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Sigfrid L, Maskell K, Bannister PG, Ismail SA, Collinson S, Regmi S, Blackmore C, Harriss E, Longuere KS, Gobat N, Horby P, Clarke M, Carson G. Addressing challenges for clinical research responses to emerging epidemics and pandemics: a scoping review. BMC Med 2020; 18:190. [PMID: 32586391 PMCID: PMC7315698 DOI: 10.1186/s12916-020-01624-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Major infectious disease outbreaks are a constant threat to human health. Clinical research responses to outbreaks generate evidence to improve outcomes and outbreak control. Experiences from previous epidemics have identified multiple challenges to undertaking timely clinical research responses. This scoping review is a systematic appraisal of political, economic, administrative, regulatory, logistical, ethical and social (PEARLES) challenges to clinical research responses to emergency epidemics and solutions identified to address these. METHODS A scoping review. We searched six databases (MEDLINE, Embase, Global Health, PsycINFO, Scopus and Epistemonikos) for articles published from 2008 to July 2018. We included publications reporting PEARLES challenges to clinical research responses to emerging epidemics and pandemics and solutions identified to address these. Two reviewers screened articles for inclusion, extracted and analysed the data. RESULTS Of 2678 articles screened, 76 were included. Most presented data relating to the 2014-2016 Ebola virus outbreak or the H1N1 outbreak in 2009. The articles related to clinical research responses in Africa (n = 37), Europe (n = 8), North America (n = 5), Latin America and the Caribbean (n = 3) and Asia (n = 1) and/or globally (n = 22). A wide range of solutions to PEARLES challenges was presented, including a need to strengthen global collaborations and coordination at all levels and develop pre-approved protocols and equitable frameworks, protocols and standards for emergencies. Clinical trial networks and expedited funding and approvals were some solutions implemented. National ownership and community engagement from the outset were a key enabler for delivery. Despite the wide range of recommended solutions, none had been formally evaluated. CONCLUSIONS To strengthen global preparedness and response to the COVID-19 pandemic and future epidemics, identified solutions for rapid clinical research deployment, delivery, and dissemination must be implemented. Improvements are urgently needed to strengthen collaborations, funding mechanisms, global and national research capacity and capability, targeting regions vulnerable to epidemics and pandemics. Solutions need to be flexible to allow timely adaptations to context, and research led by governments of affected regions. Research communities globally need to evaluate their activities and incorporate lessons learnt to refine and rehearse collaborative outbreak response plans in between epidemics.
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Affiliation(s)
- Louise Sigfrid
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Oxford, OX3 7LG, UK.
| | - Katherine Maskell
- Deparment for Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Peter G Bannister
- Deparment for Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Sharif A Ismail
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Shelui Collinson
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Sadie Regmi
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Claire Blackmore
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Eli Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Kajsa-Stina Longuere
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Oxford, OX3 7LG, UK
| | - Nina Gobat
- Nuffield Dep of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Horby
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Oxford, OX3 7LG, UK
| | - Mike Clarke
- Evidence Aid, Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Gail Carson
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Oxford, OX3 7LG, UK
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2
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Bruno W, Haar RJ. A systematic literature review of the ethics of conducting research in the humanitarian setting. Confl Health 2020; 14:27. [PMID: 32489418 PMCID: PMC7245798 DOI: 10.1186/s13031-020-00282-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 05/13/2020] [Indexed: 11/17/2022] Open
Abstract
Background Research around humanitarian crises, aid delivery, and the impact of these crises on health and well-being has expanded dramatically. Ethical issues around these topics have recently received more attention. We conducted a systematic literature review to synthesize the lessons learned regarding the ethics of research in humanitarian crises. Methods We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines to identify articles regarding the ethics of research in humanitarian contexts between January 1, 1997 and September 1, 2019. We analyzed the articles to extract key themes and develop an agenda for future research. Results We identified 52 articles that matched our inclusion criteria. We categorized the article data into five categories of analysis: 32 were expert statements, 18 were case studies, 11 contained original research, eight were literature reviews and three were book chapters. All included articles were published in English. Using a step-wise qualitative analysis, we identified 10 major themes that encompassed these concepts and points. These major themes were: ethics review process (21 articles, [40.38%]); community engagement (15 articles [28.85%]); the dual imperative, or necessity that research be both academically sound and policy driven, clinical trials in the humanitarian setting (13 articles for each, [25.0%)]; informed consent (10 articles [19.23%]); cultural considerations (6 articles, [11.54%]); risks to researchers (5 articles, [9.62%]); child participation (4 articles [7.69%]); and finally mental health, and data ownership (2 articles for each [3.85%]). Conclusions Interest in the ethics of studying humanitarian crises has been dramatically increasing in recent years. While key concepts within all research settings such as beneficence, justice and respect for persons are crucially relevant, there are considerations unique to the humanitarian context. The particular vulnerabilities of conflict-affected populations, the contextual challenges of working in humanitarian settings, and the need for ensuring strong community engagement at all levels make this area of research particularly challenging. Humanitarian crises are prevalent throughout the globe, and studying them with the utmost ethical forethought is critical to maintaining sound research principles and ethical standards.
