Access to COVID-19 Vaccines in High-, Middle-, and Low-Income Countries Hosting Clinical Trials

Global Disparities in Access to Vaccine Clinical Trials: A Review of the Literature

Vaccines are an effective tool to reduce the disease burden from infectious diseases on a population, infrastructural, and individual level. Before vaccines can be administered to populations at large, they must go through rigorous testing in the form of clinical trials. While vaccine trials can be used to assess the efficacy of interventions on a local populace as well as target local endemic diseases, most clinical trials are sponsored and conducted by companies in high-income countries (HICs). This can lead to vaccines that are not optimized for low- and middle-income countries (LMICs) and that often neglect to address diseases specific to the local population. This narrative review aims to explore the factors leading to discrepancies in the execution of and access to vaccine trials between HICs and LMICs, thus guiding future efforts in confronting them. This review was written using the literature sourced from the PubMed database and supplemented with articles from Google Scholar along with grey literature. Several themes are highlighted including poorly defined regulatory and ethical guidelines, staff shortages, lack of research infrastructure, and logistical barriers. We discuss how these challenges have affected vaccine development in various capacities through case examples of SARS-CoV-2, poliovirus, and malaria. Many challenges remain in equitable vaccine clinical trial development and implementation. Facilitating the implementation of locally sponsored vaccine clinical trials in LMICs may be one avenue to address these challenges. In doing so, LMICs can become active stakeholders in the health of their citizens by addressing endemic diseases, tailoring vaccine specifications based on local needs, and implementing wide-scale vaccine access and delivery.

Last-mile delivery increases vaccine uptake in Sierra Leone

Less than 30% of people in Africa received a dose of the COVID-19 vaccine even 18 months after vaccine development1. Here, motivated by the observation that residents of remote, rural areas of Sierra Leone faced severe access difficulties2, we conducted an intervention with last-mile delivery of doses and health professionals to the most inaccessible areas, along with community mobilization. A cluster randomized controlled trial in 150 communities showed that this intervention with mobile vaccination teams increased the immunization rate by about 26 percentage points within 48-72 h. Moreover, auxiliary populations visited our community vaccination points, which more than doubled the number of inoculations administered. The additional people vaccinated per intervention site translated to an implementation cost of US $33 per person vaccinated. Transportation to reach remote villages accounted for a large share of total intervention costs. Therefore, bundling multiple maternal and child health interventions in the same visit would further reduce costs per person treated. Current research on vaccine delivery maintains a large focus on individual behavioural issues such as hesitancy. Our study demonstrates that prioritizing mobile services to overcome access difficulties faced by remote populations in developing countries can generate increased returns in terms of uptake of health services3.

Ensuring Ethical Postprogression Therapy for Patients in Randomized Trial Control Arms

@Eddie_Cliff et al explore the scientific & ethical reasons why patients randomized to the control arm of trials should 'crossover' to receive the investigational therapy if their disease progresses

Coronavirus Disease 2019 Convalescent Plasma Outpatient Therapy to Prevent Outpatient Hospitalization: A Meta-Analysis of Individual Participant Data From 5 Randomized Trials

BACKGROUND

Outpatient monoclonal antibodies are no longer effective and antiviral treatments for coronavirus disease 2019 (COVID-19) disease remain largely unavailable in many countries worldwide. Although treatment with COVID-19 convalescent plasma (CCP) is promising, clinical trials among outpatients have shown mixed results.

METHODS

We conducted an individual participant data meta-analysis from outpatient trials to assess the overall risk reduction for all-cause hospitalizations by day 28 in transfused participants. Relevant trials were identified by searching Medline, Embase, medRxiv, World Health Organization COVID-19 Research Database, Cochrane Library, and Web of Science from January 2020 to September 2022.

