1
|
Dabira ED, Fehr A, Beloum N, Van Geertruyden JP, Achan J, Erhart A, Martinez-Alvarez M, D'Alessandro U. Perceptions and acceptability of the controlled human malaria infection (CHMI) model in The Gambia: a qualitative study. Sci Rep 2023; 13:8708. [PMID: 37248260 DOI: 10.1038/s41598-023-35752-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/23/2023] [Indexed: 05/31/2023] Open
Abstract
Controlled human malaria infection (CHMI) studies, i.e. the deliberate infection of healthy volunteers with malaria parasites to study immune response and/or test drug or vaccine efficacy, are increasingly being conducted in malaria endemic countries, including in sub-Saharan Africa. However, there have been few studies on the perceptions and acceptability of CHMI by the local communities. This qualitative study assessed the perception and acceptability of such studies in The Gambia following the first CHMI study conducted in the country in March-May 2018. Data were collected through non-participant observation, in-depth interviews and focus group discussions and analyzed using NVivo 12 software with an inductive-deductive approach. Sixty-seven participants were involved, including volunteers enrolled in the CHMI, community stakeholders and members of the Gambian Ethics Committee. Respondents expressed a positive view about CHMI. Key motivating factors for participation were the financial compensation, comprehensive health checks, and willingness to support malaria research. Risks associated with participation were considered low. Concerns raised included the frequency of bleeding and the blood volume collected.
Collapse
Affiliation(s)
- Edgard Diniba Dabira
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine (MRCG at LSHTM), Fajara, The Gambia.
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.
| | - Alexandra Fehr
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nathalie Beloum
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine (MRCG at LSHTM), Fajara, The Gambia
| | | | | | - Annette Erhart
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine (MRCG at LSHTM), Fajara, The Gambia
| | - Melisa Martinez-Alvarez
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine (MRCG at LSHTM), Fajara, The Gambia
| | - Umberto D'Alessandro
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine (MRCG at LSHTM), Fajara, The Gambia
| |
Collapse
|
2
|
Marsh AA, Magalhaes M, Peeler M, Rose SM, Darton TC, Eyal N, Morrison J, Shah SK, Schmit V. Characterizing altruistic motivation in potential volunteers for SARS-CoV-2 challenge trials. PLoS One 2022; 17:e0275823. [PMID: 36322529 PMCID: PMC9629635 DOI: 10.1371/journal.pone.0275823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/23/2022] [Indexed: 11/05/2022] Open
Abstract
In human challenge trials (HCTs), volunteers are deliberately infected with an infectious agent. Such trials can be used to accelerate vaccine development and answer important scientific questions. Starting early in the COVID-19 pandemic, ethical concerns were raised about using HCTs to accelerate development and approval of a vaccine. Some of those concerns pertained to potential exploitation of and/or lack of truly informed consent from volunteers. Specific areas of concern arose around individuals who may be unusually risk-seeking or too economically vulnerable to refuse the payments these trials provide, as opposed to being motivated primarily by altruistic goals. This pre-registered study is the first large-scale survey to characterize people who, early in the pandemic, expressed interest and intention to volunteer to participate in COVID-19 HCTs. We found that individuals expressing interest in SARS-CoV-2 HCTs exhibit consistently altruistic motivations without any special indication of poor risk perception or economic vulnerability. In finding that, early in the pandemic, COVID-19 HCTs were able to attract volunteers whose values align with the nature of these trials, and who are not unusually vulnerable to exploitation, this study may allay some ethical concerns about the volunteers interested in participating in such trials.
