adopt the most scientifically suitable, efficient, ethical and context-appropriate of these. The need for capacity development is most pressing from the LMIC perspective, where limited resources create an urgency to seek the most efficient trial design and method. The aim of this paper is to encourage broad debate about this complex area of research. By opening up this debate, GFBR aims to promote the appropriate and ethical use of novel designs and methods so their full potential to address the health needs in LMICs can be realised.
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Affiliation(s)
| | - Carla Saenz
- Pan American Health Organisation, Washington, DC USA
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7
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Caparrotta TM, Dear JW, Colhoun HM, Webb DJ. Pharmacoepidemiology: Using randomised control trials and observational studies in clinical decision-making. Br J Clin Pharmacol 2019; 85:1907-1924. [PMID: 31206748 DOI: 10.1111/bcp.14024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/23/2019] [Accepted: 05/24/2019] [Indexed: 12/14/2022] Open
Abstract
Weighing up sources of evidence is a key skill for clinical decision-makers. Randomised controlled trials (RCTs) and observational studies each have advantages and disadvantages, and in both cases perceived weaknesses can be improved through modifications of design and analysis. In the field of pharmacoepidemiology, RCTs are the best way to determine whether an intervention modifies an outcome being studied, largely because randomisation reduces bias and confounding. Observational studies are useful to investigate whether benefits/harms of a treatment are seen in day-to-day clinical practice in a wider group of patients. Although observational studies, even in a small cohort, can provide very useful clinical evidence, they may also be misleading (as shown by subsequent RCTs), in part because of allocation bias. There is an unmet need for clinicians to become well versed in appraising the study design and statistical analysis of observational pharmacoepidemiology (OP) studies, rather like the medical training already offered for RCT evaluation. This is because OP studies are likely to become more common with the computerisation of healthcare records and increasingly contribute to the evidence base available for clinical decision-making. However, when the results of an RCT conflict with the results of an OP study, the findings of the RCT should be preferred, especially if its findings have been repeated elsewhere. Conversely, OP studies that align with the findings of RCTs can provide rich and useful information to complement that generated by RCTs.
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Affiliation(s)
| | - James W Dear
- Queen's Medical Research Institute, University of Edinburgh, UK
| | - Helen M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, UK
| | - David J Webb
- Queen's Medical Research Institute, University of Edinburgh, UK
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8
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9
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Gupta SB, Coller BA, Feinberg M. Unprecedented pace and partnerships: the story of and lessons learned from one Ebola vaccine program. Expert Rev Vaccines 2018; 17:913-923. [PMID: 30269612 DOI: 10.1080/14760584.2018.1527692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The Ebola epidemic in West Africa from 2014 to 2016 was unique in its size, location, and duration; this article reviews the experiences and lessons learned for one vaccine candidate developed during the outbreak and discusses critical gaps that still exist today which will need to be addressed for successful end to end emerging infectious disease vaccine product development in the future. AREAS COVERED Through the formation of numerous international partnerships, the rVSVΔG-ZEBOV-GP vaccine advanced through Phase I/II/III clinical trials which resulted in favorable Phase III efficacy results. Key lessons learned that could be used to facilitate future vaccine development efforts include sufficient preclinical work in relevant animal models, innovative partnerships created to pool resources and expertise, and 'hyper' coordination and communication among partners to build trust and ensure an adequate regulatory package needed to license a vaccine. EXPERT COMMENTARY As evidenced by the 2014-2016 outbreak in West Africa as well as the two other most recent outbreaks in the Democratic Republic of the Congo in 2018, there is an urgent need to develop new models for emerging infection vaccine development where trusted partners come together and where the development of vaccines is a shared responsibility conducted in advance of the next crisis.
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Affiliation(s)
- Swati B Gupta
- a Global Clinical Development , Merck & Co., Inc , Kenilworth , NJ , USA.,b Research Integration & Innovation , International AIDS Vaccine Initiative , New York , NY , USA
| | - Beth-Ann Coller
- a Global Clinical Development , Merck & Co., Inc , Kenilworth , NJ , USA
| | - Mark Feinberg
- a Global Clinical Development , Merck & Co., Inc , Kenilworth , NJ , USA.,c Executive Office , International AIDS Vaccine Initiative , New York , NY , USA
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10
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Brueckner M, Titman A, Jaki T, Rojek A, Horby P. Performance of different clinical trial designs to evaluate treatments during an epidemic. PLoS One 2018; 13:e0203387. [PMID: 30204799 PMCID: PMC6133355 DOI: 10.1371/journal.pone.0203387] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/20/2018] [Indexed: 12/14/2022] Open
Abstract
In the 2013-2016 west Africa outbreak of Ebola Virus Disease (EVD), most of the planned clinical trials failed to reach a conclusion within the time frame of the epidemic. The performance of clinical trial designs for the evaluation of one or more experimental treatments in the specific context of an ongoing epidemic with changing case fatality rates (CFR) and unpredictable case numbers is unclear. We conduct a comprehensive evaluation of commonly used two- and multi-arm clinical trial designs based on real data, which was recorded during the 2013-16 EVD epidemic in west Africa. The primary endpoint is death within 14 days of hospitalization. The impact of the recruitment start times relative to the time course of the epidemic on the operating characteristics of the clinical trials is analysed. Designs with frequent interim analyses with the possibility of early stopping are shown to outperform designs with only a single analysis not only in terms of average time to conclusion and average sample size, but also in terms of the probability of reaching any conclusion at all. Historic control designs almost always result in substantially inflated false positive rates, when the case fatality rate changes over time. Response-adaptive randomization may be a compromise between the goal of scientific validity and the ethical goal of minimizing the number of patients allocated to ineffective treatments.
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Affiliation(s)
- Matthias Brueckner
- Department of Mathematics and Statistics, Lancaster University, Lancaster, United Kingdom
- * E-mail:
| | - Andrew Titman
- Department of Mathematics and Statistics, Lancaster University, Lancaster, United Kingdom
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, United Kingdom
| | - Amanda Rojek
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Peter Horby
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Dhama K, Karthik K, Khandia R, Chakraborty S, Munjal A, Latheef SK, Kumar D, Ramakrishnan MA, Malik YS, Singh R, Malik SVS, Singh RK, Chaicumpa W. Advances in Designing and Developing Vaccines, Drugs, and Therapies to Counter Ebola Virus. Front Immunol 2018; 9:1803. [PMID: 30147687 PMCID: PMC6095993 DOI: 10.3389/fimmu.2018.01803] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/23/2018] [Indexed: 01/10/2023] Open
Abstract
Ebola virus (EBOV), a member of the family Filoviridae, is responsible for causing Ebola virus disease (EVD) (formerly named Ebola hemorrhagic fever). This is a severe, often fatal illness with mortality rates varying from 50 to 90% in humans. Although the virus and associated disease has been recognized since 1976, it was only when the recent outbreak of EBOV in 2014-2016 highlighted the danger and global impact of this virus, necessitating the need for coming up with the effective vaccines and drugs to counter its pandemic threat. Albeit no commercial vaccine is available so far against EBOV, a few vaccine candidates are under evaluation and clinical trials to assess their prophylactic efficacy. These include recombinant viral vector (recombinant vesicular stomatitis virus vector, chimpanzee adenovirus type 3-vector, and modified vaccinia Ankara virus), Ebola virus-like particles, virus-like replicon particles, DNA, and plant-based vaccines. Due to improvement in the field of genomics and proteomics, epitope-targeted vaccines have gained top priority. Correspondingly, several therapies have also been developed, including immunoglobulins against specific viral structures small cell-penetrating antibody fragments that target intracellular EBOV proteins. Small interfering RNAs and oligomer-mediated inhibition have also been verified for EVD treatment. Other treatment options include viral entry inhibitors, transfusion of convalescent blood/serum, neutralizing antibodies, and gene expression inhibitors. Repurposed drugs, which have proven safety profiles, can be adapted after high-throughput screening for efficacy and potency for EVD treatment. Herbal and other natural products are also being explored for EVD treatment. Further studies to better understand the pathogenesis and antigenic structures of the virus can help in developing an effective vaccine and identifying appropriate antiviral targets. This review presents the recent advances in designing and developing vaccines, drugs, and therapies to counter the EBOV threat.