RESULTS

Five included studies from 4 countries enrolled and transfused 2620 adult patients. Comorbidities were present in 1795 (69%). The virus neutralizing antibody dilutional titer levels ranged from 8 to 14 580 in diverse assays. One hundred sixty of 1315 (12.2%) control patients were hospitalized, versus 111 of 1305 (8.5%) CCP-treated patients, yielding a 3.7% (95% confidence interval [CI], 1.3%-6.0%; P = .001) absolute risk reduction and 30.1% relative risk reduction for all-cause hospitalization. The hospitalization reduction was greatest in those with both early transfusion and high titer with a 7.6% absolute risk reduction (95% CI, 4.0%-11.1%; P = .0001) accompanied by at 51.4% relative risk reduction. No significant reduction in hospitalization was seen with treatment >5 days after symptom onset or in those receiving CCP with antibody titers below the median titer.

CONCLUSIONS

Among outpatients with COVID-19, treatment with CCP reduced the rate of all-cause hospitalization and may be most effective when given within 5 days of symptom onset and when antibody titer is higher.

Dynamic antibody response in SARS-CoV-2 infected patients and COVID-19 vaccine recipients alongside vaccine effectiveness in comorbid and multimorbid groups

Objectives

Underlying medical conditions are critical risk factors for COVID-19 susceptibility and its rapid clinical manifestation. Therefore, the preexisting burden of non-communicable diseases (NCDs) makes the preparedness for COVID-19 more challenging for low- and middle-income countries (LMICs). These countries have relied on vaccination campaigns as an effective measure to tackle COVID-19. In this study, we investigated the impact of comorbidities on humoral antibody responses against the specific receptor-binding domain (RBD) of SARS-CoV2.

Methods

A total of 1005 patients were selected for the SARS-CoV-2 specific immunoglobulin G (IgG1, IgG2, IgG3, and IgG4 subclasses) and total antibody (TAb) tests (IgG and IgM), of which 912 serum samples were ultimately selected based on the specimen cutoff analyte value. Patients with multimorbidity (N = 60) were recruited for follow-up studies from the initial cohort, and their immune response (IgG and TAb) was measured at multiple time points after the second dose of vaccination. Siemens Dimension Vista SARS-CoV-2 IgG (CV2G) and SARS-CoV-2 TAb assay (CV2T) were used to carry out the serology test.

Results

Out of a total of 912 participants, vaccinated individuals (N = 711) had detectable antibody responses up to 7-8 months. The synergistic effect of natural infection and vaccine response was also studied. Participants with breakthrough infections (N = 49) mounted a greater antibody response compared to individuals with normal vaccination response (N = 397) and those who were naturally infected before receiving the second dose of vaccine (N = 132). Investigation of the impact of comorbidities revealed that diabetes mellitus (DM) (N = 117) and kidney disease (N = 50) had a significant negative impact on the decline of the humoral antibody response against SARS-CoV-2. IgG and TAb declined more rapidly in diabetic and kidney disease patients compared to the other four comorbid groups. Follow-up studies demonstrated that antibody response rapidly declined within 4 months after receiving the second dose.

Conclusion

The generalized immunization schedule for COVID-19 needs to be adjusted for high-risk comorbid groups, and a booster dose must be administered early within 4 months after receiving the second dose.

Improving social justice in observational studies: protocol for the development of a global and Indigenous STROBE-equity reporting guideline

BACKGROUND

Addressing persistent and pervasive health inequities is a global moral imperative, which has been highlighted and magnified by the societal and health impacts of the COVID-19 pandemic. Observational studies can aid our understanding of the impact of health and structural oppression based on the intersection of gender, race, ethnicity, age and other factors, as they frequently collect this data. However, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline, does not provide guidance related to reporting of health equity. The goal of this project is to develop a STROBE-Equity reporting guideline extension.