Collapse
Affiliation(s)
- Abigail A. Marsh
- Department of Psychology, Georgetown University, Washington, DC, United States of America
- * E-mail:
| | - Monica Magalhaes
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, New Jersey, United States of America
| | - Matthew Peeler
- Department of Mathematics, Rowan-Cabarrus Community College, Salisbury, North Carolina, United States of America
| | - Sophie M. Rose
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Thomas C. Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Nir Eyal
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, New Jersey, United States of America
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, United States of America
- Department of Philosophy, Rutgers University, New Brunswick, New Jersey, United States of America
| | - Josh Morrison
- 1Day Sooner, Claymont, Delaware, United States of America
| | - Seema K. Shah
- Smith Child Health Outcomes, Research and Evaluation Center, Lurie Children’s Hospital, Chicago, Illinois, United States of America
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | | |
Collapse
|
3
|
Abstract
"The Primate Malarias" book has been a uniquely important resource for multiple generations of scientists, since its debut in 1971, and remains pertinent to the present day. Indeed, nonhuman primates (NHPs) have been instrumental for major breakthroughs in basic and pre-clinical research on malaria for over 50 years. Research involving NHPs have provided critical insights and data that have been essential for malaria research on many parasite species, drugs, vaccines, pathogenesis, and transmission, leading to improved clinical care and advancing research goals for malaria control, elimination, and eradication. Whilst most malaria scientists over the decades have been studying Plasmodium falciparum, with NHP infections, in clinical studies with humans, or using in vitro culture or rodent model systems, others have been dedicated to advancing research on Plasmodium vivax, as well as on phylogenetically related simian species, including Plasmodium cynomolgi, Plasmodium coatneyi, and Plasmodium knowlesi. In-depth study of these four phylogenetically related species over the years has spawned the design of NHP longitudinal infection strategies for gathering information about ongoing infections, which can be related to human infections. These Plasmodium-NHP infection model systems are reviewed here, with emphasis on modern systems biological approaches to studying longitudinal infections, pathogenesis, immunity, and vaccines. Recent discoveries capitalizing on NHP longitudinal infections include an advanced understanding of chronic infections, relapses, anaemia, and immune memory. With quickly emerging new technological advances, more in-depth research and mechanistic discoveries can be anticipated on these and additional critical topics, including hypnozoite biology, antigenic variation, gametocyte transmission, bone marrow dysfunction, and loss of uninfected RBCs. New strategies and insights published by the Malaria Host-Pathogen Interaction Center (MaHPIC) are recapped here along with a vision that stresses the importance of educating future experts well trained in utilizing NHP infection model systems for the pursuit of innovative, effective interventions against malaria.
Collapse
Affiliation(s)
- Mary R Galinski
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
- Emory Vaccine Center, Emory University, Atlanta, GA, USA.
- Emory National Primate Research Center (Yerkes National Primate Research Center), Emory University, Atlanta, GA, USA.
| |
Collapse
|
4
|
Clarkson KA, Porter CK, Talaat KR, Kapulu MC, Chen WH, Frenck RW, Bourgeois AL, Kaminski RW, Martin LB. Shigella-Controlled Human Infection Models: Current and Future Perspectives. Curr Top Microbiol Immunol 2022. [PMID: 35616717 DOI: 10.1007/82_2021_248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Shigella-controlled human infection models (CHIMs) are an invaluable tool utilized by the vaccine community to combat one of the leading global causes of infectious diarrhea, which affects infants, children and adults regardless of socioeconomic status. The impact of shigellosis disproportionately affects children in low- and middle-income countries (LMICs) resulting in cognitive and physical stunting, perpetuating a cycle that must be halted. Shigella-CHIMs not only facilitate the early evaluation of enteric countermeasures and up-selection of the most promising products but also provide insight into mechanisms of infection and immunity that are not possible utilizing animal models or in vitro systems. The greater understanding of shigellosis obtained in CHIMs builds and empowers the development of new generation solutions to global health issues which are unattainable in the conventional laboratory and clinical settings. Therefore, refining, mining and expansion of safe and reproducible infection models hold the potential to create effective means to end diarrheal disease and associated co-morbidities associated with Shigella infection.
