So much at stake: Ethical tradeoffs in accelerating SARSCoV-2 vaccine development

A risk science perspective on vaccines

Vaccines can be seen as one of the greatest successes in modern medicine. Good examples are the vaccines against smallpox, polio, and measles. Unfortunately, vaccines can have side effects, but the risks are considered by the health authorities and experts to be small compared to their benefits. Nevertheless, there are many who are skeptical of vaccination, something which has been very clearly demonstrated in relation to the COVID-19 disease. Risk is the key concept when evaluating a vaccine, in relation to both its ability to protect against the disease and its side effects. However, risk is a challenging concept to measure, which makes communication about vaccines' performance and side effects difficult. The present article aims at providing new insights into vaccine risks-the understanding, perception, communication, and handling of them-by adopting what is here referred to as a contemporary risk science perspective. This perspective clarifies the relationships between the risk concept and terms like uncertainty, knowledge, and probability. The skepticism toward vaccines is multifaceted, and influenced by concerns that extend beyond the effectiveness and safety of the vaccines. However, by clarifying the relationships between key concepts of risk, particularly how uncertainty affects risk and its characterization, we can improve our understanding of this issue.

Anticipatory regulation for pandemic responses: are we there yet?

Can drug and vaccine regulatory agencies leverage their experience during the coronavirus disease 2019 (COVID-19) pandemic to advance from reactive regulation to adaptive regulation and beyond to anticipatory regulation to prevent or curb future pandemics?

Research ethics and public trust in vaccines: the case of COVID-19 challenge trials

Despite their clearly demonstrated safety and effectiveness, approved vaccines against COVID-19 are commonly mistrusted. Nations should find and implement effective ways to boost vaccine confidence. But the implications for ethical vaccine development are less straightforward than some have assumed. Opponents of COVID-19 vaccine challenge trials, in particular, made speculative or empirically implausible warnings on this matter, some of which, if applied consistently, would have ruled out most COVID-19 vaccine trials and many non-pharmaceutical responses.

The value of nurse bioethicists

BACKGROUND

The field of nursing has long been concerned with ethical issues. The history of the nursing profession has a rich legacy of attention to social justice and to societal questions regarding issues of fairness, access, equity, and equality. Some nurses have found that their clinical experiences spur an interest in ethical patient care, and many are now nurse bioethicists, having pursued additional training in bioethics and related fields (e.g., psychology, sociology).

PURPOSE

The authors describe how the clinical and research experiences of nurses give them a unique voice in the field of bioethics.

RESULTS

Authors present reasons for the relative invisibility of nurse bioethicists, compared with physician, theologian, or philosopher bioethicists, as well as current efforts to increase the visibility of nurse bioethicists. They also describe four specific areas where nurse bioethicists have made and continue to make important contributions: as ethics consultants to colleagues in hospitals and other settings; as bioethics researchers or as advisers to researchers conducting trials with human subjects; as educators of trainees, patients and families, healthcare providers, and the public; and in helping to draft humane and ethical policies for the care of vulnerable patients and underserved populations.

CONCLUSION

Nurse bioethicists are central to the future goals of healthcare bringing a unique perspective to the day-to-day ethical challenges of both clinical care and research, as well as to the education of health professionals and the public.

Risk, benefit, and social value in Covid-19 human challenge studies: pandemic decision making in historical context

During the Covid-19 pandemic, ethicists and researchers proposed human challenge studies as a way to speed development of a vaccine that could prevent disease and end the global public health crisis. The risks to healthy volunteers of being deliberately infected with a deadly and novel pathogen were not low, but the benefits could have been immense. This essay is a history of the three major efforts to set up a challenge model and run challenge studies in 2020 and 2021. The pharmaceutical company Johnson and Johnson, the National Institutes of Health in the United States, and a private-public partnership of industry, university, and government partners in Britain all undertook preparations. The United Kingdom's consortium began their Human Challenge Programme in March of 2021.Beyond documenting each effort, the essay puts these scientific and ethical debates in dialogue with the social, epidemiological, and institutional conditions of the pandemic as well as the commercial, intellectual, and political systems in which medical research and Covid-19 challenge studies operated. It shows how different institutions understood risk, benefit, and social value depending on their specific contexts. Ultimately the example of Covid-19 challenge studies highlights the constructedness of such assessments and reveals the utility of deconstructing them retrospectively so as to better understand the interplay of medical research and research ethics with larger social systems and historical contexts.

Do coronavirus vaccine challenge trials have a distinctive generalisability problem?