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Affiliation(s)
- William Bruno
- Department of Emergency Medicine, University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - Rohini J Haar
- Division of Epidemiology and Biostatistics, School of Public Health, Research Fellow, Human Rights Center, School of Law, University of California at Berkeley, Berkeley, USA
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Ippolito G, Vairo F. Ebola: Basic and Social Science, Public Health, and Policy at the Crossroads. J Infect Dis 2020; 221:687-689. [PMID: 30942883 DOI: 10.1093/infdis/jiz108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Giuseppe Ippolito
- National Institute for Infectious Diseases "Lazzaro Spallanzani"-Istituto di ricovero e cura a carattere scientifico - IRCCS, Rome, Italy
| | - Francesco Vairo
- National Institute for Infectious Diseases "Lazzaro Spallanzani"-Istituto di ricovero e cura a carattere scientifico - IRCCS, Rome, Italy
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4
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Lanini S, Portella G, Vairo F, Kobinger GP, Pesenti A, Langer M, Kabia S, Brogiato G, Amone J, Castilletti C, Miccio R, Capobianchi MR, Strada G, Zumla A, Di Caro A, Ippolito G. Relationship Between Viremia and Specific Organ Damage in Ebola Patients: A Cohort Study. Clin Infect Dis 2019; 66:36-44. [PMID: 29020340 DOI: 10.1093/cid/cix704] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/07/2017] [Indexed: 12/18/2022] Open
Abstract
Background Pathogenesis of Ebola virus disease remains poorly understood. We used concomitant determination of routine laboratory biomarkers and Ebola viremia to explore the potential role of viral replication in specific organ damage. Methods We recruited patients with detectable Ebola viremia admitted to the EMERGENCY Organizzazione Non Governativa Organizzazione Non Lucrativa di Utilità Sociale (ONG ONLUS) Ebola Treatment Center in Sierra Leone. Repeated measure of Ebola viremia, alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), activated prothrombin time (aPTT), international normalized ratio (INR), creatinine, and blood urea nitrogen (BUN) were recorded. Patients were followed up from admission until death or discharge. Results One hundred patients (49 survivors and 51 nonsurvivors) were included in the analysis. Unadjusted analysis to compare survivors and nonsurvivors provided evidence that all biomarkers were significantly above the normal range and that the extent of these abnormalities was generally higher in nonsurvivors than in survivors. Multivariable mixed-effects models provided strong evidence for a biological gradient (suggestive of a direct role in organ damage) between the viremia levels and either ALT, AST, CPK LDH, aPTT, and INR. In contrast, no direct linear association was found between viremia and either creatinine, BUN, or bilirubin. Conclusions This study provides evidence to support that Ebola virus may have a direct role in muscular damage and imbalance of the coagulation system. We did not find strong evidence suggestive of a direct role of Ebola virus in kidney damage. The role of the virus in liver damage remains unclear, but our evidence suggests that acute severe liver injury is not a typical feature of Ebola virus disease.