METHODS

We assembled a diverse team across multiple domains, including gender, age, ethnicity, Indigenous background, disciplines, geographies, lived experience of health inequity and decision-making organizations. Using an inclusive, integrated knowledge translation approach, we will implement a five-phase plan which will include: (1) assessing the reporting of health equity in published observational studies, (2) seeking wide international feedback on items to improve reporting of health equity, (3) establishing consensus amongst knowledge users and researchers, (4) evaluating in partnership with Indigenous contributors the relevance to Indigenous peoples who have globally experienced the oppressive legacy of colonization, and (5) widely disseminating and seeking endorsement from relevant knowledge users. We will seek input from external collaborators using social media, mailing lists and other communication channels.

DISCUSSION

Achieving global imperatives such as the Sustainable Development Goals (e.g., SDG 10 Reduced inequalities, SDG 3 Good health and wellbeing) requires advancing health equity in research. The implementation of the STROBE-Equity guidelines will enable a better awareness and understanding of health inequities through better reporting. We will broadly disseminate the reporting guideline with tools to enable adoption and use by journal editors, authors, and funding agencies, using diverse strategies tailored to specific audiences.

COVID-19 Vaccination Perception and Acceptance Among Female Medical and Nursing Students at Al-Azhar University, Egypt

Background

There are still many concerns related to various types of COVID-19 vaccines, which may result in individuals' hesitancy presenting a problem for public health authorities to achieve coverage for population immunity. As trustworthy health-care workers, medical and nursing students' perception towards COVID-19 vaccines may greatly influence the future population's uptake of vaccines; however, studies related to the vaccine acceptance rates among them are limited.

Objective

To identify the perception of medical and nursing students toward COVID-19 vaccines and the factors acting either as motivators or barriers to be vaccinated.

Methods

A cross-sectional comparative study was conducted on 500 undergraduate students aged ≥18 years from medical and nursing faculties. Data were collected via a semi-structured self-administered questionnaire that consisted of questions on general characteristics of the participants and source of information about the vaccine. Also, it includes items assessing the perception and acceptance of COVID-19 vaccines. Descriptive statistics, chi-squared, t-test and multiple logistic regressions were performed using SPSS version 22.

Results

Positive perception was detected among more than half of overall students. Although medical students had significant higher positive perception toward COVID-19 vaccines than nursing students (54.9% vs. 41.1%, p <0.05), they were more hesitant to get vaccinated than nursing students (25.7% vs. 19.6%, p >0.05). While, medical students had a higher intention to encourage family members or friends to get vaccinated than did nursing students (47.7% vs .43.8%, respectively) (p >0:05). Furthermore, participants were more likely to accept vaccination if they reported higher levels of positive perception especially for vaccine safety and increasing recovery rate.

Conclusion

Academic medical and nursing leaders should consider female students' vaccine concerns, and future efforts are needed to reduce their hesitancy and raise awareness about vaccinations that may eventually improve perception and acceptance of COVID-19 vaccines.

COVID-19 Convalescent Plasma Outpatient Therapy to Prevent Outpatient Hospitalization: A Meta-analysis of Individual Participant Data From Five Randomized Trials

Background

Monoclonal antibody and antiviral treatments for COVID-19 disease remain largely unavailable worldwide, and existing monoclonal antibodies may be less active against circulating omicron variants. Although treatment with COVID-19 convalescent plasma (CCP) is promising, randomized clinical trials (RCTs) among outpatients have shown mixed results.

Methods

We conducted an individual participant data meta-analysis from all outpatient CCP RCTs to assess the overall risk reduction for all-cause hospitalizations by day 28 in all participants who had transfusion initiated. Relevant trials were identified by searching MEDLINE, Embase, MedRxiv, WHO, Cochrane Library, and Web of Science from January 2020 to September 2022.

Results

Five included studies from four countries enrolled and transfused 2,620 adult patients. Comorbidities were present in 1,795 (69%). The anti-Spike or virus neutralizing antibody titer range across all trials was broad. 160 (12.2%) of 1315 control patients were hospitalized, versus 111 (8.5%) of 1305 CCP-treated patients, yielding a 3.7% (95%CI: 1.3%-6.0%; p=.001) ARR and 30.1% RRR for all-cause hospitalization. The effect size was greatest in those with both early transfusion and high titer with a 7.6% ARR (95%CI: 4.0%-11.1%; p=.0001) accompanied by at 51.4% RRR. No significant reduction in hospitalization was seen with treatment > 5 days after symptom onset or in those receiving CCP with antibody titers below the median titer.