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Affiliation(s)
- Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Kumaragurubaran Karthik
- Central University Laboratory, Tamil Nadu Veterinary and Animal Sciences University, Chennai, India
| | - Rekha Khandia
- Department of Biochemistry and Genetics, Barkatullah University, Bhopal, India
| | - Sandip Chakraborty
- Department of Veterinary Microbiology, College of Veterinary Sciences and Animal Husbandry, Agartala, India
| | - Ashok Munjal
- Department of Biochemistry and Genetics, Barkatullah University, Bhopal, India
| | - Shyma K. Latheef
- Immunology Section, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Deepak Kumar
- Division of Veterinary Biotechnology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | | | - Yashpal Singh Malik
- Division of Biological Standardization, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Rajendra Singh
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Satya Veer Singh Malik
- Division of Veterinary Public Health, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Raj Kumar Singh
- ICAR-Indian Veterinary Research Institute, Bareilly, Uttar Pradesh, India
| | - Wanpen Chaicumpa
- Center of Research Excellence on Therapeutic Proteins and Antibody Engineering, Department of Parasitology, Faculty of Medicine SIriraj Hospital, Mahidol University, Bangkok, Thailand
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12
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Saenz C, Luna F, Salas SP, Canario JA, Chamorro JB, Palacios R, Quiroz E, Saidón P, Villela BM. [Ethics in clinical trials designs and alternative methods]. Rev Panam Salud Publica 2018; 42. [PMID: 29622899 PMCID: PMC5881927 DOI: 10.26633/rpsp.2018.38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Carla Saenz
- Programa Regional de Bioética, Organización Panamericana de la Salud, Washington D.C., Estados Unidos de América
| | - Florencia Luna
- Programa de Bioética, FLACSO Argentina, Buenos Aires, Argentina
| | - Sofía P Salas
- Facultad de Medicina, Universidad Diego Portales, Santiago de Chile, Chile
| | - Julio Arturo Canario
- Centro Nacional de Investigaciones en Salud Materno Infantil, Dr. Hugo Mendoza (CENISMI), Santo Domingo, República Dominicana
| | | | | | - Estela Quiroz
- Universidad Nacional Federico Villarreal, Lima, Perú
| | - Patricia Saidón
- Comisión Nacional Salud Investiga, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | - Bertha María Villela
- Investigación en Salud, Coordinación Interinstitucional, Ministerio de Salud Pública y Asistencia Social, Guatemala, Guatemala
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13
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Abstract
Unprecedented global effort is under way to facilitate the testing of countermeasures in infectious disease emergencies. Better understanding of the various options for trial design is needed in advance of outbreaks, as is preliminary global agreement on the most suitable designs for the various scenarios. What would enhance the speed, validity, and ethics of clinical studies of such countermeasures? Focusing on studies of vaccine efficacy and effectiveness in emergencies, we highlight three needs: for formal randomized trials-even in most emergencies; for individually randomized trials-even in many emergencies; and for six areas of innovation in trial methodology. These needs should inform current updates of protocols and roadmaps.
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Affiliation(s)
- Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, and Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Nir Eyal
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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14
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Alirol E, Kuesel AC, Guraiib MM, dela Fuente-Núñez V, Saxena A, Gomes MF. Ethics review of studies during public health emergencies - the experience of the WHO ethics review committee during the Ebola virus disease epidemic. BMC Med Ethics 2017; 18:43. [PMID: 28651650 PMCID: PMC5485606 DOI: 10.1186/s12910-017-0201-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 06/08/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Between 2013 and 2016, West Africa experienced the largest ever outbreak of Ebola Virus Disease. In the absence of registered treatments or vaccines to control this lethal disease, the World Health Organization coordinated and supported research to expedite identification of interventions that could control the outbreak and improve future control efforts. Consequently, the World Health Organization Research Ethics Review Committee (WHO-ERC) was heavily involved in reviews and ethics discussions. It reviewed 24 new and 22 amended protocols for research studies including interventional (drug, vaccine) and observational studies. WHO-ERC REVIEWS WHO-ERC provided the reviews within on average 6 working days. The WHO-ERC often could not provide immediate approval of protocols for reasons which were not Ebola Virus Disease specific but related to protocol inconsistencies, missing information and complex informed consents. WHO-ERC considerations on Ebola Virus Disease specific issues (benefit-risk assessment, study design, exclusion of pregnant women and children from interventional studies, data and sample sharing, collaborative partnerships including international and local researchers and communities, community engagement and participant information) are presented. CONCLUSIONS To accelerate study approval in future public health emergencies, we recommend: (1) internally consistent and complete submissions with information documents in language participants are likely to understand, (2) close collaboration between local and international researchers from research inception, (3) generation of template agreements for data and sample sharing and use during the ongoing global consultations on bio-banks, (4) formation of Joint Scientific Advisory and Data Safety Review Committees for all studies linked to a particular intervention or group of interventions, (5) formation of a Joint Ethics Review Committee with representatives of the Ethics Committees of all institutions and countries involved to strengthen reviews through the different perspectives provided without the 'opportunity costs' for time to final approval of multiple, independent reviews, (6) direct information exchange between the chairs of advisory, safety review and ethics committees, (7) more Ethics Committee support for investigators than is standard and (8) a global consultation on criteria for inclusion of pregnant women and children in interventional studies for conditions which put them at particularly high risk of mortality or other irreversible adverse outcomes under standard-of-care.
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Affiliation(s)
- Emilie Alirol
- Global Antibiotics Research and Development Partnership (GARDP), Drugs for Neglected Diseases initiative (DNDi), 15 chemin Louis Dunant, 1202 Geneva, Switzerland
| | - Annette C. Kuesel
- World Health Organization, UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
| | - Maria Magdalena Guraiib
- World Health Organization, Department for Information Evidence and Research, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
| | - Vânia dela Fuente-Núñez
- World Health Organization, Department for Information Evidence and Research, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
| | - Abha Saxena
- World Health Organization, Department for Information Evidence and Research, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
| | - Melba F. Gomes
- World Health Organization, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
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15
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Carazo Perez S, Folkesson E, Anglaret X, Beavogui AH, Berbain E, Camara AM, Depoortere E, Lefevre A, Maes P, Malme KN, Malvy JMD, Ombelet S, Poelaert G, Sissoko D, Tounkara A, Trbovic P, Piguet P, Antierens A. Challenges in preparing and implementing a clinical trial at field level in an Ebola emergency: A case study in Guinea, West Africa. PLoS Negl Trop Dis 2017. [PMID: 28640812 PMCID: PMC5480829 DOI: 10.1371/journal.pntd.0005545] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
During the large Ebola outbreak that affected West Africa in 2014 and 2015, studies were launched to evaluate potential treatments for the disease. A clinical trial to evaluate the effectiveness of the antiviral drug favipiravir was conducted in Guinea. This paper describes the main challenges of the implementation of the trial in the Ebola treatment center of Guéckédou. Following the principles of the Good Clinical Research Practices, we explored the aspects of the community’s communication and engagement, ethical conduct, trial protocol compliance, informed consent of participants, ongoing benefit/risk assessment, record keeping, confidentiality of patients and study data, and roles and responsibilities of the actors involved. We concluded that several challenges have to be addressed to successfully implement a clinical trial during an international medical emergency but that the potential for collaboration between research teams and humanitarian organizations needs to be highlighted.
