Recruiting young pre-symptomatic children for a clinical trial in type 1 diabetes: Insights from the Fr1da insulin intervention study

EDENT1FI Master Protocol for screening of presymptomatic early-stage type 1 diabetes in children and adolescents

INTRODUCTION

The identification of type 1 diabetes at an early presymptomatic stage has clinical benefits. These include a reduced risk of diabetic ketoacidosis (DKA) at the clinical manifestation of the disease and a significant reduction in clinical symptoms. The European action for the Diagnosis of Early Non-clinical Type 1 diabetes For disease Interception (EDENT1FI) represents a pioneering effort to advance early detection of type 1 diabetes through public health screening. With the EDENT1FI Master Protocol, the project aims to harmonise and standardise screening for early-stage type 1 diabetes and care.

METHODS AND ANALYSIS

Public health islet autoantibody screening is conducted in the Czech Republic, Denmark, Germany, Italy, Poland, Portugal, Sweden and the UK. Between November 2023 (start date) and October 2028 (planned end date), an estimated number of 200 000 children and adolescents aged 1-17 years are expected to be screened. Screening is performed in capillary blood, examining different islet autoantibodies (autoantibodies against insulin, glutamic acid decarboxylase-65, insulinoma-associated antigen-2 and/or zinc transporter-8). Positive screening results undergo confirmation through a second antibody method. A second (venous) blood sample is requested if at least two autoantibodies are detected, to confirm the autoantibody status. Children and adolescents with confirmed two or more autoantibodies are invited to metabolic staging (oral glucose tolerance test, haemoglobin A1c (HbA1c), random glucose, optionally continuous glucose monitoring); an educational programme and recommendations for monitoring are provided. The feasibility and acceptability of screening are evaluated by feedback questionnaires. Pseudonymised data is collated in the EDENT1FI Registry. Study outcomes include country-specific screening rates, prevalences of stage 1 and stage 2 type 1 diabetes, number in EDENT1FI Registry, proportion with DKA and symptoms at clinical diagnosis and median HbA1c.

ETHICS AND DISSEMINATION

Following the EDENT1FI Master Protocol, site-specific protocols are developed and approved by local ethics committees (Technical University of Munich, Medical Faculty, Nr. 70/14; Medizinische Hochschule Hannover, Nr. 9588_BO_S_2021; Technische Universität Dresden, Nr. BO-EK-356082020; Center for Sundhed Region Hovedstaden, Nr. H-22053116; Swedish Ethical Review Authority, Nr. 2023-00312-01; National Health Service Health Research Authority and Health Care Research Wales, IRAS (Integrated Research Application System) project ID 309252; Italian National Institute of Health, National ethics committee for clinical trials of public research bodies (EPR) and other national public institutions, Prot. PRE BIO CE Nr. 0059835; Charles University in Prague, Ethics Committee for Multi-Centric Clinical Trials of the University Hopital Motol and 2nd Faculty of Medicine, Nr. 1271/23; Bioethics Committee at the Medical University of Warsaw, Nr. 21/2024 and KB/6/R/2024; Associação Protectora dos Diabéticos de Portugal, Nr. 211/2024). Results are disseminated through peer-reviewed journals and conference presentations and will be shared openly.

Parental Perceptions of Early Childhood In-Home Research with Monitoring: A Qualitative Study

OBJECTIVE

To explore perceptions, concerns, and enthusiasm from a diverse group of parents regarding early childhood research that involves home monitoring technologies for collecting environmental exposure data.

STUDY DESIGN

A diverse group of new and expecting parents participated in semi-structured interviews. A single interviewer conducted all sessions and introduced a hypothetical longitudinal early childhood research study, which included novel home monitoring approaches: 1) wearable devices, 2) audio monitoring, and 3) environmental sampling. Interviews were audio-recorded, transcribed, and coded. Qualitative description guided the study, and a constant comparative approach was used to identify themes from transcripts.

RESULTS

Twenty-four interviews were completed. Emerging themes included 1) Ready and Willing to Participate; 2) Helping Others, Helping Ourselves: Motivation for Participation; 3) Trust and Transparency: Understanding the "What?" and the "Why?"; 4) Data Privacy and Security: "What If It Gets into the Wrong Hands?"; 5) It's a Lot to Juggle: Logistical Realities. Perceptions were similar across racial, ethnic, and socioeconomic groups. Perceptions were positive, and participants desired additional information about study feasibility and purpose. Many had concerns related to wearable device safety and data privacy; a trusting relationship with the research team was a priority.

CONCLUSION

Participants had positive sentiments regarding longitudinal observational studies involving pregnancy and infancy yet expressed concerns about safety, privacy, feasibility, and transparency. These findings can inform future early childhood research study design to ensure protocols are transparent, inclusive, and appealing to parents.

Motivations for and against Participation in Neonatal Research: Insights from Interviews of Diverse Parents Approached for Neonatal Research in the United States

OBJECTIVE

To describe parents' motivations for and against participation in neonatal research, including the views of those who declined participation.

STUDY DESIGN

We performed 44 semi-structured, qualitative interviews of parents approached for neonatal research. Here we describe their motivations for and against participation.

RESULTS

Altruism was an important reason parents chose to participate. Some hoped participation in research would benefit their infant. Burdens of participation to the family, such as transportation to follow up (distinct from risks/burdens to the infant), were often deciding factors among those who declined participation. Perceived risks to the infant were reasons against participation, but parents often did not differentiate between baseline risks and incremental risk of study participation. Concerns regarding their infant being treated like a "guinea pig" were common among those who declined. Finally, historical abuses and institutional racism were reported as important concerns by some research decliners from minoritized populations.