Collapse
Affiliation(s)
- Kristen A Clarkson
- Department of Diarrheal Disease Research, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA
| | - Chad K Porter
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA
| | - Kawsar R Talaat
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway Street Hampton House, Baltimore, MD, 21205, USA
| | - Melissa C Kapulu
- Department of Biosciences, KEMRI-Wellcome Trust Research Programme, Kilifi County Hospital, Off Bofa Road, Kilifi, 80108, Kenya
| | - Wilbur H Chen
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 West Baltimore Street, Baltimore, MD, 21201, USA
| | - Robert W Frenck
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - A Louis Bourgeois
- PATH Center for Vaccine Innovation and Access, 455 Massachusetts Avenue NW, Washington, DC, 20001, USA
| | - Robert W Kaminski
- Department of Diarrheal Disease Research, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA
| | - Laura B Martin
- GSK Vaccines Institute for Global Health, Via Fiorentina 1, 53100, Siena, Italy.
| |
Collapse
|
5
|
Mumba N, Njuguna P, Chi P, Marsh V, Awuor E, Hamaluba M, Mauncho C, Mwalukore S, Masha J, Mwangoma M, Kalama B, Alphan H, Wambua J, Bejon P, Kamuya D, Kapulu MC. Undertaking Community Engagement for a Controlled Human Malaria Infection Study in Kenya: Approaches and Lessons Learnt. Front Public Health 2022; 10:793913. [PMID: 35570883 PMCID: PMC9099019 DOI: 10.3389/fpubh.2022.793913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Human infection studies (HIS) involve deliberately infecting healthy volunteers with disease-causing pathogens under controlled conditions. These studies are "controlled" by way of using specific types of pathogens, including dose, and the availability of emergency medical facilities to research volunteers. Most HIS involve diseases whose treatment is known and are done to accelerate the development of novel therapeutics such as vaccines, to address emerging and existing infectious diseases. Traditionally, HIS have been conducted primarily in high-income countries (HICs) but are now increasingly being conducted in low-and-middle income countries (LMICs). In LMICs settings, HIS are likely to raise concerns among various stakeholders including participating populations and regulatory bodies, that are unfamiliar with this type of research. Deliberately infecting a healthy individual with a disease-causing pathogen seems to go against the normal practice of medicine of "do no harm". Such types of studies can give rise to increased rumors and jeopardize research participation in study activities, including non-HIS research. Community engagement can be one approach to address particular issues that HIS studies raise through meaningfully engaging with communities, where views and voices inform the conduct of HIS studies. In addition, engagement can inform the ethical conduct and acceptability of HIS studies in LMICs settings and provide opportunities for sharing information, listening to, and responding to concerns and views from potential participants, and the larger community in which the study would be conducted. Despite community engagement being an important aspect to consider, very few published and gray literature cover the types of approaches that have been used, and lessons learnt in engagement for HIS. This article outlinesthe community engagement approaches that were used to engage stakeholders and communities for malaria HIS-controlled human malaria infection (CHMI), undertaken in Kilifi, Kenya. It outlines the engagement activities across the research cycle, from activities conducted during protocol development, to planning, and implementation of the study. We discuss the challenges experienced, lessons learnt, and provide some recommendations for engagement around HIS.
Collapse
Affiliation(s)
- Noni Mumba
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Patricia Njuguna
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya.,PATH Centre for Vaccine Innovation and Access, Nairobi, Kenya
| | - Primus Chi
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Vicki Marsh
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Esther Awuor
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mainga Hamaluba
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Cynthia Mauncho
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Salim Mwalukore
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Johnson Masha
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mary Mwangoma
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Betty Kalama
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Hassan Alphan
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Juliana Wambua
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Bejon
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Dorcas Kamuya
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Melissa C Kapulu
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| |
Collapse
|
6
|
