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Gupta A, Hughes MD, Garcia-Prats AJ, McIntire K, Hesseling AC. Inclusion of key populations in clinical trials of new antituberculosis treatments: Current barriers and recommendations for pregnant and lactating women, children, and HIV-infected persons. PLoS Med 2019; 16:e1002882. [PMID: 31415563 PMCID: PMC6695091 DOI: 10.1371/journal.pmed.1002882] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Amita Gupta and colleagues discuss priorities in clinical research aimed at improving tuberculosis prevention and treatment in pregnant women, children, and people with HIV.
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Affiliation(s)
- Amita Gupta
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michael D. Hughes
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Anthony J. Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Katherine McIntire
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Wada K, Evans MK, de Vrijer B, Nisker J. Clinical Research With Pregnant Women: Perspectives of Pregnant Women, Health Care Providers, and Researchers. QUALITATIVE HEALTH RESEARCH 2018; 28:2033-2047. [PMID: 29865990 DOI: 10.1177/1049732318773724] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Limited clinical research with pregnant women has resulted in insufficient data to promote evidence-informed prenatal care. Charmaz's constructivist grounded theory methodology was used to explore how research with pregnant women would be determined ethically acceptable from the perspectives of pregnant women, health care providers, and researchers in reproductive sciences. Semistructured interviews were conducted with a purposive sample of 12 pregnant women, 10 health care providers, and nine reproductive science researchers. All three groups suggested the importance of informed consent and that permissible risk would be very limited and complex, being dependent on the personal benefits and risks of each particular study. Pregnant women, clinicians, and researchers shared concerns about the well-being of the woman and her fetus, and expressed a dilemma between promoting research for evidence-informed prenatal care while securing the safety in the course of research participation.
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Affiliation(s)
- Kyoko Wada
- 1 St. Joseph's Health Centre Toronto, Toronto, Ontario, Canada
| | | | | | - Jeff Nisker
- 2 Western University, London, Ontario, Canada
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Gupta A, Mathad JS, Abdel-Rahman SM, Albano JD, Botgros R, Brown V, Browning RS, Dawson L, Dooley KE, Gnanashanmugam D, Grinsztejn B, Hernandez-Diaz S, Jean-Philippe P, Kim P, Lyerly AD, Mirochnick M, Mofenson LM, Montepiedra G, Piper J, Sahin L, Savic R, Smith B, Spiegel H, Swaminathan S, Watts DH, White A. Toward Earlier Inclusion of Pregnant and Postpartum Women in Tuberculosis Drug Trials: Consensus Statements From an International Expert Panel. Clin Infect Dis 2016; 62:761-769. [PMID: 26658057 PMCID: PMC4772846 DOI: 10.1093/cid/civ991] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/20/2015] [Indexed: 12/29/2022] Open
Abstract
Tuberculosis is a major cause of morbidity and mortality in women of childbearing age (15-44 years). Despite increased tuberculosis risk during pregnancy, optimal clinical treatment remains unclear: safety, tolerability, and pharmacokinetic data for many tuberculosis drugs are lacking, and trials of promising new tuberculosis drugs exclude pregnant women. To advance inclusion of pregnant and postpartum women in tuberculosis drug trials, the US National Institutes of Health convened an international expert panel. Discussions generated consensus statements (>75% agreement among panelists) identifying high-priority research areas during pregnancy, including: (1) preventing progression of latent tuberculosis infection, especially in women coinfected with human immunodeficiency virus; (2) evaluating new agents/regimens for treatment of multidrug-resistant tuberculosis; and (3) evaluating safety, tolerability and pharmacokinetics of tuberculosis drugs already in use during pregnancy and postpartum. Incorporating pregnant women into clinical trials would extend evidence-based tuberculosis prevention and treatment standards to this special population.
