Clinical research and trials in developing countries

Clinical stroke research in resource limited settings: Tips and hints

Background Most stroke research is conducted in high income countries, yet most stroke occurs in low- and middle-income countries. There is an urgent need to build stroke research capacity in low- and middle-income countries. Aims To review the global health literature on how to improve research capacity in low- and middle-income countries, provide additional data from the recently completed ATTEND Trial and provide examples from our own experience. Summary of review The main themes from our literature review were: manpower and workload, research training, research question and methodology and research funding. The literature and our own experience emphasized the importance of local stakeholders to ensure that the research was appropriate, that there were robust local ethics and regulatory processes, and research was conducted by trained personnel. Research training opportunities can be developed locally, or internationally, with many international schemes available to help support new researchers from low- and middle-income country settings. International collaboration can successfully leverage funding from high income countries that not only generate data for the local country, but also provide new data appropriate to high income countries. Conclusions Building stroke research capacity in low- and middle-income countries will be vital in improving global health given the huge burden of stroke in these countries.

Vaccine development and trials in low and lower-middle income countries: Key issues, advances and future opportunities

Over the past 10 years there has been an increase in the number of vaccine clinical studies conducted in resource limited countries. These include vaccine trials for diseases such as malaria and dengue fever which are endemic to many low and lower-middle income countries. Concurrent with the increase in the number of trials, has been the increase and improvement in local infrastructure to enable the appropriate conduct and oversight of trials in these settings, including strengthening of local scientific capabilities, ethical and regulatory oversight. While significant advances have been made, there remain gaps to be addressed including strengthening pharmacovigilance in these regions. There are also opportunities to establish novel collaborations to address diseases specific to these populations including strengthening local manufacturers, new ways to engage established large pharmaceutical companies and leveraging established global infrastructure and pathways to develop innovative products beyond vaccines.

Improving patient follow-up in developing regions

BACKGROUND

Cleft surgery follow-up in developing regions is challenging. This study evaluated rates, costs, and satisfaction of 2 follow-up programs at the Guwahati Comprehensive Cleft Care Centre (GC4) in Assam, India.

METHODS

For this study, 10,582 postoperative visits were analyzed from May 2011 to November 2013. A questionnaire was administered to subsets of follow-up patients at both locations. Costs were calculated.

RESULTS

Eighty-five percent of patients had follow-up at GC4, and 15% were seen in the patients' local districts. One hundred ninety-five questionnaires were completed (122 at GC4, 73 in local districts). Patients with local follow-up had fewer accompanying family members (mean, 1.95 vs 0.99; P = 0.00), fewer days off work (mean, 1.84 vs 1.15; P = 0.19), less lost income (Indian rupees 367 vs 143, P = 0.00), and lower direct costs (mean Rs, 911 vs 299; P = 0.00). The financial burden of local follow-up was significantly lower (P = 0.003). No significant differences were seen for convenience, likelihood of attending follow-up, or satisfaction. Follow-ups increased after revising programs from a mean of 139 monthly visits (follow-up to surgery ratio of 0.722) to a mean of 363 visits (ratio of 1.57). The center's mean cost for local follow-up was Rs 303 per patient, whereas the estimated costs would have been Rs 1100 for follow-up at the center.

CONCLUSIONS

This study demonstrates potential improvements in costs and outcomes by changing the model of care. Despite significant follow-up challenges, much progress can be achieved through process changes and outreach follow-up programs. The results have important applications across the developing world.

Geographic location of antineoplastic agent clinical trials conducted in developed and developing countries

BACKGROUND

For the past 30 years, clinical trials have been increasingly conducted in developing countries. These trials allow results to be generalizable to similar populations, offer access to treatment for patients in need, and examine diseases with differing patterns than developed countries. However, the characteristics of antineoplastic clinical trials and recent trends in study location in developing countries are unknown.

OBJECTIVE

The primary objective was to evaluate the location, study phase, results, funding source, and ethics board approval of randomized double-blind controlled clinical trials evaluating antineoplastic agents by geographic location.

SETTING

This is a retrospective evaluation of studies indexed in the PubMed/Medline database published in 2007-2011.

METHODS

Clinical trials were identified with the search terms "drug therapy", "antineoplastic agents" and "double blind method" and limited to English language, human, and randomized controlled trial.

MAIN OUTCOME MEASURE

We assessed frequencies of characteristics of antineoplastic clinical trials.

RESULTS

A total of 116 trials evaluating antineoplastic drug therapy were identified. The highest frequency of clinical trials were published in 2009 (27.6 %), followed by 2011 (23.3 %), 2010 (20.7 %), 2007 (14.6 %), and 2008 (13.8 %). According to geographic region, 33.8 % were conducted in North America, followed by Europe (31.5 %) and Asia (16.2 %). Based on economic status, the majority (77.8 %) of clinical trial locations were in developed countries and 22.2 % were in developing countries. No significant difference was found between study locations in developed countries and developing countries from 2007 to 2011. When comparing studies conducted in developing and developed countries, there was no difference in the year published, study phase, results, funding source, or investigational review board approval and informed consent. Studies conducted in developed countries were significantly more likely to be single country studies (p = 0.02) and published in a journal with an impact factor greater than 10 (p = 0.013) when compared to studies conducted in developing countries.

CONCLUSIONS

Based on economic status, there was no significant location change of antineoplastic clinical trials from 2007 to 2011. Clinical trials conducted in developing countries were more often multi-country studies and published in journals with lower impact factors.

Randomized controlled trials of HIV/AIDS prevention and treatment in Africa: results from the Cochrane HIV/AIDS Specialized Register

Introduction

To effectively address HIV/AIDS in Africa, evidence on preventing new infections and providing effective treatment is needed. Ideally, decisions on which interventions are effective should be based on evidence from randomized controlled trials (RCTs). Our previous research described African RCTs of HIV/AIDS reported between 1987 and 2003. This study updates that analysis with RCTs published between 2004 and 2008.