Chi PC, Owino EA, Jao I, Bejon P, Kapulu M, Marsh V, Kamuya D. Ethical considerations around volunteer payments in a malaria human infection study in Kenya: an embedded empirical ethics study. BMC Med Ethics 2022; 23:46. [PMID: 35443642 PMCID: PMC9019790 DOI: 10.1186/s12910-022-00783-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Human Infection Studies (HIS) have emerged as an important research approach with the potential to fast track the global development of vaccines and treatments for infectious diseases, including in low resource settings. Given the high level of burdens involved in many HIS, particularly prolonged residency and biological sampling requirements, it can be challenging to identify levels of study payments that provide adequate compensation but avoid 'undue' levels of inducement to participate. Through this embedded ethics study, involving 97 healthy volunteers and other research stakeholders in a malaria HIS programme in Kenya, and using in-depth interviews, focus group discussions and observations during and after a malaria HIS, we give a grounded account of ethical issues emerging in relation to study payments in this setting. While careful community, national, international scientific and ethics review processes meant that risks of serious harm were highly unlikely, the levels of motivation to join HIS seen could raise concerns about study payments being too high. Particular value was placed on the reliability, rather than level, of study payment in this setting, where subsistence livelihoods are common. Study volunteers were generally clear about the study aims at the point of recruitment, and this knowledge was retained over a year later, although most reported experiencing more burdens than anticipated at enrolment. Strict study screening procedures, regular clinical and laboratory monitoring of volunteers, with prompt treatment with antimalarial at predetermined endpoints suggested that the risks of serious harm were highly unlikely. Ethical concerns emerged in relation to volunteers' attempts to conceal symptoms, hoping to prolong residency periods and increase study payments; and volunteers making decisions that compromised important family relationships and personal values. Our findings support an interpretation that, although study volunteers were keen to join the study to access cash payments, they also paid attention to other features of the study and the general clinical research landscape, including levels of risk associated with study participation. Overall, our analysis shows that the ethical concerns emerging from the study payments can be addressed through practical measures, hinged on reducing burdens and strengthening communication, raising important issues for research policy and planning.
Collapse
Affiliation(s)
- Primus Che Chi
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Esther Awuor Owino
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Irene Jao
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Bejon
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Melissa Kapulu
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Vicki Marsh
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Dorcas Kamuya
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| |
Collapse
|
7
|
Gupta A, Styczynski MP, Galinski MR, Voit EO, Fonseca LL. Dramatic transcriptomic differences in Macaca mulatta and Macaca fascicularis with Plasmodium knowlesi infections. Sci Rep 2021; 11:19519. [PMID: 34593836 PMCID: PMC8484567 DOI: 10.1038/s41598-021-98024-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/30/2021] [Indexed: 12/02/2022] Open
Abstract
Plasmodium knowlesi, a model malaria parasite, is responsible for a significant portion of zoonotic malaria cases in Southeast Asia and must be controlled to avoid disease severity and fatalities. However, little is known about the host-parasite interactions and molecular mechanisms in play during the course of P. knowlesi malaria infections, which also may be relevant across Plasmodium species. Here we contrast P. knowlesi sporozoite-initiated infections in Macaca mulatta and Macaca fascicularis using whole blood RNA-sequencing and transcriptomic analysis. These macaque hosts are evolutionarily close, yet malaria-naïve M. mulatta will succumb to blood-stage infection without treatment, whereas malaria-naïve M. fascicularis controls parasitemia without treatment. This comparative analysis reveals transcriptomic differences as early as the liver phase of infection, in the form of signaling pathways that are activated in M. fascicularis, but not M. mulatta. Additionally, while most immune responses are initially similar during the acute stage of the blood infection, significant differences arise subsequently. The observed differences point to prolonged inflammation and anti-inflammatory effects of IL10 in M. mulatta, while M. fascicularis undergoes a transcriptional makeover towards cell proliferation, consistent with its recovery. Together, these findings suggest that timely detection of P. knowlesi in M. fascicularis, coupled with control of inflammation while initiating the replenishment of key cell populations, helps contain the infection. Overall, this study points to specific genes and pathways that could be investigated as a basis for new drug targets that support recovery from acute malaria.