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Affiliation(s)
- Simone Lanini
- National Institute for Infectious Diseases "Lazzaro Spallanzani," Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,International Public Health Crisis Group, Milan, Italy
| | | | - Francesco Vairo
- National Institute for Infectious Diseases "Lazzaro Spallanzani," Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,International Public Health Crisis Group, Milan, Italy
| | - Gary P Kobinger
- International Public Health Crisis Group, Milan, Italy.,Research Centre on Infectious Diseases, Faculty of Medicine, Université Laval, Québec, Canada
| | - Antonio Pesenti
- EMERGENCY, Milan, Italy.,Department of Anesthesia, Critical Care Medicine and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda-Ospedale Maggiore Policlinico, and Department of Pathophysiology and Transplantation, University of Milan
| | - Martin Langer
- EMERGENCY, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, and Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Soccoh Kabia
- Connaught Hospital Tower Hill, Freetown, Sierra Leone
| | | | - Jackson Amone
- Department of Clinical Services, Ministry of Health, Kampala, Uganda
| | - Concetta Castilletti
- National Institute for Infectious Diseases "Lazzaro Spallanzani," Istituto di Ricovero e Cura a Carattere Scientifico , Rome, Italy
| | | | - Maria Rosaria Capobianchi
- National Institute for Infectious Diseases "Lazzaro Spallanzani," Istituto di Ricovero e Cura a Carattere Scientifico , Rome, Italy
| | - Gino Strada
- International Public Health Crisis Group, Milan, Italy.,EMERGENCY, Milan, Italy
| | - Alimuddin Zumla
- International Public Health Crisis Group, Milan, Italy.,Division of Infection and Immunity, University College London, and National Institute for Health Research Biomedical Research Centre at University College London Hospitals NHS Foundation Trust, United Kingdom
| | - Antonino Di Caro
- National Institute for Infectious Diseases "Lazzaro Spallanzani," Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,International Public Health Crisis Group, Milan, Italy
| | - Giuseppe Ippolito
- National Institute for Infectious Diseases "Lazzaro Spallanzani," Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,International Public Health Crisis Group, Milan, Italy
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5
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Lanini S, Portella G, Vairo F, Di Caro A, Kobinger G, Zumla A, Ippolito G. Reply to Reisler et al. Clin Infect Dis 2019; 66:1480-1481. [PMID: 29272344 DOI: 10.1093/cid/cix1026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Simone Lanini
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome
| | | | - Francesco Vairo
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome
| | - Antonino Di Caro
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome
| | - Gary Kobinger
- Research Centre on Infectious Diseases, Faculty of Medicine, Université Laval, Québec, Canada
| | - Alimmudin Zumla
- Division of Infection and Immunity, University College London (UCL), United Kingdom
- National Institute for Health Research Biomedical Research Centre at UCL Hospitals NHS Foundation Trust, United Kingdom
| | - Giuseppe Ippolito
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome
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6
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Lanini S, Ioannidis JPA, Vairo F, Pletschette M, Portella G, Di Bari V, Mammone A, Pisapia R, Merler S, Nguhuni B, Langer M, Di Caro A, Edwards SJL, Petrosillo N, Zumla A, Ippolito G. Non-inferiority versus superiority trial design for new antibiotics in an era of high antimicrobial resistance: the case for post-marketing, adaptive randomised controlled trials. THE LANCET. INFECTIOUS DISEASES 2019; 19:e444-e451. [PMID: 31451421 DOI: 10.1016/s1473-3099(19)30284-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 05/11/2019] [Accepted: 05/23/2019] [Indexed: 12/25/2022]
Abstract
Antimicrobial resistance is one of the most important threats to global health security. A range of Gram-negative bacteria associated with high morbidity and mortality are now resistant to almost all available antibiotics. In this context of urgency to develop novel drugs, new antibiotics for multidrug-resistant Gram-negative bacteria (namely, ceftazidime-avibactam, plazomicin, and meropenem-vaborbactam) have been approved by regulatory authorities based on non-inferiority trials that provided no direct evidence of their efficacy against multidrug-resistant bacteria such as Enterobacteriaceae spp, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia cepacia, and Acinetobacter baumannii. The use of non-inferiority and superiority trials, and selection of appropriate and optimal study designs, remains a major challenge in the development, registration, and post-marketing implementation of new antibiotics. Using an example of the development process of ceftazidime-avibactam, we propose a strategy for a new research framework based on adaptive randomised clinical trials. The operational research strategy has the aim of assessing the efficacy of new antibiotics in special groups of patients, such as those infected with multidrug-resistant bacteria, who were not included in earlier phase studies, and for whom it is important to establish an appropriate standard of care.