Conclusions

Among outpatients with COVID-19, treatment with CCP reduced the rate of all-cause hospitalization. CCP may be most effective when given within 5 days of symptom onset and when antibody titer is higher.

Key Points

While the outpatient COVID-19 randomized controlled trial meta-analysis indicated heterogeneity in participant risk factors and convalescent plasma, the combined CCP efficacy for reducing hospitalization was significant, improving with transfusion within 5 days of symptom onset and high antibody neutralization levels.

Participant Recruitment From Low- and Middle-Income Countries for Pivotal Trials of Drugs Approved by the U.S. Food and Drug Administration : A Cross-Sectional Analysis

BACKGROUND

Many participants in clinical trials supporting U.S. Food and Drug Administration (FDA) drug approvals are recruited from outside the United States, including from low- and middle-income countries (LMICs). Where participants are recruited for pivotal trials has implications for ethical research conduct and generalizability.

OBJECTIVE

To describe LMIC recruitment for pivotal trials of newly approved drugs for cancer, neurologic disease, and cardiovascular disease.

DESIGN

Cross-sectional analysis.

SETTING

Pivotal trials of new cancer, cardiovascular, and neurologic drugs approved from 2012 to 2019 matched to ClinicalTrials.gov, FDA records, and publications.

MEASUREMENTS

Host countries and available per country enrollments were extracted. The primary end point was the proportion of pivotal trials enrolling participants in LMICs. The secondary end point was the proportion of pivotal trial participants contributed by LMICs for each indication area.

RESULTS

Data were obtained from 66 new drugs and 144 pivotal clinical trials. All cardiovascular approvals (12 drugs, 29 trials) and neurologic approvals (26 drugs, 54 trials) were analyzed, as well as a random sample of cancer approvals (28 of 85 drugs [33%]) matched to their pivotal trials (61 of 210 trials [29%]). Among the trials, 56% in cancer, 79% in cardiovascular disease, and 56% in neurology recruited from an LMIC. For multicountry trials, country-level enrollment figures were not available for 71 trials (55%). For those reporting per country enrollment, the percentage of participants recruited from LMICs was 8% for cancer trials, 36% for cardiovascular trials, and 17% for neurology trials.

LIMITATIONS

The study was limited to FDA-approved drugs in 3 areas, including a sample of cancer drugs. Pivotal trials of nonapproved drugs or drugs for other indications were not captured.

CONCLUSION

Most pivotal trials for FDA-approved drugs recruit from LMICs. Publications and FDA documents generally do not provide country-level data on recruitment.

PRIMARY FUNDING SOURCE

None.

Factors influencing the COVID-19 pandemic situation in Indonesia, Malaysia and Taiwan in 2021

Objectives

The COVID-19 pandemic started over 2 years ago and spread rapidly throughout the world. The total number of cases and deaths is still increasing and the situation remains active across the globe. In the Asian region, COVID-19 vaccination began in early 2021; however, the COVID-19 situation remains uncertain. This study aims to compare the factors that influenced the COVID-19 pandemic situation in three countries in Asia (namely, Indonesia, Malaysia and Taiwan) throughout 2021.

Study design

This ecological study utilises the data from the 'Our World in Data' website.

Methods

In this study, the COVID-19 pandemic situation in each country is described by looking at the average daily number of deaths and cases per million population throughout 2021. A paired t-test was conducted to compare the significance of differences in the pandemic situation between 2020 and 2021. In addition, the COVID-19 vaccination profiles throughout 2021 were investigated. A multiple linear regression analysis was then performed to develop models to explain the factors influencing the COVID-19 pandemic situation in these three countries.