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Affiliation(s)
- Amita Gupta
- Division of Infectious Diseases and Department of International Health, Johns Hopkins University
| | - Jyoti S Mathad
- Division of Infectious Diseases, Center for Global Health Weill Cornell Medical College, New York, New York
| | - Susan M Abdel-Rahman
- Division of Clinical Pharmacology, Children's Mercy Hospital, Kansas City, Missouri
| | | | - Radu Botgros
- European Medicines Agency, London, United Kingdom
| | - Vikki Brown
- Women's Health and Medical Affairs, INC Research, Raleigh
| | - Renee S Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Liza Dawson
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore
| | | | - Beatriz Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| | | | - Patrick Jean-Philippe
- Department of Health and Human Services, HJF-DAIDS, a division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, contractor to the National Institute of Allergy and Infectious Diseases
| | - Peter Kim
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Anne D Lyerly
- University of North Carolina at Chapel Hill Center for Bioethics and Department of Social Medicine
| | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Massachusetts
| | - Lynne M Mofenson
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
| | - Grace Montepiedra
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health
| | - Jeanna Piper
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Leyla Sahin
- Division of Pediatric and Maternal Health, FDA Office of New Drugs, Silver Spring, Maryland
| | - Radojka Savic
- Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy and Medicine, University of California San Francisco
| | - Betsy Smith
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Hans Spiegel
- Department of Health and Human Services, HJF-DAIDS, a division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, contractor to the National Institute of Allergy and Infectious Diseases
| | | | - D Heather Watts
- Office of the Global AIDS Coordinator, US Department of State, Washington D.C
| | - Amina White
- Department of Bioethics, NIH Clinical Center, Bethesda
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White A. Accelerating the paradigm shift toward inclusion of pregnant women in drug research: Ethical and regulatory considerations. Semin Perinatol 2015; 39:537-40. [PMID: 26385413 DOI: 10.1053/j.semperi.2015.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although there has been long-standing reluctance to include pregnant women as clinical trial participants, increasing recognition of profound gaps in research on the safety and efficacy of drugs often prescribed to pregnant women calls into question the practice of routinely excluding them. This article presents compelling reasons for including pregnant women in clinical research, highlights certain regulatory barriers to the inclusion of pregnant women, and proposes that professional societies with expertise in obstetrics and maternal-fetal medicine can be instrumental in hastening the paradigm shift from the systematic exclusion of pregnant women in research to a one of responsible and fair inclusion.
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Affiliation(s)
- Amina White
- National Institutes of Health, Department of Bioethics, Clinical Center, 10 Center Dr, 1C118, Bethesda, MD 20892-1156.
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McIlleron H, Abdel-Rahman S, Dave JA, Blockman M, Owen A. Special populations and pharmacogenetic issues in tuberculosis drug development and clinical research. J Infect Dis 2015; 211 Suppl 3:S115-25. [PMID: 26009615 PMCID: PMC4551115 DOI: 10.1093/infdis/jiu600] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Special populations, including children and pregnant women, have been neglected in tuberculosis drug development. Patients in developing countries are inadequately represented in pharmacology research, and postmarketing pharmacovigilance activities tend to be rudimentary in these settings. There is an ethical imperative to generate evidence at an early stage to support optimal treatment in these populations and in populations with common comorbid conditions, such as diabetes and human immunodeficiency virus (HIV) infection. This article highlights the research needed to support equitable access to new antituberculosis regimens. Efficient and opportunistic pharmacokinetic study designs, typically using sparse sampling and population analysis methods, can facilitate optimal dose selection for children and pregnant women. Formulations suitable for children should be developed early and used in pharmacokinetic studies to guide dose selection. Drug-drug interactions between commonly coprescribed medications also need to be evaluated, and when these are significant, alternative approaches should be sought. A potent rifamycin-sparing regimen could revolutionize the treatment of adults and children requiring a protease inhibitor as part of antiretroviral treatment regimens for HIV infection. A sufficiently wide formulary of drugs should be developed for those with contraindications to the standard approaches. Because genetic variations may influence an individual's response to tuberculosis treatment, depending on the population being treated, it is important that samples be collected and stored for pharmacogenetic study in future clinical trials.