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Affiliation(s)
- Simone Lanini
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - John P A Ioannidis
- Department of Medicine, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA; Departments of Health Research and Policy and of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA
| | - Francesco Vairo
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Michel Pletschette
- Department of Tropical and Infectious Diseases, Medical Center of the University of Munich, Munich, Germany
| | | | - Virginia Di Bari
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Alessia Mammone
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Raffaella Pisapia
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Stefano Merler
- Center for Information Technology, Bruno Kessler Foundation, Trento, Italy
| | - Boniface Nguhuni
- Division of Health, President's Office Regional Administration and Local Government (PORALG), Dodoma, Tanzania
| | | | - Antonino Di Caro
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | | | - Nicola Petrosillo
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, London, UK; NIHR Biomedical Research Centre, University College London Hospitals, London, UK
| | - Giuseppe Ippolito
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy.
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7
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Saxena A, Horby P, Amuasi J, Aagaard N, Köhler J, Gooshki ES, Denis E, Reis AA, Ravinetto R. Ethics preparedness: facilitating ethics review during outbreaks - recommendations from an expert panel. BMC Med Ethics 2019; 20:29. [PMID: 31060618 PMCID: PMC6501283 DOI: 10.1186/s12910-019-0366-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 04/17/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Ensuring that countries have adequate research capacities is essential for an effective and efficient response to infectious disease outbreaks. The need for ethical principles and values embodied in international research ethics guidelines to be upheld during public health emergencies is widely recognized. Public health officials, researchers and other concerned stakeholders also have to carefully balance time and resources allocated to immediate treatment and control activities, with an approach that integrates research as part of the outbreak response. Under such circumstances, research "ethics preparedness" constitutes an important foundation for an effective response to infectious disease outbreaks and other health emergencies. MAIN TEXT A two-day workshop was convened in March 2018 by the World Health Organisation Global Health Ethics Team and the African coaLition for Epidemic Research, Response and Training, with representatives of National Ethics Committees, to identify practical processes and procedures related to ethics review preparedness. The workshop considered five areas where work might be undertaken to facilitate rapid and sound ethics review: preparing national ethics committees for outbreak response; pre-review of protocols; multi-country review; coordination between national ethics committees and other key stakeholders; data and benefit sharing; and export of samples to third countries. In this paper, we present the recommendations that resulted from the workshop. In particular, the participants recommended that Ethics Committees would develop a formal national standard operating procedure for emergency response ethical review; that there is a need to clarify the terminology and expectations of pre-review of generic protocols and agree upon specific terminology; that there is a need to explore mechanisms for multi-country emergency ethical consultation, and to establish procedures for communication between national ethics committees and other oversight bodies and public health authorities. In addition, it was suggested that ethics committees should request from researchers, at a minimum, a preliminary data sharing and sample sharing plan that outlines the benefit to the population from which data and samples are to be drawn. This should be followed in due time by a full plan. CONCLUSION It is hoped that the national ethics committees, supported by the WHO, relevant collaborative research consortia and external funding agencies, will work towards bringing these recommendations into practice, for supporting the conduct of effective research during outbreaks.