Collapse
Affiliation(s)
- Anuj Gupta
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Mark P Styczynski
- School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Mary R Galinski
- Emory Vaccine Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Eberhard O Voit
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
| | - Luis L Fonseca
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Laboratory for Systems Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| |
Collapse
|
8
|
Lee K, Eyal N. COVID-19 controlled human infection studies: worries about local community impact and demands for local engagement. JOURNAL OF MEDICAL ETHICS 2021; 47:539-542. [PMID: 33980657 PMCID: PMC8117466 DOI: 10.1136/medethics-2021-107229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/29/2021] [Accepted: 04/08/2021] [Indexed: 05/05/2023]
Abstract
In spring, summer and autumn 2020, one abiding argument against controlled human infection (CHI) studies of SARS-CoV-2 vaccines has been their impact on local communities. Leading scientists and bioethicists expressed concern about undue usage of local residents' direly needed scarce resources at a time of great need and even about their unintended infection. They recommended either avoiding CHI trials or engaging local communities before conducting any CHIs. Similar recommendations were not made for the alternative-standard phase III field trials of these same vaccines. We argue that the health effects of CHI studies on local residents not participating in the study tend to be smaller and more positive than those of field trials. That is all the more so now that tested vaccines are being rolled out. Whether or not local community engagement is necessary for urgent vaccine studies in the pandemic, the case for its engagement is stronger prior to field trials than prior to CHI studies.
Collapse
Affiliation(s)
- Kyungdo Lee
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Nir Eyal
- Center for Population-Level Bioethics, Department of Philosophy (SAS) and Department of HBSP (SPH), Rutgers University, New Brunswick, New Jersey, USA
| |
Collapse
|
9
|
Chi PC, Owino EA, Jao I, Olewe F, Ogutu B, Bejon P, Kapulu M, Kamuya D, Marsh V. Understanding the benefits and burdens associated with a malaria human infection study in Kenya: experiences of study volunteers and other stakeholders. Trials 2021; 22:494. [PMID: 34311781 DOI: 10.21203/rs.3.rs-143195/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/13/2021] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Human infection studies (HIS) that involve deliberately infecting healthy volunteers with a pathogen raise important ethical issues, including the need to ensure that benefits and burdens are understood and appropriately accounted for. Building on earlier work, we embedded social science research within an ongoing malaria human infection study in coastal Kenya to understand the study benefits and burdens experienced by study stakeholders in this low-resource setting and assess the wider implications for future research planning and policy. METHODS Data were collected using qualitative research methods, including in-depth interviews (44), focus group discussions (10) and non-participation observation. Study participants were purposively selected (key informant or maximal diversity sampling), including volunteers in the human infection study, study staff, community representatives and local administrative authorities. Data were collected during and up to 18 months following study residency, from sites in Coastal and Western Kenya. Voice recordings of interviews and discussions were transcribed, translated, and analysed using framework analysis, combining data- and theory-driven perspectives. FINDINGS Physical, psychological, economic and social forms of benefits and burdens were experienced across study stages. Important benefits for volunteers included the study compensation, access to health checks, good residential living conditions, new learning opportunities, developing friendships and satisfaction at contributing towards a new malaria vaccine. Burdens primarily affected study volunteers, including experiences of discomfort and ill health; fear and anxiety around aspects of the trial process, particularly deliberate infection and the implications of prolonged residency; anxieties about early residency exit; and interpersonal conflict. These issues had important implications for volunteers' families, study staff and the research institution's reputation more widely. CONCLUSION Developing ethically and scientifically strong HIS relies on grounded accounts of volunteers, study staff and the wider community, understood in the socioeconomic, political and cultural context where studies are implemented. Recognition of the diverse, and sometimes perverse, nature of potential benefits and burdens in a given context, and who this might implicate, is critical to this process. Prior and ongoing stakeholder engagement is core to developing these insights.
