1
|
Jamrozik E, Littler K, Meln I, Van Molle W, Morel S, Olesen OF, Rubbrecht M, Balasingam S, Neels P. Ethical approval for controlled human infectious model clinical trial protocols - A workshop report. Biologicals 2024; 85:101748. [PMID: 38350349 PMCID: PMC11004724 DOI: 10.1016/j.biologicals.2024.101748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/28/2024] [Indexed: 02/15/2024] Open
Abstract
Controlled Human Infectious Model studies (CHIM) involve deliberately exposing volunteers to pathogens. To discuss ethical issues related to CHIM, the European Vaccine Initiative and the International Alliance for Biological Standardization organised the workshop "Ethical Approval for CHIM Clinical Trial Protocols", which took place on May 30-31, 2023, in Brussels, Belgium. The event allowed CHIM researchers, regulators, ethics committee (EC) members, and ethicists to examine the ethical criteria for CHIM and the role(s) of CHIM in pharmaceutical development. The discussions led to several recommendations, including continued assurance that routine ethical requirements are met, assurance that participants are well-informed, and that preparation of study documents must be both ethically and scientifically sound from an early stage. Study applications must clearly state the rationale for the challenge compared to alternative study designs. ECs need to have clear guidance and procedures for evaluating social value and assessing third-party risks. Among other things, public trust in research requires minimisation of harm to healthy volunteers and third-party risk. Other important considerations include appropriate stakeholder engagement, public education, and access to health care for participants after the study.
Collapse
Affiliation(s)
- Euzebiusz Jamrozik
- The Ethox Centre & Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, United Kingdom
| | - Katherine Littler
- Health Ethics and Governance Unit, Research for Health Department, Science Division, World Health Organization, Geneva, Switzerland
| | - Irina Meln
- European Vaccine Initiative, Heidelberg, Germany
| | | | | | - Ole F Olesen
- European Vaccine Initiative, Heidelberg, Germany
| | | | | | - Pieter Neels
- International Alliance for Biological Standardization (IABS), Lyon, France.
| |
Collapse
|
2
|
Rosenheck M. Risk, benefit, and social value in Covid-19 human challenge studies: pandemic decision making in historical context. New Bioeth 2022; 40:188-213. [PMID: 35705839 PMCID: PMC9200217 DOI: 10.1007/s40592-022-00156-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/18/2022] [Accepted: 03/30/2022] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mabel Rosenheck
- Independent Scholar, 424 Morris Street, #2, 19148, PA, Philadelphia, USA.
| |
Collapse
|
3
|
Steuwer B, Jamrozik E, Eyal N. Prioritizing second-generation SARS-CoV-2 vaccines through low-dosage challenge studies. Int J Infect Dis 2021; 105:307-311. [PMID: 33592338 PMCID: PMC7881292 DOI: 10.1016/j.ijid.2021.02.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/25/2022] Open
Abstract
The design of human challenge studies balances scientific validity, efficiency and study safety. This Perspective explores some advantages and disadvantages of ‘low-dosage’ challenge studies, in the setting of testing second-generation vaccines against COVID-19. Compared with a conventional vaccine challenge, a low-dosage vaccine challenge would be more likely to start, and start earlier. A low-dosage challenge would also be less likely to rule out a vaccine candidate that would have potentially been effective, particularly in certain target uses. A key ethical advantage of a low-dosage challenge over a conventional challenge is that both it and its dose escalation process are safer for each participant. Low-dosage studies would require larger numbers of participants than conventional challenges, but this and other potential disadvantages are less serious than they may initially appear. Overall, low-dosage challenges should be considered for certain roles such as prioritizing between second-generation vaccines against COVID-19.
Collapse
Affiliation(s)
- Bastian Steuwer
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, NJ, USA; Rutgers Biomedical and Health Sciences, Newark, NJ, USA.
| | - Euzebiusz Jamrozik
- Ethox Centre and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK; Monash Bioethics Centre, Monash University, Melbourne, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.
| | - Nir Eyal
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, NJ, USA; Department of Philosophy, Rutgers University, New Brunswick, NJ, USA; Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA.
| |
Collapse
|
4
|
Eyal N, Lipsitch M. Testing SARS-CoV-2 vaccine efficacy through deliberate natural viral exposure. Clin Microbiol Infect 2021; 27:372-377. [PMID: 33421580 PMCID: PMC7787506 DOI: 10.1016/j.cmi.2020.12.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/19/2020] [Accepted: 12/24/2020] [Indexed: 12/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Nir Eyal
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, NJ, USA; Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA; Department of Philosophy, Rutgers University, New Brunswick, NJ, USA.
| | - Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
5
|
Jamrozik E, Heriot GS, Selgelid MJ. Coronavirus Human Infection Challenge Studies: Assessing Potential Benefits and Risks. J Bioeth Inq 2020; 17:709-715. [PMID: 32840856 PMCID: PMC7445815 DOI: 10.1007/s11673-020-10030-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/11/2020] [Indexed: 05/03/2023]
Abstract
Human infection challenge studies (HCS) have been proposed as a means to accelerate SARS-CoV2 vaccine development and thereby help to mitigate a prolonged global public health crisis. A key criterion for the ethical acceptability of SARS-CoV2 HCS is that potential benefits outweigh risks. Although the assessment of risks and benefits is meant to be a standard part of research ethics review, systematic comparisons are particularly important in the context of SARS-CoV2 HCS in light of the significant potential benefits and harms at stake as well as the need to preserve public trust in research and vaccines. In this paper we explore several considerations that should inform systematic assessment of SARS-CoV-2 HCS. First, we detail key potential benefits of SARS-CoV-2 HCS including, but not limited to, those related to the acceleration of vaccine development. Second, we identify where modelling is needed to inform risk-benefit (and thus ethical) assessments. Modelling will be particularly useful in (i) comparing potential benefits and risks of HCS with those of vaccine field trials under different epidemiological conditions and (ii) estimating marginal risks to HCS participants in light of the background probabilities of infection in their local community. We highlight interactions between public health policy and research priorities, including situations in which research ethics assessments may need to strike a balance between competing considerations.