Results

The COVID-19 pandemic situation in Indonesia, Malaysia and Taiwan in 2021 is significantly different from 2020. Malaysia had the highest COVID-19 vaccination coverage (79.4%), followed by Taiwan (78.5%) and Indonesia (58.3%). This study found that the following three factors consistently influenced the number of deaths and cases in these three countries [1]: positivity rate [2]; number of tests per 1000 population; and [3] number of tests per case.

Conclusions

Although the severity of the COVID-19 pandemic situations in Indonesia, Malaysia and Taiwan was different, it is significantly influenced by the quality and quantity of COVID-19 testing and screening, in addition to the vaccination programmes and restriction policies implemented in each country. As a result of the ability of the SARS-CoV-2 virus to mutate, it is recommended that each country strengthen their comprehensive approach to have an effective and efficient coping strategy for the COVID-19 pandemic.

Trend of Polymer Research Related to COVID-19 Pandemic: Bibliometric Analysis

Polymeric materials are used for personal protective equipment (PPE), which is mandatory for clinicians to use when handling coronavirus disease 2019 (COVID-19) patients. The development of diagnostic tools and vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is also dependent on polymer technology. This current report aims to provide readers with the trend of polymer research regarding the COVID-19 pandemic, by employing bibliometric analysis. A literature search on the Scopus database (31 January 2022) was carried out using predetermined terms. Using Scopus database features, the publications were filtered based on the year of publication (2020–2022), types of articles (original research and review), and language (English). The metadata were extracted in a CSV (.csv) file, to be later used in VOSviewer software. The data were presented in a table, graph, and network visualization. As many as 512 publications were included, consisting of 66.4% original research articles and 33.6% review articles. Most of the publications were written by authors whose affiliation was in the United States (n = 118, 23%) and covering the Materials Science subject area (n = 142, 27.7%). The Ministry of Education of China was the most productive organization, publishing 11 articles. The National Science Foundation of China was the top funding source, supporting 45 publications. Heinz C. Schröder was the most prolific author, publishing nine articles. Science of the Total Environment was the leading journal publishing the included studies. The trend of polymer technology related to COVID-19 mostly covers PPE and waste-management themes. The use of polymer technology as a delivery system for the anti-SARS-CoV-2 and COVID-19 vaccine is also among the frequently researched areas. We encourage more research in the field of polymer technology be carried out, to overcome the global pandemic.

COVID-19 Vaccine Acceptance Rate and Its Factors among Healthcare Students: A Systematic Review with Meta-Analysis

Healthcare students are clinicians-in-training likely to come into contact with COVID-19 as much as other frontline healthcare professionals. It is therefore necessary to prioritize vaccinations for this group. We conducted a global systematic assessment of COVID-19 vaccine acceptance rates and related factors among healthcare students using the PubMed, Scopus, and Web of Science databases and keyword searches in March of 2022. We found 1779 articles with relevant information and 31 articles that matched our inclusion criteria. We performed a random-effects meta-analysis and quality assessment using the eight-item Joanna Briggs Institute Critical Appraisal test for cross-sectional studies. A total of 30,272 individuals from 16 countries were studied. Most of the studies were carried out in the U.S. (n = 6), China (n = 5), Poland (n = 5), India (n = 2), Italy (n = 2), and Israel (n = 2). The prevalence of the COVID-19 vaccine acceptance rate was 68.8% (95% confidence interval [CI]: 60.8-76.3, I2 = 100%), and the prevalence of the vaccine hesitancy rate was 25.8% (95% CI: 18.5-33.8, I2 = 99%). In country-specific analyses, Romania showed the highest acceptance rate (88.0%, 95% CI: 44.5-100%), while Iraq showed the lowest acceptance rate (66.2%, 95% CI: 35.5-90.8%). In time-trend analyses, we found that acceptance rates among healthcare students decreased over time. Students concerned about potentially serious side effects of the vaccine were less willing to accept the vaccine. National and international interventions should be adopted to reduce COVID-19 vaccination hesitancy rates among these important frontline workers.