Notwithstanding the success of conventional field trials for vaccines against COVID-19, human challenge trials (HCTs) that could obtain more information about these and about other vaccines and further strategies against it are about to start in the UK. One critique of COVID-19 HCTs is their distinct paucity of information on crucial population groups. For safety reasons, these HCTs will exclude candidate participants of advanced age or with comorbidities that worsen COVID-19, yet a vaccine should (perhaps especially) protect such populations. We turn this cliché on its head. The truth is that either an HCT or a field trial has intrinsic generalisability limitations, that an HCT can expedite protection of high-risk participants even without challenging them with the virus, and that an important route to obtaining results generalisable to high-risk groups under either strategy is facilitated by HCTs.

Factors associated with the intention to participate in COVID-19 vaccine clinical trials: A cross-sectional study in Peru

OBJECTIVE

To evaluate the factors associated with the intention to participate in COVID-19 vaccine clinical trials in the Peruvian population.

METHODS

Cross-sectional study and secondary analysis of a database that involved Peruvian population during September 2020. The Poisson regression model was used to estimate the associated factors.

RESULTS

Data from 3231 individuals were analyzed, 44.1% of whom intended to participate in COVID-19 vaccine clinical trials. Factors associated with the outcome were being male (RPa: 1.25; 95% CI: 1.15-1.35), being from the highlands region (RPa: 1.18; 95% CI: 1.09-1.28) or jungle (RPa: 1.30; 95% CI: 1.15-1.47), having a relative that is a healthcare professional (PRa: 1.16; 95% CI: 1.06-1.28), using a medical source of information (PRa: 1.28; 95% CI: 1.17-1.41), and trusting in the possible effectiveness of vaccines (PRa: 1.40; 95% CI: 1.29-1.51). The main reason for not participating in the trial was the possibility of developing side effects (69.80%).

CONCLUSION

There is an urgent need to generate a perception of safety in COVID-19 vaccine clinical trials, to increase the population's intention to participate in these studies, and to provide evidence-based information about the vaccine.

Perspective Chapter: Ethics of Using Placebo Controlled Trials for Covid-19 Vaccine Development in Vulnerable Populations

When clinical trials are conducted in vulnerable communities such as those found within low-to-middle-income-countries (LMICs), there is always the risk of exploitation or harm to these communities during the course of biomedical research. Historically, there have been multiple instances where significant harm was caused. Various organisations have proposed guidelines to minimise the risk of this occurring, however, questionable clinical trials are still conducted. Research Ethics Committees have an additional duty of care to protect these vulnerable populations. During the Covid-19 pandemic the ongoing use of placebo-controlled trials (PCTs), even after approval of a safe and efficacious vaccine, is a topic of great debate and is discussed from an ethical and moral perspective.

Racial and Ethnic Diversity in SARS-CoV-2 Vaccine Clinical Trials Conducted in the United States

Evidence shows that White and non-Hispanic individuals are overrepresented in clinical trials. The development of new vaccines and drugs, however, necessitates that clinical research trials include representative participants, particularly in light of evidence showing that underrepresented minorities may have a different response to certain medications and vaccines. Racial and ethnic disparities among clinical trials are multilayered and complex, and this requires action. The results of this study indicate that significant racial and ethnic disparities consistently exist among the most recent early SARS-CoV-2 vaccine clinical trials as compared to the pandemic H1N1 vaccine clinical trials of 2009. New strategies, policies, training programs, and reforms are required to address these disparities among clinical trials.

Replacing vaccine paper package inserts: a multi-country questionnaire study on the acceptability of an electronic replacement in different target groups

Background

In the European Union it is mandatory to include paper package leaflets (PPL) with all medicines, including vaccines, to inform the recipient. However, it is difficult to meet the necessity for localized PPLs in each of the 24 official European languages. Replacing PPLs with electronic versions offers many advantages including redistribution across nations, reduced storage space, accessibility by the visually impaired, easily updated information or the addition of video content. We wanted to assess the attitudes of patients (vaccine recipients or their parents) to the potential of replacing PPL with electronic versions.

Methods

We surveyed vaccinees or their parents in four European countries—Belgium, Italy, Bulgaria and France—for their actual use of vaccine PPLs and their opinions about switching to an electronic package leaflet. Our survey was conducted online because of the COVID-19 pandemic and resulted in 2518 responses to a questionnaire targeted at three specific groups with particular information needs: parents of young children, pregnant women and the elderly (≥ 60 years).