Collapse
Affiliation(s)
- Euzebiusz Jamrozik
- Monash Bioethics Centre, Monash University, Melbourne, Australia.
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Melbourne, Australia.
| | - George S Heriot
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | |
Collapse
|
6
|
Jamrozik E, Littler K, Bull S, Emerson C, Kang G, Kapulu M, Rey E, Saenz C, Shah S, Smith PG, Upshur R, Weijer C, Selgelid MJ. Key criteria for the ethical acceptability of COVID-19 human challenge studies: Report of a WHO Working Group. Vaccine 2020; 39:633-640. [PMID: 33341309 PMCID: PMC7598752 DOI: 10.1016/j.vaccine.2020.10.075] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022]
Abstract
This report of the WHO Working Group for Guidance on Human Challenge Studies in COVID-19 outlines ethical standards for COVID-19 challenge studies. It includes eight Key Criteria related to scientific justification, risk-benefit assessment, consultation and engagement, co-ordination of research, site selection, participant selection, expert review, and informed consent. The document aims to provide comprehensive guidance to scientists, research ethics committees, funders, policymakers, and regulators in deliberations regarding SARS-CoV-2 challenge studies by outlining criteria that would need to be satisfied in order for such studies to be ethically acceptable.
Collapse
Affiliation(s)
- Euzebiusz Jamrozik
- The Ethox Centre & Wellcome Centre for Ethics and the Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK; Monash Bioethics Centre, Monash University, Clayton, Victoria, Australia; Royal Melbourne Hospital Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Katherine Littler
- Global Health Ethics Unit, World Health Organization, Geneva, Switzerland
| | - Susan Bull
- The Ethox Centre & Wellcome Centre for Ethics and the Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Claudia Emerson
- Institute on Ethics & Policy for Innovation, Department of Philosophy, McMaster University, Hamilton, Ontario, Canada
| | - Gagandeep Kang
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Melissa Kapulu
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elena Rey
- Centro Internacional de Entrenamiento e Investigaciones Médicas - CIDEIM. Cali, Colombia; Universidad Icesi. Cali, Colombia
| | - Carla Saenz
- Department of Health Systems and Services, Pan American Health Organization, USA
| | - Seema Shah
- Lurie Children's Hospital & Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Peter G Smith
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, Toronto, Canada
| | - Charles Weijer
- Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, Canada
| | - Michael J Selgelid
- Monash Bioethics Centre, Monash University, Clayton, Victoria, Australia
| | | |
Collapse
|
7
|
Calina D, Hartung T, Docea AO, Spandidos DA, Egorov AM, Shtilman MI, Carvalho F, Tsatsakis A. COVID-19 vaccines: ethical framework concerning human challenge studies. ACTA ACUST UNITED AC 2020; 28:807-12. [PMID: 32851596 DOI: 10.1007/s40199-020-00371-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/21/2020] [Indexed: 12/17/2022]
Abstract
Background The pandemic associated with the new SARS-CoV-2 coronavirus continues to spread worldwide. The most favorable epidemic control scenario, which provides long-term protection against COVID-19 outbreak, is the development and distribution of an effective and safe vaccine. The need to develop a new COVID-19 vaccine is pressing; however, it is likely to take a long time, possibly several years. This is due to the time required to demonstrate the safety and efficacy of the proposed vaccine. and the time required to manufacture and distribute millions of doses. Objectives To accelerate this development and associated safety testing, the deliberate infection of healthy volunteers has been suggested. The purpose of this short communication is to describe the ethical aspects of this type of testing, Results Deliberate infection of volunteers with a dangerous virus such as SARS-CoV-2 was initially considered unethical by researchers; but the current pandemic is so different from previous ones that these studies are considered ethical if certain criteria are met. Participants in human challenge studies must be relatively young, in good health and must receive the highest quality medical care, with frequent monitoring. Tests should also be performed with great caution and specialized medical supervision. Besides, the fact that obtaining vaccines faster through deliberate infection studies of healthy people has greater benefits than risks, has been demonstrated by obtaining other vaccines in other historical pandemics such as: smallpox, influenza, malaria, typhoid fever, Dengue fever and Zika. Conclusions One possibility to shorten the time required for the development of COVID-19 vaccines is to reduce clinical phases II and III by using human challenge studies through eliberate infection of healthy volunteers with SARS-CoV-2 after administration of the candidate vaccine. Accelerating the development of a COVID-19 vaccine even for a few weeks or months would have a great beneficial impact on public health by saving many lives. Graphical abstract ![]()
Collapse
|
8
|
Abstract
The increasing recent interest in human challenge studies or controlled human infection model studies for accelerating vaccine development has been driven by the recognition of the unique ability of these studies to contribute to the understanding of response to infection and the performance of vaccines. With streamlining of ethical processes, conduct and supervision and the availability of new investigative tools from immunophenotyping to glycobiology, the potential to derive valuable data to inform vaccine testing and development has never been greater. However, issues of availability and standardization of challenge strains, conduct of studies in disease endemic locations and the iteration between clinical and laboratory studies still need to be addressed to gain maximal value for vaccine development.
Collapse
Affiliation(s)
- Amrita Sekhar
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Gagandeep Kang
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India.
| |
Collapse
|