CONCLUSIONS

Within a diverse sample of parents approached to enroll their infant in neonatal research, motivations for and against participation emerged, which may be targets of future interventions. These motivations included reasons for participation which we may hope to encourage, such as altruism. They also included reasons against participation, which we may hope to, as feasible, eliminate, mitigate, or at least acknowledge. These findings can help clinical trialists, regulators, and funders attempting to improve neonatal research recruitment processes.

Parental Views of Facilitators and Barriers to Research Participation: Systematic Review

BACKGROUND AND OBJECTIVES

Low enrollment within pediatric research increases the cost of research, decreases generalizability, and threatens to exacerbate existing health disparities. To assess barriers and facilitators to pediatric research participation and evaluate differences by enrollment status.

METHODS

Data Sources include PubMed, Embase, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. Study selection include peer reviewed articles that contained information related to facilitators and barriers to the parental decision whether to enroll their child in research and included the views of parents who declined. We extracted barriers and facilitators to research, enrollment status, and study characteristics, including study design, quality, and patient population.

RESULTS

Seventy articles were included for analysis. Facilitators of participation included: benefits, trust, support of research, informational and consent related, and relational issues. Common facilitators within those categories included health benefit to child (N = 39), altruism (N = 30), and the importance of research (N = 26). Barriers to participation included: study-related concerns, burdens of participation, lack of trust, general research concerns, informational and consent related, and relational issues. Common barriers within those categories included risks to child (N = 46), burdens of participation (N = 35), and the stress of the decision (N = 29). We had a limited ability to directly compare by enrollment status and no ability to analyze interactions between facilitators and barriers. We only included studies written in English.

CONCLUSIONS

This review identified key facilitators and barriers to research participation in pediatrics. The findings from this review may guide researchers aiming to create interventions to improve the parental experience of recruitment for pediatric studies and to optimize enrollment rates.

EarLy Surveillance for Autoimmune diabetes: protocol for a qualitative study of general population and stakeholder perspectives on screening for type 1 diabetes in the UK (ELSA 1)

OBJECTIVE

Type 1 diabetes (T1D) is the most common form of diabetes in children, accounting for 96% of cases, with 29 000 children affected in the UK. Studies have recently identified immunotherapies that safely delay the development of T1D for at least 3 years, and further therapies are in development. General population screening programs in other countries can now accurately identify children with presymptomatic T1D who can be entered into prevention studies. The UK does not have such a system in place. We aim to explore whether parents and children in the UK would want to be part of such a program of testing for T1D in the general population, how they would want to be informed and participate in such a program, and how any barriers to recruitment and participation can be addressed. Additionally, the views of stakeholders who would be involved in the testing program will be collected and analyzed.

RESEARCH DESIGN AND METHODS

We will interview parents/guardians and children aged 3-13 years about their views on screening for T1D. We will recruit purposefully to ensure representation across ethnicities and socioeconomic groups. Interviews will be transcribed, analyzed and used to inform iterative co-design work with additional families to address any issues raised. Similar qualitative work will be undertaken with professional stakeholders who would be involved in implementing any future screening program. Where possible, all aspects of this study will be performed remotely by phone or online to minimize infection risk.

CONCLUSIONS

This qualitative study will provide the first insights into acceptability of testing and monitoring for T1D in the general population from the perspective of families and stakeholders in the UK. Co-design work will help establish the barriers and identify strategies to mitigate and overcome these issues, as an important step towards consideration of national testing for T1D.

Typ-1-Diabetes: Früherkennung und Ansätze zur Prävention

Die Inzidenz des Typ-1-Diabetes nimmt zu, besonders bei Kleinkindern. Die Erkrankung kann effektiv bereits im asymptomatischen Frühstadium der Inselautoimmunität erkannt werden. Ein Screening ist nicht nur für Risikofamilien, sondern auch in bevölkerungsweiten Studien wie Fr1da^plus in Bayern möglich und sinnvoll. Komplikationen bei der Manifestation kann durch eine frühe Diagnosestellung vorgebeugt werden. Die Teilnahme an experimentellen Interventionen zur Verzögerung der Stadienprogression ist möglich. Unterschiedliche Ansätze zur sekundären Prävention werden verfolgt. Mit dem monoklonalen Antikörper Teplizumab gelang es erstmals, bei Patienten in Stadium 2 den Zeitpunkt der Manifestation hinauszuzögern. Säuglinge mit einem hohen Risiko für die Entwicklung eines Typ-1-Diabetes können durch genetisches Screening identifiziert werden. Bei der Primärprävention wird u. a. das Ziel verfolgt, das Entstehen der Autoimmunreaktion zu verhindern. In der POInT-Studie sollen bei Risikokindern durch frühe orale Exposition zu Insulin die Immuntoleranz verbessert und das Auftreten eines Frühstadiums verzögert oder verhindert werden.

Anknüpfend an das Leitthemenheft Früherkennung und präventive Behandlung des Typ-1-Diabetes dieser Zeitschrift von 2018 werden in diesem Beitrag ausgewählte Entwicklungen als Update der letzten 2 Jahre vorgestellt.

Prevention of Type 1 Diabetes: Past Experiences and Future Opportunities

Type 1 diabetes (T1D) results from autoimmune destruction of insulin-producing beta-cells in the pancreas, caused by the interplay of genetic and environmental factors. Despite the introduction of advanced technologies for diabetes management, most patients fail to achieve target glycemic control, and T1D still has a high burden of long-term end-organ complications. Over several decades, multiple clinical trials have attempted to find prevention for T1D in at-risk individuals or to stabilize, ultimately reverse, the disease in those with T1D. To date, T1D remains yet incurable condition; however, recently improved understanding of the natural history of the disease may lead to new strategies to preserve or improve beta-cell function in those at increased risk and T1D patients. This publication aims to provide an overview of past experiences and recent findings in the prevention of T1D.