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Affiliation(s)
- Abha Saxena
- Global Health Ethics Team, World Health Organization, Geneva, Switzerland
- University of Geneva, Geneva, Switzerland
| | - Peter Horby
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - John Amuasi
- Kumasi Center for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Nic Aagaard
- Ethics Committees, Ministry of Health, Wellington, New Zealand
| | - Johannes Köhler
- Global Health Ethics Team, World Health Organization, Geneva, Switzerland
| | - Ehsan Shamsi Gooshki
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Emmanuelle Denis
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Andreas A Reis
- Global Health Ethics Team, World Health Organization, Geneva, Switzerland
| | - Raffaella Ravinetto
- Institutional Review Board, Institute of Tropical Medicine, Antwerp, Belgium.
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Abstract
The clinical management of Ebola created a significant challenge during the outbreak in West Africa, due to the paucity of previous research conducted into the optimum treatment regimen. That left many centres, to some extent, having to ‘work out’ best practice as they went along, and attempting to conduct real time prospective research. Médecins Sans Frontières (MSF) [1] were the only organization to have provided relatively in depth practical guidance prior to the outbreak and this manual was the basis of further planning between the WHO, national Ministry of Health and Sanitation in Sierra Leone, and other relevant stakeholders. Additionally, guidance changed over the epidemic as experience grew. This chapter will describe four key areas in the management of Ebola in West Africa. Firstly, it outlines the most recent WHO guidance; secondly, it looks back at how Ebola was managed in differing low and high resource settings; thirdly it outlines possible and optimal options for managing complications, paying particular attention to some of the controversies faced; fourthly it describes recent and ongoing studies into potential novel therapies that may shape future practice.
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Affiliation(s)
- Marta Lado
- King’s Sierra Leone Partnership, Freetown, Sierra Leone
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10
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Bradbury N, Nguyen-Van-Tam J, Lim WS. Clinicians' attitude towards a placebo-controlled randomised clinical trial investigating the effect of neuraminidase inhibitors in adults hospitalised with influenza. BMC Health Serv Res 2018; 18:311. [PMID: 29716584 PMCID: PMC5930775 DOI: 10.1186/s12913-018-3122-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/15/2018] [Indexed: 11/23/2022] Open
Abstract
Background The value of neuraminidase inhibitors (NAIs) in reducing severe clinical outcomes from influenza is debated. A clinical trial to generate better evidence is desirable. However, it is unknown whether UK clinicians would support a placebo-controlled trial. A survey was conducted to determine the attitude of clinicians towards a clinical trial and their current practice in managing adults admitted to hospital with suspected influenza. Methods Senior clinicians (n = 50) across the UK actively involved in the care of patients hospitalised with severe respiratory infections and/or respiratory infection research were invited to participate in an on-line survey. Participants were asked their opinion on the evidence for benefit of NAIs in influenza, their current practice in relation to: a) testing for influenza; b) treating empirically with NAIs; and c) when influenza infection is virolologically confirmed, prescribing NAIs. Results Thirty-five (70%) of 50 clinicians completed the survey. Respondents were drawn mainly from infectious diseases, intensive care and respiratory medicine. Only 11 (31%) of 35 respondents agreed that NAIs are effective at reducing influenza mortality; 14 (40%) disagreed, 10 (28.6%) neither agreed nor disagreed. When managing adults admitted to non-ICU wards with a respiratory infection during an influenza season, 15 (51.7%) clinicians indicated they would usually perform a test for influenza in greater than 60% of patients but only 9 (31%) would treat empirically with NAIs in greater than 60% of patients. Few clinicians would either test or empirically treat patients presenting with other (non-respiratory infection related) diagnoses. If influenza infection is confirmed, 17 (64.5%) clinicians would prescribe NAIs in greater than 80% of patients with a respiratory infection treated on non-ICU wards Thirty-one (89%) clinicians agreed that a placebo-controlled clinical trial should be conducted and 29 (85%) would participate in such a trial. Conclusions There is strong support from UK clinicians for a placebo-controlled trial of NAI treatment in adults hospitalised with suspected influenza. Current variation in medical opinion and clinical practice demonstrates collective equipoise, supporting ethical justification for a trial. Low use of NAIs in the UK suggests randomisation of treatment would not substantially divert patients towards placebo. Electronic supplementary material The online version of this article (10.1186/s12913-018-3122-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Naomi Bradbury
- Zeeman Institute: Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, CV4 7AL, UK.,School of Life Sciences, University of Warwick, Coventry, CV4 7AL, UK
| | - Jonathan Nguyen-Van-Tam
- Faculty of Medicine & Health Sciences, University of Nottingham. Clinical Sciences Building, Nottingham City Hospital, Nottingham, NG5 1PB, UK
| | - Wei Shen Lim
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK.