Results

Our main findings are that currently vaccine PPLs are rarely used and frequently unavailable for the vaccinee. Across the four countries surveyed 55–82% of vaccinees would accept an electronic version, as did 64% when there was an option to request a printout of the leaflet.

Conclusions

We found that switching to electronic versions of vaccine PPLs is an acceptable alternative for the public, potentially increasing the quality and amount of information reaching vaccinees while eliminating some barriers to redistribution of vaccines between countries.

Should nurses take a COVID-19 vaccine?

The issue as to whether health care professionals have a moral obligation to take a vaccine for a communicable disease is not new. Nonetheless, this issue takes on a fresh urgency within nursing practice in the context of the present COVID-19 pandemic, i.e., is there an ethical requirement for nurses to take a COVID-19 vaccine? This paper approaches the issue by using a hypothetical example of Nurse X who has inadvertently infected Patient Y. French's (1984a) Principle of Responsive Adjustment is adapted to claim that there would be a moral expectation that Nurse X takes a COVID-19 vaccine (unless there are justifiable reasons not to). The proposition is also made that, should Nurse X not take a COVID-19 vaccine, they could be morally associated with originally infecting Patient Y.

Physicians' opinions on the necessity of COVID-19 vaccination in patients with epilepsy

The aim of the current study was to investigate the opinions of neurologists and psychiatrists in Iran on the necessity of COVID-19 vaccination in patients with epilepsy (PWE). These data can help policy makers understand the concerns of these healthcare professionals. This was a survey study. On September 1st, 2020 we sent a questionnaire (using Google-forms) to all neurologists and psychiatrists in Iran via WhatsApp. The survey included three general questions (age, sex, and discipline) and six COVID-specific questions. In total, 202 physicians participated in this study (116 neurologists and 86 psychiatrists). Of the participants, 27% believed that PWE are at increased risk of contracting COVID-19. The majority (74%) of the participants would confidently recommend COVID-19 vaccine to their patients. However, only 49% of the physicians would recommend such a vaccine to all patients; others would consider it in special populations only. The overwhelming majority (91%) of the participants would recommend COVID-19 vaccine only when a reliable vaccine becomes available. Many physicians would trust a vaccine that is approved by the World Health Organization (WHO) (46%) or a vaccine that is approved by the Food and Drug Administration (FDA-USA) (34%). Physicians have concerns on the issue of the necessity of (a future) COVID-19 vaccine in PWE. The most important concern is the reliability of a vaccine and in this regard, two health agencies, the WHO and the FDA, are the most trusted organizations to approve a vaccine against COVID-19.

Testing SARS-CoV-2 vaccine efficacy through deliberate natural viral exposure

BACKGROUND

A vaccine trial with a conventional challenge design can be very fast once it starts, but it requires a long prior process, in part to grow and standardize challenge virus in the laboratory. This detracts somewhat from its overall promise for accelerated efficacy testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine candidates, and from the ability of developing countries and small companies to conduct it.

AIMS

We set out to identify a challenge design that avoids this part of the long prior process.

SOURCES

Literature in trial design (including a proof of concept flu challenge trial by B. Killingley et al.), vaccinology, medical ethics, and various aspects of COVID response.

CONTENT

A challenge design with deliberate natural viral exposure avoids the need to grow culture. This new design is described and compared both to a conventional challenge design and to a conventional phase III field trial. In comparison, the proposed design has ethical, scientific, and feasibility strengths.

IMPLICATIONS

The proposed new design should be considered for future vaccine trials.

Assessment of the Inclusion of Racial/Ethnic Minority, Female, and Older Individuals in Vaccine Clinical Trials

Importance

Medical research has not equitably included members of racial/ethnic minority groups or female and older individuals. There are limited data on participant demographic characteristics in vaccine trials despite the importance of these data to current trials aimed at preventing coronavirus disease 2019.

Objective

To investigate whether racial/ethnic minority groups and female and older adults are underrepresented among participants in vaccine clinical trials.

Design, Setting, and Participants

This cross-sectional study examined data from completed US-based vaccine trials registered on ClinicalTrials.gov from July 1, 2011, through June 30, 2020. The terms vaccine, vaccination, immunization, and inoculation were used to identify trials. Only those addressing vaccine immunogenicity or efficacy of preventative vaccines were included.

Main Outcomes and Measures

The numbers and percentages of racial/ethnic minority, female, and older individuals compared with US census data from 2011 and 2018. Secondary outcome measures were inclusion by trial phase and year of completion.