The balancing role of distribution speed against varying efficacy levels of COVID-19 vaccines under variants

During a pandemic, vaccination plays an important role in reducing the infection spread or adverse outcomes such as hospitalizations and deaths. However, a vaccine’s overall public health impact depends not only on its initial efficacy, but also its efficacy against emerging variants and ease and speed of distribution. For example, mutations in SARS-CoV-2 raised concerns about diminishing vaccine effectiveness against COVID-19 caused by particular variants. Furthermore, due to supply-chain challenges, the accessibility and distribution of the vaccines have been hindered in many regions, especially in low-income countries, while the second or third wave of the COVID-19 pandemic has occurred due to the variants. Hence, we evaluated the interactions between the speed of distribution and efficacy against infection of multiple vaccines when variants emerge by utilizing a Susceptible-Infected-Recovered-Deceased model and assessing the level of infection attack rate. Our results show that speed is a key factor to a successful immunization strategy to control the pandemic even when the emerging variants may reduce the efficacy of a vaccine. Understanding the interactions between speed and efficacy and distributing vaccines that are available as quickly as possible are crucial to eradicate the pandemic before new variants spread.

The Importance of Vaccination in the Context of the COVID-19 Pandemic: A Brief Update Regarding the Use of Vaccines

The COVID-19 pandemic has led the world to undertake the largest vaccination campaign in human history. In record time, unprecedented scientific and governmental efforts have resulted in the acquisition of immunizers utilizing different technologies (nucleotide acids, viral vectors, inactivated and protein-based vaccines). Currently, 33 vaccines have already been approved by regulatory agencies in different countries, and more than 10 billion doses have been administered worldwide. Despite the undeniable impact of vaccination on the control of the pandemic, the recurrent emergence of new variants of interest has raised new challenges. The recent viral mutations precede new outbreaks that rapidly spread at global proportions. In addition, reducing protective efficacy rates have been observed among the main authorized vaccines. Besides these issues, several other crucial issues for the appropriate combatting of the pandemic remain uncertain or under investigation. Particularly noteworthy issues include the use of vaccine-boosting strategies to increase protection; concerns related to the long-term safety of vaccines, child immunization reliability and uncommon adverse events; the persistence of the virus in society; and the transition from a pandemic to an endemic state. In this review, we describe the updated scenario regarding SARS-CoV-2 variants and COVID-19 vaccines. In addition, we outline current discussions covering COVID-19 vaccine safety and efficacy, and the future pandemic perspectives.

Ethical considerations in international clinical trial site selection

New medicines and vaccines are predominantly tested in high-income countries. However, as the COVID-19 pandemic highlighted, the populations who can benefit from these interventions are not limited to these wealthier regions. One-third of novel Food and Drug Administration approved drugs, sponsored by large companies, treat infectious diseases like tuberculosis and HIV, which disproportionately affect low-income and middle-income countries (LMICs). The medicines for non-communicable diseases (NCDs) are also relevant to LMIC health needs, as over three-quarters of deaths from NCDs occur in LMICs. There are concerns clinical trial data may not extrapolate across geographical regions, as product effectiveness can vary substantially by region. The pentavalent rotavirus vaccine, for example, had markedly lower efficacy in LMICs. Efficacy variations have also been found for other vaccines and drugs. We argue there are strong ethical arguments for remedying some of this uneven distribution of clinical trial sites by geography and income. Chief among them, is that these disparities can impede equitable access to the benefits of clinical research, such as representation in the evidence base generated to guide prescribing and use of medicines and vaccines. We suggest trial site locations should be made more transparent and for later stage trials their selection should be informed by the global distribution of disease burden targeted by an experimental product. Countries with high prevalence, incidence, severity or infection transmission rates for targeted diseases should have real opportunities to engage in and enrol their populations in trials for novel medicines and vaccines.