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Affiliation(s)
- Sara Carazo Perez
- Médecins Sans Frontières, Brussels, Belgium
- Department of Preventive and Social Medicine, Laval University, Québec City, Canada
- * E-mail: (SCP); (AA)
| | | | - Xavier Anglaret
- Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France
- Programme PACCI, Abidjan, Côte d’Ivoire
| | | | | | | | - Evelyn Depoortere
- Médecins Sans Frontières, Brussels, Belgium
- Institute of Tropical Medicine, Antwerpen, Belgium
| | | | - Piet Maes
- European Mobile Laboratory Project, Hamburg, Germany
- KU Leuven, Rega Institute for Medical Research, Leuven, Belgium
| | | | - Jean-Marie Denis Malvy
- Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France
- Pellegrin Hospital, Bordeaux, France
| | | | | | - Daouda Sissoko
- Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France
- Pellegrin Hospital, Bordeaux, France
| | | | | | | | - Annick Antierens
- Médecins Sans Frontières, Brussels, Belgium
- * E-mail: (SCP); (AA)
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16
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Liu X, Speranza E, Muñoz-Fontela C, Haldenby S, Rickett NY, Garcia-Dorival I, Fang Y, Hall Y, Zekeng EG, Lüdtke A, Xia D, Kerber R, Krumkamp R, Duraffour S, Sissoko D, Kenny J, Rockliffe N, Williamson ED, Laws TR, N'Faly M, Matthews DA, Günther S, Cossins AR, Sprecher A, Connor JH, Carroll MW, Hiscox JA. Transcriptomic signatures differentiate survival from fatal outcomes in humans infected with Ebola virus. Genome Biol 2017; 18:4. [PMID: 28100256 PMCID: PMC5244546 DOI: 10.1186/s13059-016-1137-3] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/15/2016] [Indexed: 12/24/2022] Open
Abstract
Background In 2014, Western Africa experienced an unanticipated explosion of Ebola virus infections. What distinguishes fatal from non-fatal outcomes remains largely unknown, yet is key to optimising personalised treatment strategies. We used transcriptome data for peripheral blood taken from infected and convalescent recovering patients to identify early stage host factors that are associated with acute illness and those that differentiate patient survival from fatality. Results The data demonstrate that individuals who succumbed to the disease show stronger upregulation of interferon signalling and acute phase responses compared to survivors during the acute phase of infection. Particularly notable is the strong upregulation of albumin and fibrinogen genes, which suggest significant liver pathology. Cell subtype prediction using messenger RNA expression patterns indicated that NK-cell populations increase in patients who survive infection. By selecting genes whose expression properties discriminated between fatal cases and survivors, we identify a small panel of responding genes that act as strong predictors of patient outcome, independent of viral load. Conclusions Transcriptomic analysis of the host response to pathogen infection using blood samples taken during an outbreak situation can provide multiple levels of information on both disease state and mechanisms of pathogenesis. Host biomarkers were identified that provide high predictive value under conditions where other predictors, such as viral load, are poor prognostic indicators. The data suggested that rapid analysis of the host response to infection in an outbreak situation can provide valuable information to guide an understanding of disease outcome and mechanisms of disease. Electronic supplementary material The online version of this article (doi:10.1186/s13059-016-1137-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xuan Liu
- National Institute of Health Research, Health Protection Research Unit In Emerging and Zoonotic Infections, Liverpool, UK.,Centre for Genomic Research, Institute of Integrative Biology, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Emily Speranza
- Department of Microbiology, School of Medicine, National Emerging and Infectious Diseases Laboratories, Bioinformatics Program, Boston University, Boston, MA, 02118, USA
| | - César Muñoz-Fontela
- Heinrich Pette Institute - Leibniz Institute for Experimental Virology, 20251, Hamburg, Germany.,Bernhard Nocht Institute for Tropical Medicine, D-20359, Hamburg, Germany.,German Center for Infection Research (DZIF), partner site Hamburg, Germany
| | - Sam Haldenby
- Centre for Genomic Research, Institute of Integrative Biology, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Natasha Y Rickett
- National Institute of Health Research, Health Protection Research Unit In Emerging and Zoonotic Infections, Liverpool, UK.,Institute of Infection and Global Health, University of Liverpool, Liverpool, L69 7BE, UK
| | - Isabel Garcia-Dorival
- Institute of Infection and Global Health, University of Liverpool, Liverpool, L69 7BE, UK
| | - Yongxiang Fang
- Centre for Genomic Research, Institute of Integrative Biology, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Yper Hall
- Public Health England, Porton Down, Wiltshire, SP4 0JG, UK
| | - Elsa-Gayle Zekeng
- National Institute of Health Research, Health Protection Research Unit In Emerging and Zoonotic Infections, Liverpool, UK.,Institute of Infection and Global Health, University of Liverpool, Liverpool, L69 7BE, UK
| | - Anja Lüdtke
- Heinrich Pette Institute - Leibniz Institute for Experimental Virology, 20251, Hamburg, Germany.,Bernhard Nocht Institute for Tropical Medicine, D-20359, Hamburg, Germany
| | - Dong Xia
- Institute of Infection and Global Health, University of Liverpool, Liverpool, L69 7BE, UK
| | - Romy Kerber
- Bernhard Nocht Institute for Tropical Medicine, D-20359, Hamburg, Germany
| | - Ralf Krumkamp
- Bernhard Nocht Institute for Tropical Medicine, D-20359, Hamburg, Germany
| | - Sophie Duraffour
- Bernhard Nocht Institute for Tropical Medicine, D-20359, Hamburg, Germany
| | - Daouda Sissoko
- Bordeaux Hospital University Center (CHU) -INSERM U1219- Bordeaux University, Bordeaux, France
| | - John Kenny
- Centre for Genomic Research, Institute of Integrative Biology, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Nichola Rockliffe
- Centre for Genomic Research, Institute of Integrative Biology, University of Liverpool, Liverpool, L69 7ZB, UK
| | - E Diane Williamson
- Defence Science Technology Laboratories (Porton Down), Porton Down, Salisbury, UK
| | - Thomas R Laws
- Defence Science Technology Laboratories (Porton Down), Porton Down, Salisbury, UK
| | - Magassouba N'Faly
- Hôpital National Donka service des Maladies infectieuses et Tropicales, Conakry, Guinea
| | - David A Matthews
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, BS8 1TD, UK
| | - Stephan Günther
- Bernhard Nocht Institute for Tropical Medicine, D-20359, Hamburg, Germany.,German Center for Infection Research (DZIF), partner site Hamburg, Germany
| | - Andrew R Cossins
- Centre for Genomic Research, Institute of Integrative Biology, University of Liverpool, Liverpool, L69 7ZB, UK
| | | | - John H Connor
- Department of Microbiology, School of Medicine, National Emerging and Infectious Diseases Laboratories, Bioinformatics Program, Boston University, Boston, MA, 02118, USA.
| | - Miles W Carroll
- Public Health England, Porton Down, Wiltshire, SP4 0JG, UK. .,National Institute of Health Research in Emerging and Zoonotic Infections, Porton Down, SP4 0JQ, Salisbury, UK.
| | - Julian A Hiscox
- National Institute of Health Research, Health Protection Research Unit In Emerging and Zoonotic Infections, Liverpool, UK. .,Institute of Infection and Global Health, University of Liverpool, Liverpool, L69 7BE, UK.