Results

A total of 230 US-based trials with 219 555 participants were included in the study. Most trials were randomized (180 [78.3%]), included viral vaccinations (159 [69.1%]), and represented all trial phases. Every trial reported age and sex; 134 (58.3%) reported race and 79 (34.3%) reported ethnicity. Overall, among adult study participants, White individuals were overrepresented (77.9%; 95% CI, 77.4%-78.4%), and Black or African American individuals (10.6%; 95% CI, 10.2%-11.0%) and American Indian or Alaska Native individuals (0.4%; 95% CI, 0.3%-0.5%) were underrepresented compared with US census data; enrollment of Asian individuals was similar (5.7%; 95% CI, 5.5%-6.0%). Enrollment of Hispanic or Latino individuals (11.6%; 95% CI, 11.1%-12.0%) was also low even among the limited number of adult trials reporting ethnicity. Adult trials were composed of more female participants (75 325 [56.0%]), but among those reporting age as a percentage, enrollment of participants who were aged 65 years or older was low (12.1%; 95% CI, 12.0%-12.3%). Black or African American participants (10.1%; 95% CI, 9.7%-10.6%) and Hispanic or Latino participants (22.5%; 95% CI, 21.6%-23.4%) were also underrepresented in pediatric trials. Among trials reporting race/ethnicity, 65 (48.5%) did not include American Indian or Alaska Native participants and 81 (60.4%) did not include Hawaiian or Pacific Islander participants.

Conclusions and Relevance

This cross-sectional study found that among US-based vaccine clinical trials, members of racial/ethnic minority groups and older adults were underrepresented, whereas female adults were overrepresented. These findings suggest that diversity enrollment targets should be included for all vaccine trials targeting epidemiologically important infections.

Covid-19 vaccines: A model of acceptance behavior in the healthcare sector

The emergence of Covid-19 has affected all aspects of human life across the globe. Lockdowns everywhere are having dramatic social and economic consequences. No therapy has yet been approved, and vaccines are a priority potential tool to control the pandemic and its impacts. Multiple vaccines are in the last stage of the development process, but part of the population is not willing to get vaccinated for Covid-19. Several studies have examined the percentage of the population willing to get vaccinated, but few have analyzed the reasons for their decision. In this context, researching the factors influencing individuals’ intention to use a potential Covid-19 vaccine will be important to public health strategies. This paper analyzes these factors with an adapted Cognitive-Affective-Normative (CAN) model. Perceived vaccine efficacy is used as a cognitive variable, fear of the vaccine and fear of Covid-19 are used as affective variables, and social influence is used as the normative variable. The proposed model strongly explains the intention to use the Covid-19 vaccine (R2 = 0.81). The results show that vaccine efficacy will be the most important determinant of Covid-19 vaccine acceptance, followed by social influence. The findings can be very helpful for public health policies aimed at achieving widespread vaccination, a must for vaccine success.

Public Willingness to Participate in COVID-19 Vaccine Clinical Trials: A Study from Jordan

PURPOSE

The development and production of novel vaccine to prevent COVID-19 is an international imperative to human lives. For that purpose, clinical trials have to be carried out as per international ethical standards. The current study was undertaken to examine the willingness to participate in COVID-19 vaccine clinical trials and to determine factors that might affect their decision to participate.

PATIENTS AND METHODS

A cross-sectional survey study was carried out among the public in Jordan. During the study period, a convenience sample of adults (aged 18 years or above) were asked to participate via an online self-administered survey that was designed to evaluate the willingness to participate in COVID-19 vaccine clinical trials and to determine factors affecting their decision to participate.

RESULTS

Results showed that, among participants (n=1,287), 36.1% reported to be willing to participate in clinical trials of the vaccine. Additionally, a lower percentage (18.1%) were willing to allow their children to participate. Motivators that encourage participation were the desire to return to normal life (73.2%), followed by the desire to help in finding a treatment for COVID-19 infection (68.1%). Barriers towards the participation were not wanting to be challenged by the virus (54.7%), fear (40.7%), lack of time (40.4%), and mistrust in pharmaceutical companies (38.9%). Finally, results showed that higher educational level was associated with lower willingness to participate (P=0.001), whereas having a previous participation in clinical studies is associated with a significantly higher willingness to participate in COVID-19 vaccine clinical trials (P<0.001).

CONCLUSION

A good portion of Jordanians are positive regarding participation in clinical studies of COVID-19 vaccine. Educational level and previous participation in clinical studies were among the determinants of such willingness. In addition, fear and lack of time were among the barriers of participation.