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11
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Is there sufficient evidence to repeal three decades of clinical research on chronic hepatitis C? Clin Microbiol Infect 2018; 24:328-331. [PMID: 29326009 DOI: 10.1016/j.cmi.2018.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 12/30/2017] [Accepted: 01/02/2018] [Indexed: 12/18/2022]
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12
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Calain P. The Ebola clinical trials: a precedent for research ethics in disasters. JOURNAL OF MEDICAL ETHICS 2018; 44:3-8. [PMID: 27573153 PMCID: PMC5749307 DOI: 10.1136/medethics-2016-103474] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/15/2016] [Accepted: 08/07/2016] [Indexed: 05/07/2023]
Abstract
The West African Ebola epidemic has set in motion a collective endeavour to conduct accelerated clinical trials, testing unproven but potentially lifesaving interventions in the course of a major public health crisis. This unprecedented effort was supported by the recommendations of an ad hoc ethics panel convened in August 2014 by the WHO. By considering why and on what conditions the exceptional circumstances of the Ebola epidemic justified the use of unproven interventions, the panel's recommendations have challenged conventional thinking about therapeutic development and clinical research ethics. At the same time, unanswered ethical questions have emerged, in particular: (i) the specification of exceptional circumstances, (ii) the specification of unproven interventions, (iii) the goals of interventional research in terms of individual versus collective interests, (iv) the place of adaptive trial designs and (v) the exact meaning of compassionate use with unapproved interventions. Examination of these questions, in parallel with empirical data from research sites, will help build pragmatic foundations for disaster research ethics. Furthermore, the Ebola clinical trials signal an evolution in the current paradigms of therapeutic research, beyond the case of epidemic emergencies.
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13
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Bothwell LE, Kesselheim AS. The Real-World Ethics of Adaptive-Design Clinical Trials. Hastings Cent Rep 2017; 47:27-37. [DOI: 10.1002/hast.783] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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14
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Enabling Rapid Response to the 2014-2016 Ebola Epidemic: The Experience and the Results of the National Institute for Infectious Diseases Lazzaro Spallanzani. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 972:103-122. [PMID: 27864803 DOI: 10.1007/5584_2016_134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
The unprecedented epidemic of Ebola virus disease (EVD) in West Africa highlighted the need for stronger systems for disease surveillance, response, and prevention worldwide. Tackling an epidemic event today requires a broader view, not only limited to medical management of the patients, but which also includes heroic efforts by clinicians and public health personnel.Since its foundation in 1936, INMI has been devoted to the prevention, diagnosis and care for infectious diseases. In 2009, INMI became a WHO collaborative center for clinical care, diagnosis, response and training on Highly Infectious Diseases. This paper is aimed to present the activities and the challenging issues encountered by INMI during the 2014-2015 EVD outbreak in terms of preparedness and response to the epidemiological, clinical, diagnostic and research controversial aspects of EVD, both in Italy and in the field.