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Doussau A, Grady C. Deciphering assumptions about stepped wedge designs: the case of Ebola vaccine research. JOURNAL OF MEDICAL ETHICS 2016; 42:797-804. [PMID: 27754861 DOI: 10.1136/medethics-2015-103292] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 08/01/2016] [Accepted: 09/19/2016] [Indexed: 06/06/2023]
Abstract
Ethical concerns about randomising persons to a no-treatment arm in the context of Ebola epidemic led to consideration of alternative designs. The stepped wedge (SW) design, in which participants or clusters are randomised to receive an intervention at different time points, gained popularity. Common arguments in favour of using this design are (1) when an intervention is likely to do more good than harm, (2) all participants should receive the experimental intervention at some time point during the study and (3) the design might be preferable for practical reasons. We examine these assumptions when considering Ebola vaccine research. First, based on the claim that a stepped wedge design is indicated when it is likely that the intervention will do more good than harm, we reviewed published and ongoing SW trials to explore previous use of this design to test experimental drugs or vaccines, and found that SW design has never been used for trials of experimental drugs or vaccines. Given that Ebola vaccines were all experimental with no prior efficacy data, the use of a stepped wedge design would have been unprecedented. Second, we show that it is rarely true that all participants receive the intervention in SW studies, but rather, depending on certain design features, all clusters receive the intervention. Third, we explore whether the SW design is appealing for feasibility reasons and point out that there is significant complexity. In the setting of the Ebola epidemic, spatiotemporal variation may have posed problematic challenges to a stepped wedge design for vaccine research. Finally, we propose a set of points to consider for scientific reviewers and ethics committees regarding proposals for SW designs.
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Affiliation(s)
- Adélaïde Doussau
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Christine Grady
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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18
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Oluwatoyin Folayan M, Haire B. Communitarian societies and public engagement in public health. CRITICAL PUBLIC HEALTH 2016. [DOI: 10.1080/09581596.2016.1252035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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19
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Wiwanitkit V. Emerging Zika virus infection and bioethical considerations. EINSTEIN-SAO PAULO 2016; 14:450. [PMID: 27759838 PMCID: PMC5234765 DOI: 10.1590/s1679-45082016ce3822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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20
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Ebola Virus Disease: Therapeutic and Potential Preventative Opportunities. Microbiol Spectr 2016; 4. [PMID: 27337455 DOI: 10.1128/microbiolspec.ei10-0014-2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The 2014 Ebola virus disease (EVD) epidemic in West Africa was unprecedented in its geographical distribution, scale, and toll on public health infrastructure. Standard public health measures were rapidly overwhelmed, and many projections on outbreak progression through the region were dire. At the beginning of the outbreak there were no treatments or vaccines that had been shown to be safe and effective for treating or preventing EVD, limiting health care providers to offer supportive care under extremely challenging circumstances and at great risk to themselves. Over time, however, drugs and vaccines in the development pipeline were prioritized based on all available research data and were moved forward for evaluation in clinical trials to demonstrate safety and efficacy. The armamentarium against EVD eventually included biologics such as monoclonal antibodies, convalescent plasma, and vaccines as well as small molecule therapeutics such as small interfering RNAs and nucleoside analogs. This article provides a high-level overview of the interventions and prophylactics considered for use in the outbreak and discusses the challenges faced when attempting to deploy investigational countermeasures in the midst of an evolving epidemic.
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21
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Folayan MO, Haire BG, Brown B. Critical role of ethics in clinical management and public health response to the West Africa Ebola epidemic. Risk Manag Healthc Policy 2016; 9:55-65. [PMID: 27274326 PMCID: PMC4869630 DOI: 10.2147/rmhp.s83907] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The devastation caused by the Ebola virus disease (EVD) outbreak in West Africa has brought to the fore a number of important ethical debates about how best to respond to a health crisis. These debates include issues related to prevention and containment, management of the health care workforce, clinical care, and research design, all of which are situated within the overarching moral problem of severe transnational disadvantage, which has very real and specific impacts upon the ability of citizens of EVD-affected countries to respond to a disease outbreak. Ethical issues related to prevention and containment include the appropriateness and scope of quarantine and isolation within and outside affected countries. The possibility of infection in health care workers impelled consideration of whether there is an obligation to provide health services where personal protection equipment is inadequate, alongside the issue of whether the health care workforce should have special access to experimental treatment and care interventions under development. In clinical care, ethical issues include the standards of care owed to people who comply with quarantine and isolation restrictions. Ethical issues in research include appropriate study design related to experimental vaccines and treatment interventions, and the sharing of data and biospecimens between research groups. The compassionate use of experimental drugs intersects both with research ethics and clinical care. The role of developed countries also came under scrutiny, and we concluded that developed countries have an obligation to contribute to the containment of EVD infection by contributing to the strengthening of local health care systems and infrastructure in an effort to provide fair benefits to communities engaged in research, ensuring that affected countries have ready and affordable access to any therapeutic or preventative interventions developed, and supporting affected countries on their way to recovery from the impact of EVD on their social and economic lives.
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Affiliation(s)
- Morenike O Folayan
- Institute of Public Health, Obafemi Awolowo University, Ile-Ife, Nigeria
- Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Bridget G Haire
- Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, NSW, Australia
| | - Brandon Brown
- Center for Healthy Communities, Department of Social Medicine and Population Health, University of California Riverside School of Medicine, Riverside, CA, USA
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22
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Experimental Treatment with Favipiravir for Ebola Virus Disease (the JIKI Trial): A Historically Controlled, Single-Arm Proof-of-Concept Trial in Guinea. PLoS Med 2016; 13:e1001967. [PMID: 26930627 PMCID: PMC4773183 DOI: 10.1371/journal.pmed.1001967] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/21/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ebola virus disease (EVD) is a highly lethal condition for which no specific treatment has proven efficacy. In September 2014, while the Ebola outbreak was at its peak, the World Health Organization released a short list of drugs suitable for EVD research. Favipiravir, an antiviral developed for the treatment of severe influenza, was one of these. In late 2014, the conditions for starting a randomized Ebola trial were not fulfilled for two reasons. One was the perception that, given the high number of patients presenting simultaneously and the very high mortality rate of the disease, it was ethically unacceptable to allocate patients from within the same family or village to receive or not receive an experimental drug, using a randomization process impossible to understand by very sick patients. The other was that, in the context of rumors and distrust of Ebola treatment centers, using a randomized design at the outset might lead even more patients to refuse to seek care. Therefore, we chose to conduct a multicenter non-randomized trial, in which all patients would receive favipiravir along with standardized care. The objectives of the trial were to test the feasibility and acceptability of an emergency trial in the context of a large Ebola outbreak, and to collect data on the safety and effectiveness of favipiravir in reducing mortality and viral load in patients with EVD. The trial was not aimed at directly informing future guidelines on Ebola treatment but at quickly gathering standardized preliminary data to optimize the design of future studies. METHODS AND FINDINGS Inclusion criteria were positive Ebola virus reverse transcription PCR (RT-PCR) test, age ≥ 1 y, weight ≥ 10 kg, ability to take oral drugs, and informed consent. All participants received oral favipiravir (day 0: 6,000 mg; day 1 to day 9: 2,400 mg/d). Semi-quantitative Ebola virus RT-PCR (results expressed in "cycle threshold" [Ct]) and biochemistry tests were performed at day 0, day 2, day 4, end of symptoms, day 14, and day 30. Frozen samples were shipped to a reference biosafety level 4 laboratory for RNA viral load measurement using a quantitative reference technique (genome copies/milliliter). Outcomes were mortality, viral load evolution, and adverse events. The analysis was stratified by age and Ct value. A "target value" of mortality was defined a priori for each stratum, to guide the interpretation of interim and final analysis. Between 17 December 2014 and 8 April 2015, 126 patients were included, of whom 111 were analyzed (adults and adolescents, ≥13 y, n = 99; young children, ≤6 y, n = 12). Here we present the results obtained in the 99 adults and adolescents. Of these, 55 had a baseline Ct value ≥ 20 (Group A Ct ≥ 20), and 44 had a baseline Ct value < 20 (Group A Ct < 20). Ct values and RNA viral loads were well correlated, with Ct = 20 corresponding to RNA viral load = 7.7 log10 genome copies/ml. Mortality was 20% (95% CI 11.6%-32.4%) in Group A Ct ≥ 20 and 91% (95% CI 78.8%-91.1%) in Group A Ct < 20. Both mortality 95% CIs included the predefined target value (30% and 85%, respectively). Baseline serum creatinine was ≥110 μmol/l in 48% of patients in Group A Ct ≥ 20 (≥300 μmol/l in 14%) and in 90% of patients in Group A Ct < 20 (≥300 μmol/l in 44%). In Group A Ct ≥ 20, 17% of patients with baseline creatinine ≥110 μmol/l died, versus 97% in Group A Ct < 20. In patients who survived, the mean decrease in viral load was 0.33 log10 copies/ml per day of follow-up. RNA viral load values and mortality were not significantly different between adults starting favipiravir within <72 h of symptoms compared to others. Favipiravir was well tolerated. CONCLUSIONS In the context of an outbreak at its peak, with crowded care centers, randomizing patients to receive either standard care or standard care plus an experimental drug was not felt to be appropriate. We did a non-randomized trial. This trial reaches nuanced conclusions. On the one hand, we do not conclude on the efficacy of the drug, and our conclusions on tolerance, although encouraging, are not as firm as they could have been if we had used randomization. On the other hand, we learned about how to quickly set up and run an Ebola trial, in close relationship with the community and non-governmental organizations; we integrated research into care so that it improved care; and we generated knowledge on EVD that is useful to further research. Our data illustrate the frequency of renal dysfunction and the powerful prognostic value of low Ct values. They suggest that drug trials in EVD should systematically stratify analyses by baseline Ct value, as a surrogate of viral load. They also suggest that favipiravir monotherapy merits further study in patients with medium to high viremia, but not in those with very high viremia. TRIAL REGISTRATION ClinicalTrials.gov NCT02329054.