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Affiliation(s)
| | - Susan Abdel-Rahman
- Division of Clinical Pharmacology, Children's Mercy Hospital
- Department of Pediatrics, School of Medicine, University of Missouri–Kansas City,Missouri
| | - Joel Alex Dave
- Division of Diabetic Medicine and Endocrinology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, South Africa
| | | | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, United Kingdom
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Schonfeld T. The perils of protection: vulnerability and women in clinical research. THEORETICAL MEDICINE AND BIOETHICS 2013; 34:189-206. [PMID: 23686729 DOI: 10.1007/s11017-013-9258-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Subpart B of 45 Code of Federal Regulations Part 46 (CFR) identifies the criteria according to which research involving pregnant women, human fetuses, and neonates can be conducted ethically in the United States. As such, pregnant women and fetuses fall into a category requiring "additional protections," often referred to as "vulnerable populations." The CFR does not define vulnerability, but merely gives examples of vulnerable groups by pointing to different categories of potential research subjects needing additional protections. In this paper, I assess critically the role of this categorization of pregnant women involved in research as "vulnerable," both as separate entities and in combination with the fetuses they carry. In particular, I do three things: (1) demonstrate that pregnant women qua pregnancy are either not "vulnerable" according to any meaningful definition of that term or that such vulnerability is irrelevant to her status as a research participant; (2) argue that while a fetus may be vulnerable in terms of dependency, this categorization does not equate to the vulnerability of the pregnant woman; and (3) suggest that any vulnerability that appends to women is precisely the result of federal regulations and dubious public perceptions about pregnant women. I conclude by demonstrating how this erroneous characterization of pregnant women as "vulnerable" and its associated protections have not only impeded vital research for pregnant women and their fetuses, but have also negatively affected the inclusion of all women in clinical research.
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Affiliation(s)
- Toby Schonfeld
- Center for Ethics, Emory University, 1531 Dickey Drive, 1st Floor, Atlanta, GA 30322, USA.
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Brandon AR. Ethical Barriers to Perinatal Mental Health Research and Evidence-Based Treatment: An Empirical Study. ACTA ACUST UNITED AC 2011. [DOI: 10.1080/21507716.2011.561517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Goodrum LA, Hankins GDV, Jermain D, Chanaud CM. Conference report: complex clinical, legal, and ethical issues of pregnant and postpartum women as subjects in clinical trials. J Womens Health (Larchmt) 2004; 12:857-67. [PMID: 14670165 DOI: 10.1089/154099903770948087] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Office of the Vice President for Research and School of Nursing of the University of Texas Medical Branch convened a multidisciplinary conference to address the national problem of underrepresentation of pregnant women in clinical trials. METHODS Conference participants reviewed pertinent issues through lectures and panel discussions. RESULTS More funded studies are needed to specifically examine pharmacokinetic, physiological, and pharmacological interactions in the pregnant woman. Legal, ethical, and financial issues need to be better delineated, and more focus is needed on specific diseases with particular import for pregnant women and their fetuses. CONCLUSIONS This paper provides a report on the conference and the powerful consensus statements developed by the participants.
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Affiliation(s)
- Linda A Goodrum
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0587, USA.
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Kylmä J, Vehviläinen-Julkunen K, Lähdevirta J. Ethical considerations in a grounded theory study on the dynamics of hope in HIV-positive adults and their significant others. Nurs Ethics 1999; 6:224-39. [PMID: 10455658 DOI: 10.1177/096973309900600305] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this article is to describe and reflect ethical challenges in a grounded theory study on the dynamics of hope in HIV-positive adults and their significant others. It concentrates on the justification of a research problem, sensitive research and the relationship between the researcher and the participants in data collection. The basis of ethically sound nursing research on the dynamics of hope in these two vulnerable groups lies in the relationship between the researchers and the participant. However, it is also obvious that the content, the process, the methods used and the ethics of the study cannot be divorced from this relationship. In conducting grounded theory research on the dynamics of hope in this research population, the researcher has to consider the surrounding world, that is, the reality in which these people live in hope or despair.
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Affiliation(s)
- J Kylmä
- Department of Nursing Science, University of Kuopio, Finland
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