Objectives

To describe RCTs of HIV/AIDS conducted in Africa and reported between 2004 and 2008.

Methods

We searched the Cochrane HIV/AIDS Specialized Register in September 2009. Two researchers independently evaluated studies for inclusion and extracted data using standardized forms. Details included location of trials, interventions, methodological quality, location of principal investigators and funders.

Results

Our search identified 834 RCTs, with 68 conducted in Africa. Forty-three assessed prevention-interventions and 25 treatment-interventions. Fifteen of the 43 prevention RCTs focused on preventing mother-to-child HIV transmission. Thirteen of the 25 treatment trials focused on opportunistic infections. Trials were conducted in 16 countries with most in South Africa (20), Zambia (12) and Zimbabwe (9). The median sample size was 628 (range 33-9645). Methods used for the generation of the allocation sequence and allocation concealment were adequate in 38 and 32 trials, respectively, and 58 reports included a CONSORT recommended flow diagram. Twenty-nine principal investigators resided in the United States of America (USA) and 18 were from African countries. Trials were co-funded by different agencies with most of the funding obtained from USA governmental and non-governmental agencies. Nineteen pharmaceutical companies provided partial funding to 15 RCTs and African agencies co-funded 17 RCTs. Ethical approval was reported in 65 trials and informed consent in 61 trials.

Conclusion

Prevention trials dominate the trial landscape in Africa. Of note, few principal investigators and funders are from Africa. These findings mirror our previous work and continue to indicate a need for strengthening trial research capacity in Africa.

Geographical representativeness of published and ongoing randomized controlled trials. The example of: Tobacco consumption and HIV infection

Background

The challenge for evidence-based healthcare is to reduce mortality and the burden of diseases. This study aimed to compare where research is conducted to where research is needed for 2 public health priorities: tobacco consumption and HIV infection.

Methods

We identified randomized controlled trials (RCTs) included in Cochrane systematic reviews published between 1997 and 2007 and registered ongoing RCTs identified in January 2009 through the World Health Organization's International Clinical Trials Registry Platform (WHO-ICTRP) evaluating interventions aimed at reducing or stopping tobacco use and treating or preventing HIV infection. We used the WHO and World Bank reports to classify the countries by income level, as well as map the global burden of disease and mortality attributable to tobacco use and HIV infection to the countries where the trials performed.

Results

We evaluated 740 RCTs included in systematic reviews and 346 ongoing RCTs. For tobacco use, 4% of RCTs included in systematic reviews and 2% of ongoing trials were performed in low- and middle-income countries, even though these countries represented 70% of the mortality related to tobacco use. For HIV infection, 31% of RCTs included in systematic reviews and 33% of ongoing trials were performed in low- and middle-income countries, even though these countries represented 99% of the mortality related to HIV infection.

Conclusions

Our results highlight an important underrepresentation of low- and middle-income countries in currently available evidence (RCTs included in systematic reviews) and awaiting evidence (registered ongoing RCTs) for reducing or stopping tobacco use and treating or preventing HIV infection.

Conduct of clinical trials in developing countries: a perspective

PURPOSE OF REVIEW

To provide a broad perspective of contextual factors involved in the conduct of clinical trials in developing countries.

RECENT FINDINGS

The quantity of research in developing countries continues to be inadequate, with clinical trials comprising a small fraction of the total research output. Most trials done in developing countries tend to be designed in developed countries and led by investigators in those nations. The main challenges in the conduct of trials in developing countries stem from the vulnerability of the populations due to illiteracy, poverty, limited research infrastructure, lack of sufficient numbers of experienced investigators and trained support personnel, and fragmented healthcare system.

SUMMARY

There is a need to formulate and conduct trials to test treatments that are context-specific and socially relevant. With careful planning in advance and shared partnership among sponsors, host-country research practitioners, government agencies and the community, many of the challenges facing clinical trial research can be overcome over the medium to long term. This would enable conformity to contemporary guidelines in both letter and spirit and hopefully develop research questions addressing the needs of developing countries.

Noncommunicable diseases and injuries in Latin America and the Caribbean: time for action

The region is in a privileged position to quickly translate investment in health research into practice, argue Perel and colleagues.

Randomised controlled trials in Africa of HIV and AIDS: descriptive study and spatial distribution

OBJECTIVES

To identify and describe randomised controlled trials on HIV and AIDS conducted in Africa and to map their spatial distribution using exact geographic coordinates.

DESIGN

Construction and analysis of a database of trials conducted wholly or partly in Africa and reported before 2004.

DATA SOURCES

CENTRAL, Medline, Embase, and LILACS.

RESULTS

Our comprehensive search yielded 284 distinct records that were potentially eligible for inclusion in the database. Of these, 150 articles reported on 77 eligible trials published or reported from 1987 to 2003. Seven trials were identified exclusively from the CENTRAL database. Trials were conducted in 18 of 48 countries in sub-Saharan Africa. None were conducted in north Africa. Only 19 had a principal investigator located in an African country. Forty two trials assessed prevention and 35 assessed treatment. Most studies were funded by government agencies outside Africa (n = 43), with the pharmaceutical industry providing partial support to 16 of these. The pharmaceutical industry provided full or partial support to a further 18 trials. Only 43 trials reported conducting a power calculation for determining sample size. There was no mention of ethical approval or informed consent in 19 and 17 trials, respectively.

CONCLUSION

The relatively small number of HIV/AIDS trials conducted in Africa is not commensurate with the burden of disease. Geographical mapping as an adjunct to prospective trial registration is a useful tool for researchers and decision makers to track existing and future trials.