Collapse
Affiliation(s)
- Primus Che Chi
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Esther Awuor Owino
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Irene Jao
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Fredrick Olewe
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
- Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
| | - Bernhards Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
- Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
| | - Philip Bejon
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | - Melissa Kapulu
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | - Dorcas Kamuya
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | - Vicki Marsh
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| |
Collapse
|
10
|
Chi PC, Owino EA, Jao I, Olewe F, Ogutu B, Bejon P, Kapulu M, Kamuya D, Marsh V. Understanding the benefits and burdens associated with a malaria human infection study in Kenya: experiences of study volunteers and other stakeholders. Trials 2021; 22:494. [PMID: 34311781 PMCID: PMC8313115 DOI: 10.1186/s13063-021-05455-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/13/2021] [Indexed: 11/24/2022] Open
Abstract
Background Human infection studies (HIS) that involve deliberately infecting healthy volunteers with a pathogen raise important ethical issues, including the need to ensure that benefits and burdens are understood and appropriately accounted for. Building on earlier work, we embedded social science research within an ongoing malaria human infection study in coastal Kenya to understand the study benefits and burdens experienced by study stakeholders in this low-resource setting and assess the wider implications for future research planning and policy. Methods Data were collected using qualitative research methods, including in-depth interviews (44), focus group discussions (10) and non-participation observation. Study participants were purposively selected (key informant or maximal diversity sampling), including volunteers in the human infection study, study staff, community representatives and local administrative authorities. Data were collected during and up to 18 months following study residency, from sites in Coastal and Western Kenya. Voice recordings of interviews and discussions were transcribed, translated, and analysed using framework analysis, combining data- and theory-driven perspectives. Findings Physical, psychological, economic and social forms of benefits and burdens were experienced across study stages. Important benefits for volunteers included the study compensation, access to health checks, good residential living conditions, new learning opportunities, developing friendships and satisfaction at contributing towards a new malaria vaccine. Burdens primarily affected study volunteers, including experiences of discomfort and ill health; fear and anxiety around aspects of the trial process, particularly deliberate infection and the implications of prolonged residency; anxieties about early residency exit; and interpersonal conflict. These issues had important implications for volunteers’ families, study staff and the research institution’s reputation more widely. Conclusion Developing ethically and scientifically strong HIS relies on grounded accounts of volunteers, study staff and the wider community, understood in the socioeconomic, political and cultural context where studies are implemented. Recognition of the diverse, and sometimes perverse, nature of potential benefits and burdens in a given context, and who this might implicate, is critical to this process. Prior and ongoing stakeholder engagement is core to developing these insights. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05455-7.
Collapse
Affiliation(s)
- Primus Che Chi
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Esther Awuor Owino
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Irene Jao
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Fredrick Olewe
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya.,Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
| | - Bernhards Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya.,Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
| | - Philip Bejon
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | - Melissa Kapulu
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | - Dorcas Kamuya
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | - Vicki Marsh
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | | |
Collapse
|
11
|
Parkash V, Ashwin H, Sadlova J, Vojtkova B, Jones G, Martin N, Greensted E, Allgar V, Kamhawi S, Valenzuela JG, Layton AM, Jaffe CL, Volf P, Kaye PM, Lacey CJN. A clinical study to optimise a sand fly biting protocol for use in a controlled human infection model of cutaneous leishmaniasis (the FLYBITE study). Wellcome Open Res 2021; 6:168. [PMID: 34693027 PMCID: PMC8506224 DOI: 10.12688/wellcomeopenres.16870.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/02/2023] Open
Abstract
Background: Leishmaniasis is a globally important yet neglected parasitic disease transmitted by phlebotomine sand flies. With new candidate vaccines in or near the clinic, a controlled human challenge model (CHIM) using natural sand fly challenge would provide a method for early evaluation of prophylactic efficacy. Methods : We evaluated the biting frequency and adverse effects resulting from exposure of human volunteers to bites of either Phlebotomus papatasi or P. duboscqi, two natural vectors of Leishmania major. 12 healthy participants were recruited (mean age 40.2 ± 11.8 years) with no history of significant travel to regions where L. major-transmitting sand flies are prevalent. Participants were assigned to either vector by 1:1 allocation and exposed to five female sand flies for 30 minutes in a custom biting chamber. Bite frequency was recorded to confirm a bloodmeal was taken. Participant responses and safety outcomes were monitored using a visual analogue scale (VAS), clinical examination, and blood biochemistry. Focus groups were subsequently conducted to explore participant acceptability. Results: All participants had at least one successful sand fly bite with none reporting any serious adverse events, with median VAS scores of 0-1/10 out to day 21 post-sand fly bite. Corresponding assessment of sand flies confirmed that for each participant at least 1/5 sand flies had successfully taken a bloodmeal (overall mean 3.67±1.03 bites per participant). There was no significant difference between P. papatasi and P. duboscqi in the number of bites resulting from 5 sand flies applied to human participants (3.3±0.81 vs 3.00±1.27 bites per participant; p=0.56) . In the two focus groups (n=5 per group), themes relating to positive participant-reported experiences of being bitten and the overall study, were identified. Conclusions: These results validate a protocol for achieving successful sand fly bites in humans that is safe, well-tolerated and acceptable for participants. Clinicaltrials.gov registration: NCT03999970 (27/06/2019).