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23
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Going "social" to access experimental and potentially life-saving treatment: an assessment of the policy and online patient advocacy environment for expanded access. BMC Med 2016; 14:17. [PMID: 26843367 PMCID: PMC4739083 DOI: 10.1186/s12916-016-0568-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/13/2016] [Indexed: 01/12/2023] Open
Abstract
Social media is fundamentally altering how we access health information and make decisions about medical treatment, including for terminally ill patients. This specifically includes the growing phenomenon of patients who use online petitions and social media campaigns in an attempt to gain access to experimental drugs through expanded access pathways. Importantly, controversy surrounding expanded access and "compassionate use" involves several disparate stakeholders, including patients, manufacturers, policymakers, and regulatory agencies-all with competing interests and priorities, leading to confusion, frustration, and ultimately advocacy. In order to explore this issue in detail, this correspondence article first conducts a literature review to describe how the expanded access policy and regulatory environment in the United States has evolved over time and how it currently impacts access to experimental drugs. We then conducted structured web searches to identify patient use of online petitions and social media campaigns aimed at compelling access to experimental drugs. This was carried out in order to characterize the types of communication strategies utilized, the diseases and drugs subject to expanded access petitions, and the prevalent themes associated with this form of "digital" patient advocacy. We find that patients and their families experience mixed results, but still gravitate towards the use of online campaigns out of desperation, lack of reliable information about treatment access options, and in direct response to limitations of the current fragmented structure of expanded access regulation and policy currently in place. In response, we discuss potential policy reforms to improve expanded access processes, including advocating greater transparency for expanded access programs, exploring use of targeted economic incentives for manufacturers, and developing systems to facilitate patient information about existing treatment options. This includes leveraging recent legislative attention to reform expanded access through the CURE Act Provisions contained in the proposed U.S. 21st Century Cures Act. While expanded access may not be the best option for the majority of individuals, terminally ill patients and their families nevertheless deserve better processes, policies, and availability to potentially life-changing information, before they decide to pursue an online campaign in the desperate hope of gaining access to experimental drugs.
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Faye O, Andronico A, Faye O, Salje H, Boëlle PY, Magassouba N, Bah EI, Koivogui L, Diallo B, Diallo AA, Keita S, Konde MK, Fowler R, Fall G, Cauchemez S, Sall AA. Use of Viremia to Evaluate the Baseline Case Fatality Ratio of Ebola Virus Disease and Inform Treatment Studies: A Retrospective Cohort Study. PLoS Med 2015; 12:e1001908. [PMID: 26625118 PMCID: PMC4666644 DOI: 10.1371/journal.pmed.1001908] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/19/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The case fatality ratio (CFR) of Ebola virus disease (EVD) can vary over time and space for reasons that are not fully understood. This makes it difficult to define the baseline CFRs needed to evaluate treatments in the absence of randomized controls. Here, we investigate whether viremia in EVD patients may be used to evaluate baseline EVD CFRs. METHODS AND FINDINGS We analyzed the laboratory and epidemiological records of patients with EVD confirmed by reverse transcription PCR hospitalized in the Conakry area, Guinea, between 1 March 2014 and 28 February 2015. We used viremia and other variables to model the CFR. Data for 699 EVD patients were analyzed. In the week following symptom onset, mean viremia remained stable, and the CFR increased with viremia, V, from 21% (95% CI 16%-27%) for low viremia (V < 104.4 copies/ml) to 53% (95% CI 44%-61%) for intermediate viremia (104.4 ≤ V < 105.2 copies/ml) and 81% (95% CI 75%-87%) for high viremia (V ≥ 105.2 copies/ml). Compared to adults (15-44 y old [y.o.]), the CFR was larger in young children (0-4 y.o.) (odds ratio [OR]: 2.44; 95% CI 1.02-5.86) and older adults (≥ 45 y.o.) (OR: 2.84; 95% CI 1.81-4.46) but lower in children (5-14 y.o.) (OR: 0.46; 95% CI 0.24-0.86). An order of magnitude increase in mean viremia in cases after July 2014 compared to those before coincided with a 14% increase in the CFR. Our findings come from a large hospital-based study in Conakry and may not be generalizable to settings with different case profiles, such as with individuals who never sought care. CONCLUSIONS Viremia in EVD patients was a strong predictor of death that partly explained variations in CFR in the study population. This study provides baseline CFRs by viremia group, which allow appropriate adjustment when estimating efficacy in treatment studies. In randomized controlled trials, stratifying analysis on viremia groups could reduce sample size requirements by 25%. We hypothesize that monitoring the viremia of hospitalized patients may inform the ability of surveillance systems to detect EVD patients from the different severity strata.