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Alirol E, Kuesel AC, Guraiib MM, dela Fuente-Núñez V, Saxena A, Gomes MF. Ethics review of studies during public health emergencies - the experience of the WHO ethics review committee during the Ebola virus disease epidemic. BMC Med Ethics 2017; 18:43. [PMID: 28651650 PMCID: PMC5485606 DOI: 10.1186/s12910-017-0201-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 06/08/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Between 2013 and 2016, West Africa experienced the largest ever outbreak of Ebola Virus Disease. In the absence of registered treatments or vaccines to control this lethal disease, the World Health Organization coordinated and supported research to expedite identification of interventions that could control the outbreak and improve future control efforts. Consequently, the World Health Organization Research Ethics Review Committee (WHO-ERC) was heavily involved in reviews and ethics discussions. It reviewed 24 new and 22 amended protocols for research studies including interventional (drug, vaccine) and observational studies. WHO-ERC REVIEWS WHO-ERC provided the reviews within on average 6 working days. The WHO-ERC often could not provide immediate approval of protocols for reasons which were not Ebola Virus Disease specific but related to protocol inconsistencies, missing information and complex informed consents. WHO-ERC considerations on Ebola Virus Disease specific issues (benefit-risk assessment, study design, exclusion of pregnant women and children from interventional studies, data and sample sharing, collaborative partnerships including international and local researchers and communities, community engagement and participant information) are presented. CONCLUSIONS To accelerate study approval in future public health emergencies, we recommend: (1) internally consistent and complete submissions with information documents in language participants are likely to understand, (2) close collaboration between local and international researchers from research inception, (3) generation of template agreements for data and sample sharing and use during the ongoing global consultations on bio-banks, (4) formation of Joint Scientific Advisory and Data Safety Review Committees for all studies linked to a particular intervention or group of interventions, (5) formation of a Joint Ethics Review Committee with representatives of the Ethics Committees of all institutions and countries involved to strengthen reviews through the different perspectives provided without the 'opportunity costs' for time to final approval of multiple, independent reviews, (6) direct information exchange between the chairs of advisory, safety review and ethics committees, (7) more Ethics Committee support for investigators than is standard and (8) a global consultation on criteria for inclusion of pregnant women and children in interventional studies for conditions which put them at particularly high risk of mortality or other irreversible adverse outcomes under standard-of-care.
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Affiliation(s)
- Emilie Alirol
- Global Antibiotics Research and Development Partnership (GARDP), Drugs for Neglected Diseases initiative (DNDi), 15 chemin Louis Dunant, 1202 Geneva, Switzerland
| | - Annette C. Kuesel
- World Health Organization, UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
| | - Maria Magdalena Guraiib
- World Health Organization, Department for Information Evidence and Research, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
| | - Vânia dela Fuente-Núñez
- World Health Organization, Department for Information Evidence and Research, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
| | - Abha Saxena
- World Health Organization, Department for Information Evidence and Research, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
| | - Melba F. Gomes
- World Health Organization, 20 Avenue Appia, 1211, 27 Geneva, Switzerland
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16
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Carazo Perez S, Folkesson E, Anglaret X, Beavogui AH, Berbain E, Camara AM, Depoortere E, Lefevre A, Maes P, Malme KN, Malvy JMD, Ombelet S, Poelaert G, Sissoko D, Tounkara A, Trbovic P, Piguet P, Antierens A. Challenges in preparing and implementing a clinical trial at field level in an Ebola emergency: A case study in Guinea, West Africa. PLoS Negl Trop Dis 2017. [PMID: 28640812 PMCID: PMC5480829 DOI: 10.1371/journal.pntd.0005545] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
During the large Ebola outbreak that affected West Africa in 2014 and 2015, studies were launched to evaluate potential treatments for the disease. A clinical trial to evaluate the effectiveness of the antiviral drug favipiravir was conducted in Guinea. This paper describes the main challenges of the implementation of the trial in the Ebola treatment center of Guéckédou. Following the principles of the Good Clinical Research Practices, we explored the aspects of the community’s communication and engagement, ethical conduct, trial protocol compliance, informed consent of participants, ongoing benefit/risk assessment, record keeping, confidentiality of patients and study data, and roles and responsibilities of the actors involved. We concluded that several challenges have to be addressed to successfully implement a clinical trial during an international medical emergency but that the potential for collaboration between research teams and humanitarian organizations needs to be highlighted.