Collapse
Affiliation(s)
- Vivak Parkash
- York Biomedical Research Institute, Hull York Medical School, University of York, York, N.Yorks, YO10 5DD, UK
- Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Helen Ashwin
- York Biomedical Research Institute, Hull York Medical School, University of York, York, N.Yorks, YO10 5DD, UK
| | - Jovana Sadlova
- Department of Parasitology, Charles University, Prague, Czech Republic
| | - Barbora Vojtkova
- Department of Parasitology, Charles University, Prague, Czech Republic
| | - Georgina Jones
- School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Nina Martin
- School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Elizabeth Greensted
- York Biomedical Research Institute, Hull York Medical School, University of York, York, N.Yorks, YO10 5DD, UK
| | - Victoria Allgar
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Shaden Kamhawi
- Laboratory of Malaria and Vector Research, National Institutes of Health, Rockville, MD, USA
| | - Jesus G. Valenzuela
- Laboratory of Malaria and Vector Research, National Institutes of Health, Rockville, MD, USA
| | - Alison M. Layton
- York Biomedical Research Institute, Hull York Medical School, University of York, York, N.Yorks, YO10 5DD, UK
| | - Charles L. Jaffe
- Department of Microbiology and Molecular Genetics, The Hebrew University – Hadassah Medical School, Jerusalem, Israel
| | - Petr Volf
- Department of Parasitology, Charles University, Prague, Czech Republic
| | - Paul M. Kaye
- York Biomedical Research Institute, Hull York Medical School, University of York, York, N.Yorks, YO10 5DD, UK
| | - Charles J. N. Lacey
- York Biomedical Research Institute, Hull York Medical School, University of York, York, N.Yorks, YO10 5DD, UK
| |
Collapse
|
12
|
Lynch HF, Darton TC, Levy J, McCormick F, Ogbogu U, Payne RO, Roth AE, Shah AJ, Smiley T, Largent EA. Promoting Ethical Payment in Human Infection Challenge Studies. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:11-31. [PMID: 33541252 DOI: 10.1080/15265161.2020.1854368] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
To prepare for potential human infection challenge studies (HICS) involving SARS-CoV-2, we convened a multidisciplinary working group to address ethical questions regarding whether and how much SARS-CoV-2 HICS participants should be paid. Because the goals of paying HICS participants, as well as the relevant ethical concerns, are the same as those arising for other types of clinical research, the same basic framework for ethical payment can apply. This framework divides payment into reimbursement, compensation, and incentives, focusing on fairness and promoting adequate recruitment and retention as counterweights to concerns about undue inducement. Within the basic framework, several factors are especially salient for HICS, and for SARS-CoV-2 HICS in particular, including the nature of participant confinement, anticipated discomfort, risks and uncertainty, participant motivations, and trust. These factors are reflected in a payment worksheet created to help sponsors, researchers, and ethics reviewers systematically develop and assess ethically justifiable payment amounts.