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Affiliation(s)
- Oumar Faye
- Arbovirus and Viral Hemorrhagic Fever Unit, Institut Pasteur de Dakar, Dakar, Senegal
| | - Alessio Andronico
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Paris, France
| | - Ousmane Faye
- Arbovirus and Viral Hemorrhagic Fever Unit, Institut Pasteur de Dakar, Dakar, Senegal
| | - Henrik Salje
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Paris, France
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Pierre-Yves Boëlle
- INSERM, UMR-S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, UMR-S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Paris, France
| | - N’Faly Magassouba
- Laboratoire de Fièvres Hémorragiques de Guinée, Hôpital Donka, Conakry, Guinea
| | - Elhadj Ibrahima Bah
- Service des Maladies Infectieuses, Médecins Sans Frontières, Conakry, Guinea
| | | | | | | | | | - Mandy Kader Konde
- Centre d’Excellence de Formation & Recherche sur le Paludisme & les Maladies Prioritaires en Guinée, Conakry, Guinea
| | | | - Gamou Fall
- Arbovirus and Viral Hemorrhagic Fever Unit, Institut Pasteur de Dakar, Dakar, Senegal
| | - Simon Cauchemez
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Paris, France
- * E-mail:
| | - Amadou Alpha Sall
- Arbovirus and Viral Hemorrhagic Fever Unit, Institut Pasteur de Dakar, Dakar, Senegal
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Kombe F, Folayan MO, Ambe J, Igonoh A, Abayomi A. Taking the bull by the horns: Ethical considerations in the design and implementation of an Ebola virus therapy trial. Soc Sci Med 2015; 148:163-70. [PMID: 26653137 PMCID: PMC6858863 DOI: 10.1016/j.socscimed.2015.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 08/27/2015] [Accepted: 11/11/2015] [Indexed: 01/05/2023]
Abstract
Ebola virus is categorized as one of the most dangerous pathogens in the world. Although there is no known cure for Ebola virus, there is some evidence that the severity of the disease can be curtailed using plasma from survivors. Although there is a general consensus on the importance of research, methodological and ethical challenges for conducting research in an emergency situation have been identified. Performing clinical trials is important, especially for health conditions that are of public health significance (including rare epidemics) to develop new therapies as well as to test the efficacy and effectiveness of new interventions. However, routine clinical trial procedures can be difficult to apply in emergency public health crises hence require a consideration of alternative approaches on how therapies in these situations are tested and brought to the market. This paper examines some of the ethical issues that arise when conducting clinical trials during a highly dangerous pathogen outbreak, with a special focus on the Ebola virus outbreak in West Africa. The issues presented here come from a review of a protocol that was submitted to the Global Emerging Pathogens Treatment Consortium (GET). In reviewing the proposal, which was about conducting a clinical trial to evaluate the safety and efficacy of using convalescent plasma in the management of Ebola virus disease, the authors deliberated on various issues, which were documented as minutes and later used as a basis for this paper. The experiences and reflections shared by the authors, who came from different regions and disciplines across Africa, present wide-ranging perspectives on the conduct of clinical trials during a dangerous disease outbreak in a resource-poor setting.
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Affiliation(s)
- Francis Kombe
- KEMRI-Wellcome Trust Research Programme (KWTRP), P.O Box 230, Kilifi, Kenya.
| | - Morenike O Folayan
- Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria; Global Emerging Pathogens Treatment Consortium (GET), 1 Mainland Hospital Road, Yaba, Lagos, Nigeria
| | - Jennyfer Ambe
- Global Emerging Pathogens Treatment Consortium (GET), 1 Mainland Hospital Road, Yaba, Lagos, Nigeria
| | - Adaora Igonoh
- Global Emerging Pathogens Treatment Consortium (GET), 1 Mainland Hospital Road, Yaba, Lagos, Nigeria
| | - Akin Abayomi
- Global Emerging Pathogens Treatment Consortium (GET), 1 Mainland Hospital Road, Yaba, Lagos, Nigeria; Division of Haematology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Private Bag X3, Parow Valley, 7505 Cape Town, Cape Town, South Africa
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Addressing Therapeutic Options for Ebola Virus Infection in Current and Future Outbreaks. Antimicrob Agents Chemother 2015; 59:5892-902. [PMID: 26248374 DOI: 10.1128/aac.01105-15] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ebola virus can cause severe hemorrhagic disease with high fatality rates. Currently, no specific therapeutic agent or vaccine has been approved for treatment and prevention of Ebola virus infection of humans. Although the number of Ebola cases has fallen in the last few weeks, multiple outbreaks of Ebola virus infection and the likelihood of future exposure highlight the need for development and rapid evaluation of pre- and postexposure treatments. Here, we briefly review the existing and future options for anti-Ebola therapy, based on the data coming from rare clinical reports, studies on animals, and results from in vitro models. We also project the mechanistic hypotheses of several potential drugs against Ebola virus, including small-molecule-based drugs, which are under development and being tested in animal models or in vitro using various cell types. Our paper discusses strategies toward identifying and testing anti-Ebola virus properties of known and medically approved drugs, especially those that can limit the pathological inflammatory response in Ebola patients and thereby provide protection from mortality. We underline the importance of developing combinational therapy for better treatment outcomes for Ebola patients.
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Lipsitch M, Donnelly CA, Fraser C, Blake IM, Cori A, Dorigatti I, Ferguson NM, Garske T, Mills HL, Riley S, Van Kerkhove MD, Hernán MA. Potential Biases in Estimating Absolute and Relative Case-Fatality Risks during Outbreaks. PLoS Negl Trop Dis 2015; 9:e0003846. [PMID: 26181387 PMCID: PMC4504518 DOI: 10.1371/journal.pntd.0003846] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Estimating the case-fatality risk (CFR)-the probability that a person dies from an infection given that they are a case-is a high priority in epidemiologic investigation of newly emerging infectious diseases and sometimes in new outbreaks of known infectious diseases. The data available to estimate the overall CFR are often gathered for other purposes (e.g., surveillance) in challenging circumstances. We describe two forms of bias that may affect the estimation of the overall CFR-preferential ascertainment of severe cases and bias from reporting delays-and review solutions that have been proposed and implemented in past epidemics. Also of interest is the estimation of the causal impact of specific interventions (e.g., hospitalization, or hospitalization at a particular hospital) on survival, which can be estimated as a relative CFR for two or more groups. When observational data are used for this purpose, three more sources of bias may arise: confounding, survivorship bias, and selection due to preferential inclusion in surveillance datasets of those who are hospitalized and/or die. We illustrate these biases and caution against causal interpretation of differential CFR among those receiving different interventions in observational datasets. Again, we discuss ways to reduce these biases, particularly by estimating outcomes in smaller but more systematically defined cohorts ascertained before the onset of symptoms, such as those identified by forward contact tracing. Finally, we discuss the circumstances in which these biases may affect non-causal interpretation of risk factors for death among cases.
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Affiliation(s)
- Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- * E-mail:
| | - Christl A. Donnelly
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Christophe Fraser
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Isobel M. Blake
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Anne Cori
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Ilaria Dorigatti
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Neil M. Ferguson
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Tini Garske
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Harriet L. Mills
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Steven Riley
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Maria D. Van Kerkhove
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Centre for Global Health, Institut Pasteur, Paris, France
| | - Miguel A. Hernán
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Affiliation(s)
- Robert Klitzman
- Klitzman is Professor of Psychiatry and Director of the Masters of Bioethics Program at Columbia University, New York, NY
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Smith MJ, Silva DS. Ethics for pandemics beyond influenza: Ebola, drug-resistant tuberculosis, and anticipating future ethical challenges in pandemic preparedness and response. Monash Bioeth Rev 2015; 33:130-47. [PMID: 26507138 PMCID: PMC7100556 DOI: 10.1007/s40592-015-0038-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The unprecedented outbreak of Ebola virus disease (EVD) in West Africa has raised several novel ethical issues for global outbreak preparedness. It has also illustrated that familiar ethical issues in infectious disease management endure despite considerable efforts to understand and mitigate such issues in the wake of past outbreaks. To improve future global outbreak preparedness and response, we must examine these shortcomings and reflect upon the current state of ethical preparedness. To this end, we focus our efforts in this article on the examination of one substantial area: ethical guidance in pandemic plans. We argue that, due in part to their focus on considerations arising specifically in relation to pandemics of influenza origin, pandemic plans and their existing ethical guidance are ill-equipped to anticipate and facilitate the navigation of unique ethical challenges that may arise in other infectious disease pandemics. We proceed by outlining three reasons why this is so, and situate our analysis in the context of the EVD outbreak and the threat posed by drug-resistant tuberculosis: (1) different infectious diseases have distinct characteristics that challenge anticipated or existing modes of pandemic prevention, preparedness, response, and recovery, (2) clear, transparent, context-specific ethical reasoning and justification within current influenza pandemic plans are lacking, and (3) current plans neglect the context of how other significant pandemics may manifest. We conclude the article with several options for reflecting upon and ultimately addressing ethical issues that may emerge with different infectious disease pandemics.