Collapse
|
13
|
Chi PC, Owino E, Jao I, Marsh V, Kamuya D. Considering the Importance of Context for Ethical Practice on Reimbursement, Compensation and Incentives for Volunteers in Human Infection Controlled Studies. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:40-42. [PMID: 33616502 PMCID: PMC7613538 DOI: 10.1080/15265161.2020.1870771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
| | | | - Irene Jao
- KEMRI-Wellcome Trust Research Programme
| | | | | |
Collapse
|
14
|
Vaswani V, Saxena A, Shah SK, Palacios R, Rid A. Informed consent for controlled human infection studies in low- and middle-income countries: Ethical challenges and proposed solutions. BIOETHICS 2020; 34:809-818. [PMID: 32779233 PMCID: PMC9627191 DOI: 10.1111/bioe.12795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 06/11/2023]
Abstract
In controlled human infection studies (CHIs), participants are deliberately exposed to infectious agents in order to better understand the mechanism of infection or disease and test therapies or vaccines. While most CHIs have been conducted in high-income countries, CHIs have recently been expanding into low- and middle-income countries (LMICs). One potential ethical concern about this expansion is the challenge of obtaining the voluntary informed consent of participants, especially those who may not be literate or have limited education. In some CHIs in LMICs, researchers have attempted to address this potential concern by limiting access to literate or educated populations. In this paper, we argue that this practice is unjustified, as it does not increase the chances of obtaining valid informed consent and therefore unfairly excludes illiterate populations and populations with lower education. Instead, we recommend that investigators improve the informed consent process by drawing on existing data on obtaining informed consent in these populations and interventions aimed at improving their understanding. Based on a literature review, we provide concrete suggestions for how to follow this recommendation and ensure that populations with lower literacy or education are given a fair opportunity to protect their rights and interests in the informed consent process.
Collapse
Affiliation(s)
- Vina Vaswani
- Centre for Ethics, Yenepoya University, Managlore, India
| | - Abha Saxena
- The INCLEN Trust International, New Delhi, India
- Institut Éthique Histoire Humanités, University of Geneva, Geneva, Switzerland
| | - Seema K Shah
- Division of Academic General Pediatrics, Lurie Children's Hospital, Chicago, IL, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ricardo Palacios
- Clinical Trials and Pharmacovigilance Center, Instituto Butantan, São Paulo, Brazil
| | - Annette Rid
- Department of Bioethics, The Clinical Center, National Institutes of Health, Betherda, USA
| |
Collapse
|
15
|
Jao I, Marsh V, Che Chi P, Kapulu M, Hamaluba M, Molyneux S, Bejon P, Kamuya D. Deliberately infecting healthy volunteers with malaria parasites: Perceptions and experiences of participants and other stakeholders in a Kenyan-based malaria infection study. BIOETHICS 2020; 34:819-832. [PMID: 32643809 PMCID: PMC7689838 DOI: 10.1111/bioe.12781] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 04/04/2020] [Accepted: 04/24/2020] [Indexed: 05/15/2023]
Abstract
Controlled human malaria infection (CHMI) studies involve the deliberate infection of healthy volunteers with malaria parasites under controlled conditions to study immune responses and/or test drug or vaccine efficacy. An empirical ethics study was embedded in a CHMI study at a Kenyan research programme to explore stakeholders' perceptions and experiences of deliberate infection and moral implications of these. Data for this qualitative study were collected through focus group discussions, in-depth interviews and non-participant observation. Sixty-nine participants were involved, including CHMI study volunteers, community representatives and research staff. Data were managed using QSR Nvivo 10 and analysed using an inductive-deductive approach, guided by ethics literature. CHMI volunteers had reasonable understanding of the study procedures. Decisions to join were influenced by study incentives, trust in the research institution, their assessment of associated burdens and motivation to support malaria vaccine development. However, deliberate malaria infection was a highly unusual research strategy for volunteers, community representatives and some study staff. Volunteers' experiences of physical, emotional and social burdens or harms were often greater than anticipated initially, and fluctuated over time, related to specific procedures and events. Although unlikely to deter volunteers' participation in similar studies in furture, we argue that the dissonance between level of understanding of the burdens involved and actual experiences are morally relevant in relation to community engagement, informed consent processes, and ongoing support for volunteers and research staff. We further argue that ethics oversight of CHMI studies should take account of these issues in deciding whether consent, engagement and the balance of benefits and harms are reasonable in a given context.
Collapse
Affiliation(s)
- Irene Jao
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Vicki Marsh
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineUniversity of OxfordOxfordUK
| | | | - Melissa Kapulu
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineUniversity of OxfordOxfordUK
| | | | - Sassy Molyneux
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Philip Bejon
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Dorcas Kamuya
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineUniversity of OxfordOxfordUK
| |
Collapse
|