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Affiliation(s)
- Maxwell J Smith
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, 155 College Street, Suite 549, Toronto, ON, M5T 3M7, Canada.
| | - Diego S Silva
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Bulsson Hall, Room 11008, Burnaby, BC, V5A 1S6, Canada.
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30
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Denner J. Treatment of Ebola virus infections with inhibitors of TLR4. Med Hypotheses 2015; 85:253-7. [PMID: 26003830 DOI: 10.1016/j.mehy.2015.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 05/04/2015] [Accepted: 05/10/2015] [Indexed: 01/25/2023]
Abstract
Ebola virus (EBOV) infection is associated with modulation of cytokine expression in infected patients. EBOV has been shown to interact directly with immune cells (at minimum with macrophages and dendritic cells) and modulation of cytokine expression has also been observed in vitro, which is similar to that in vivo. The modulation of cytokine expression observed in vitro was independent of virus infection and the glycoprotein GP1,2 was shown to be necessary and sufficient for cytokine modulation. Interestingly, similar changes in gene expression were observed in cells treated with lipopolysaccharide (LPS). As evidence suggests that GP1,2 and LPS use the same receptor, it is tempting to evaluate whether compounds that can inhibit signal transduction by LPS, e.g., TAK-242, can also reduce EBOV-induced pathogenesis.
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Abstract
Ebola virus disease (EVD), formerly known as Ebola hemorrhagic fever, is a severe, often fatal illness in humans. Ebola virus (EBOV) is transmitted through contact with blood or body fluids of a person who contracted or died from EVD, contaminated objects like needles and infected animals or bush meat. EVD has an incubation period of 2 to 21 days, and the infection has an acute onset without any carrier status. Currently, there is no standard treatment for EVD, so it is important to avoid infection or further spreading of the virus. Although historically the mortality of this infection exceeded 80%, modern medicine and public health measures have been able to lower this figure and reduce the impact of EBOV on individuals and communities. Its treatment involves early, aggressive supportive care with rehydration. Clinicians should consider the possibility of EVD in persons with travel or exposure history with the incubation period presenting constitutional symptoms in order to promptly identify diseased patients, and prevent further spreading of the disease.
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Lanini S, Zumla A, Ioannidis JPA, Di Caro A, Krishna S, Gostin L, Girardi E, Pletschette M, Strada G, Baritussio A, Portella G, Apolone G, Cavuto S, Satolli R, Kremsner P, Vairo F, Ippolito G. Are adaptive randomised trials or non-randomised studies the best way to address the Ebola outbreak in west Africa? THE LANCET. INFECTIOUS DISEASES 2015; 15:738-45. [PMID: 25881871 PMCID: PMC7129402 DOI: 10.1016/s1473-3099(15)70106-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The Ebola outbreak that has devastated parts of west Africa represents an unprecedented challenge for research and ethics. Estimates from the past three decades emphasise that the present effort to contain the epidemic in the three most affected countries (Guinea, Liberia, and Sierra Leone) has been insufficient, with more than 24 900 cases and about 10 300 deaths, as of March 25, 2015. Faced with such an exceptional event and the urgent response it demands, the use of randomised controlled trials (RCT) for Ebola-related research might be both unethical and infeasible and that potential interventions should be assessed in non-randomised studies on the basis of compassionate use. However, non-randomised studies might not yield valid conclusions, leading to large residual uncertainty about how to interpret the results, and can also waste scarce intervention-related resources, making them profoundly unethical. Scientifically sound and rigorous study designs, such as adaptive RCTs, could provide the best way to reduce the time needed to develop new interventions and to obtain valid results on their efficacy and safety while preserving the application of ethical precepts. We present an overview of clinical studies registered at present at the four main international trial registries and provide a simulation on how adaptive RCTs can behave in this context, when mortality varies simultaneously in either the control or the experimental group.
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Affiliation(s)
- Simone Lanini
- National institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy.
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, London, UK; National Institute for Health Research Biomedical Research Centre, UCL Hospitals National Health Service Foundation Trust, London, UK
| | - John P A Ioannidis
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Antonino Di Caro
- National institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Sanjeev Krishna
- Institute of Infection and Immunity, St George's, University of London, London, UK
| | - Lawrence Gostin
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Enrico Girardi
- National institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Michel Pletschette
- Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | | | - Aldo Baritussio
- Department of Medical and Surgical Sciences, University of Padua, Padua, Italy
| | | | | | - Silvio Cavuto
- IRCCS Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | | | - Peter Kremsner
- Institut für Tropenmedizin, Universitätsklinikum Tübingen, Tübingen, Germany; Centre de Recherches Medicales de Lambarene, Lambarene, Gabon
| | - Francesco Vairo
- National institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Giuseppe Ippolito
- National institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
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Cooper BS, Boni MF, Pan-ngum W, Day NPJ, Horby PW, Olliaro P, Lang T, White NJ, White LJ, Whitehead J. Evaluating clinical trial designs for investigational treatments of Ebola virus disease. PLoS Med 2015; 12:e1001815. [PMID: 25874579 PMCID: PMC4397078 DOI: 10.1371/journal.pmed.1001815] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/05/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Experimental treatments for Ebola virus disease (EVD) might reduce EVD mortality. There is uncertainty about the ability of different clinical trial designs to identify effective treatments, and about the feasibility of implementing individually randomised controlled trials during an Ebola epidemic. METHODS AND FINDINGS A treatment evaluation programme for use in EVD was devised using a multi-stage approach (MSA) with two or three stages, including both non-randomised and randomised elements. The probabilities of rightly or wrongly recommending the experimental treatment, the required sample size, and the consequences for epidemic outcomes over 100 d under two epidemic scenarios were compared for the MSA, a sequential randomised controlled trial (SRCT) with up to 20 interim analyses, and, as a reference case, a conventional randomised controlled trial (RCT) without interim analyses. Assuming 50% 14-d survival in the population treated with the current standard of supportive care, all designs had similar probabilities of identifying effective treatments correctly, while the MSA was less likely to recommend treatments that were ineffective. The MSA led to a smaller number of cases receiving ineffective treatments and faster roll-out of highly effective treatments. For less effective treatments, the MSA had a high probability of including an RCT component, leading to a somewhat longer time to roll-out or rejection. Assuming 100 new EVD cases per day, the MSA led to between 6% and 15% greater reductions in epidemic mortality over the first 100 d for highly effective treatments compared to the SRCT. Both the MSA and SRCT led to substantially fewer deaths than a conventional RCT if the tested interventions were either highly effective or harmful. In the proposed MSA, the major threat to the validity of the results of the non-randomised components is that referral patterns, standard of care, or the virus itself may change during the study period in ways that affect mortality. Adverse events are also harder to quantify without a concurrent control group. CONCLUSIONS The MSA discards ineffective treatments quickly, while reliably providing evidence concerning effective treatments. The MSA is appropriate for the clinical evaluation of EVD treatments.
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Affiliation(s)
- Ben S. Cooper
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Maciej F. Boni
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Viet Nam
| | - Wirichada Pan-ngum
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Peter W. Horby
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland
| | - Trudie Lang
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Lisa J. White
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - John Whitehead
- Department of Mathematics and Statistics, Lancaster University, Lancaster, United Kingdom
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Satalkar P, Elger BE, Shaw DM. Prioritising Healthcare Workers for Ebola Treatment: Treating Those at Greatest Risk to Confer Greatest Benefit. Dev World Bioeth 2015; 15:59-67. [PMID: 25655050 DOI: 10.1111/dewb.12079] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The Ebola epidemic in Western Africa has highlighted issues related to weak health systems, the politics of drug and vaccine development and the need for transparent and ethical criteria for use of scarce local and global resources during public health emergency. In this paper we explore two key themes. First, we argue that independent of any use of experimental drugs or vaccine interventions, simultaneous implementation of proven public health principles, community engagement and culturally sensitive communication are critical as these measures represent the most cost-effective and fair utilization of available resources. Second, we attempt to clarify the ethical issues related to use of scarce experimental drugs or vaccines and explore in detail the most critical ethical question related to Ebola drug or vaccine distribution in the current outbreak: who among those infected or at risk should be prioritized to receive any new experimental drugs or vaccines? We conclude that healthcare workers should be prioritised for these experimental interventions, for a variety of reasons.
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Shah SK, Wendler D, Danis M. Examining the ethics of clinical use of unproven interventions outside of clinical trials during the Ebola epidemic. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:11-6. [PMID: 25856592 DOI: 10.1080/15265161.2015.1010996] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
The recent Ebola outbreak in West Africa began in the spring of 2014 and has since caused the deaths of over 6,000 people. Since there are no approved treatments or prevention modalities specifically targeted at Ebola Virus Disease (EVD), debate has focused on whether unproven interventions should be offered to Ebola patients outside of clinical trials. Those engaged in the debate have responded rapidly to a complex and evolving crisis, however, and this debate has not provided much opportunity for in-depth analysis. Additionally, the existing literature on access to unproven therapies has focused on contexts like HIV/AIDS and oncology, which are very different than the Ebola epidemic. In this paper, we examine the ethical issues surrounding access to unproven therapies in the context of the recent Ebola outbreak to yield new insights about this controversial and unsettled issue. We argue first that, in this context, the interests of patients in obtaining access to unproven therapies are not fully aligned with the interests of their providers and drug developers. Second, we focus on the resource constraints facing providers, funders, and patients and conclude that they often counsel against the use of unproven interventions against EVD.
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Affiliation(s)
- Seema K Shah
- a Clinical Center Department of Bioethics, Division of AIDS, National Institutes of Health , Bethesda , Maryland , USA
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36
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Abstract
There are competing ethical concerns when it comes to designing any clinical research study. Clinical trials of possible treatments for Ebola virus are no exception. If anything, the competing ethical concerns are exacerbated in trying to find answers to a deadly, rapidly spreading, infectious disease. The primary goal of current research is to identify experimental therapies that can cure Ebola or cure it with reasonable probability in infected individuals. Pursuit of that goal must be methodologically sound, practical and consistent with prevailing norms governing human subjects research. Some maintain that only randomized controlled trials (RCTs) with a placebo or standard-of-care arm can meet these conditions. We maintain that there are alternative trial designs that can do so as well and that sometimes these are preferable to RCTs.
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37
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38
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Affiliation(s)
- Edward Cox
- From the Center for Drug Evaluation and Research (E.C., R.T.) and the Office of the Commissioner (L.B.), Food and Drug Administration, Silver Spring, MD
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39
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Yazdanpanah Y, Arribas JR, Malvy D. Treatment of Ebola virus disease. Intensive Care Med 2014; 41:115-7. [PMID: 25385474 DOI: 10.1007/s00134-014-3529-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/23/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Yazdan Yazdanpanah
- Service de Maladies Infectieuses et tropicales, Hôpital Bichat Claude Bernard, Paris, France,
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40
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Adebamowo C, Bah-Sow O, Binka F, Bruzzone R, Caplan A, Delfraissy JF, Heymann D, Horby P, Kaleebu P, Tamfum JJM, Olliaro P, Piot P, Tejan-Cole A, Tomori O, Toure A, Torreele E, Whitehead J. Randomised controlled trials for Ebola: practical and ethical issues. Lancet 2014; 384:1423-4. [PMID: 25390318 PMCID: PMC4392883 DOI: 10.1016/s0140-6736(14)61734-7] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | | | - Fred Binka
- University of Health and Allied Sciences, Ho, Ghana
| | - Roberto Bruzzone
- Hong Kong University-Pasteur Research Pole, School of Public Health, University of Hong Kong, Hong Kong, China
| | - Arthur Caplan
- New York University Langone Medical Center, New York, NY, USA
| | | | - David Heymann
- Centre on Global Health Security, Chatham House, London, UK
| | | | - Pontiano Kaleebu
- Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | | | - Piero Olliaro
- WHO, Geneva, Switzerland; University of Oxford, Oxford, UK.
| | - Peter Piot
- London School of Hygiene & Tropical Medicine, London, UK
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41
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Abstract
The size of the world's largest Ebola outbreak now ongoing in West Africa makes clear that further exportation of Ebola virus disease to other parts of the world will remain a real possibility for the indefinite future. Clinicians outside of West Africa, particularly those who work in emergency medicine, critical care, infectious diseases, and infection control, should be familiar with the fundamentals of Ebola virus disease, including its diagnosis, treatment, and control. In this article we provide basic information on the Ebola virus and its epidemiology and microbiology. We also describe previous outbreaks and draw comparisons to the current outbreak with a focus on the public health measures that have controlled past outbreaks. We review the pathophysiology and clinical features of the disease, highlighting diagnosis, treatment, and hospital infection control issues that are relevant to practicing clinicians. We reference official guidance and point out where important uncertainty or controversy exists.
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Kalra S, Kelkar D, Galwankar SC, Papadimos TJ, Stawicki SP, Arquilla B, Hoey BA, Sharpe RP, Sabol D, Jahre JA. The emergence of ebola as a global health security threat: from 'lessons learned' to coordinated multilateral containment efforts. J Glob Infect Dis 2014; 6:164-77. [PMID: 25538455 PMCID: PMC4265832 DOI: 10.4103/0974-777x.145247] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
First reported in remote villages of Africa in the 1970s, the Ebolavirus was originally believed to be transmitted to people from wild animals. Ebolavirus (EBOV) causes a severe, frequently fatal hemorrhagic syndrome in humans. Each outbreak of the Ebolavirus over the last three decades has perpetuated fear and economic turmoil among the local and regional populations in Africa. Until now it has been considered a tragic malady confined largely to the isolated regions of the African continent, but it is no longer so. The frequency of outbreaks has increased since the 1970s. The 2014 Ebola outbreak in Western Africa has been the most severe in history and was declared a public health emergency by the World Health Organization. Given the widespread use of modern transportation and global travel, the EBOV is now a risk to the entire Global Village, with intercontinental transmission only an airplane flight away. Clinically, symptoms typically appear after an incubation period of approximately 11 days. A flu-like syndrome can progress to full hemorrhagic fever with multiorgan failure, and frequently, death. Diagnosis is confirmed by detection of viral antigens or Ribonucleic acid (RNA) in the blood or other body fluids. Although historically the mortality of this infection exceeded 80%, modern medicine and public health measures have been able to lower this figure and reduce the impact of EBOV on individuals and communities. The treatment involves early, aggressive supportive care with rehydration. Core interventions, including contact tracing, preventive initiatives, active surveillance, effective isolation and quarantine procedures, and timely response to patients, are essential for a successful outbreak control. These measures, combined with public health education, point-of-care diagnostics, promising new vaccine and pharmaceutical efforts, and coordinated efforts of the international community, give new hope to the Global effort to eliminate Ebola as a public health threat. Here we present a review of EBOV infection in an effort to further educate medical and political communities on what the Ebolavirus disease entails, and what efforts are recommended to treat, isolate, and eventually eliminate it.
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Affiliation(s)
- Sarathi Kalra
- St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | | | | | | | | | | | - Brian A. Hoey
- St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | | | - Donna Sabol
- St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Jeffrey A. Jahre
- St Luke's University Health Network, Bethlehem, Pennsylvania, USA
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