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Affiliation(s)
- Sara Carazo Perez
- Médecins Sans Frontières, Brussels, Belgium
- Department of Preventive and Social Medicine, Laval University, Québec City, Canada
- * E-mail: (SCP); (AA)
| | | | - Xavier Anglaret
- Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France
- Programme PACCI, Abidjan, Côte d’Ivoire
| | | | | | | | - Evelyn Depoortere
- Médecins Sans Frontières, Brussels, Belgium
- Institute of Tropical Medicine, Antwerpen, Belgium
| | | | - Piet Maes
- European Mobile Laboratory Project, Hamburg, Germany
- KU Leuven, Rega Institute for Medical Research, Leuven, Belgium
| | | | - Jean-Marie Denis Malvy
- Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France
- Pellegrin Hospital, Bordeaux, France
| | | | | | - Daouda Sissoko
- Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France
- Pellegrin Hospital, Bordeaux, France
| | | | | | | | - Annick Antierens
- Médecins Sans Frontières, Brussels, Belgium
- * E-mail: (SCP); (AA)
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Abstract
Under a traditional paradigm, only those with the expected background knowledge consume academic literature. The lay press, as well as government and non-government agencies, play a complementary role of extracting findings of high interest or importance and translating them for general viewing. The need for accurate reporting and public advising is paramount when attempting to tackle epidemic outbreaks through behavior change. Yet, public trust in media outlets is at a historic low. The Crisis and Emergency Risk Communication (CERC) model for media reporting on public health emergencies was established in 2005 and has subsequently been used to analyze media reporting on outbreaks of influenza and measles as well as smoking habits and medication compliance. However, no media analysis had yet been performed on the 2013–2016 Ebola Virus Disease (EVD) outbreak. This study compared the EVD information relayed by lay press sources with general review articles in the academic literature through a mixed-methods analysis. These findings suggest that comprehensive review articles could not serve as a source to clarify and contextualize the uncertainties around the EVD outbreak, perhaps due to adherence to technical accuracy at the expense of clarity within the context of outbreak conditions. This finding does not imply inferiority of the academic literature, nor does it draw direct causation between confusion in review articles and public misunderstanding. Given the erosion of the barriers siloing academia, combined with the demands of today’s fast-paced media environment, contemporary researchers should realize that no study is outside the public forum and to therefore consider shifting the paradigm to take personal responsibility in the process of accurately translating their scientific words into public policy actions to best serve as a source of clarity.
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Grobusch MP, Goorhuis A. Safety and immunogenicity of a recombinant adenovirus vector-based Ebola vaccine. Lancet 2017; 389:578-580. [PMID: 28017405 DOI: 10.1016/s0140-6736(16)32619-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1100 DE Amsterdam, The Netherlands; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany; Lion Heart Medical Research Unit, Yele, Sierra Leone.
| | - Abraham Goorhuis
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1100 DE Amsterdam, The Netherlands; Lion Heart Medical Research Unit, Yele, Sierra Leone
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Hartley MA, Young A, Tran AM, Okoni-Williams HH, Suma M, Mancuso B, Al-Dikhari A, Faouzi M. Predicting Ebola Severity: A Clinical Prioritization Score for Ebola Virus Disease. PLoS Negl Trop Dis 2017; 11:e0005265. [PMID: 28151955 PMCID: PMC5289426 DOI: 10.1371/journal.pntd.0005265] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 12/15/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the notoriety of Ebola virus disease (EVD) as one of the world's most deadly infections, EVD has a wide range of outcomes, where asymptomatic infection may be almost as common as fatality. With increasingly sensitive EVD diagnosis, there is a need for more accurate prognostic tools that objectively stratify clinical severity to better allocate limited resources and identify those most in need of intensive treatment. METHODS/PRINCIPAL FINDINGS This retrospective cohort study analyses the clinical characteristics of 158 EVD(+) patients at the GOAL-Mathaska Ebola Treatment Centre, Sierra Leone. The prognostic potential of each characteristic was assessed and incorporated into a statistically weighted disease score. The mortality rate among EVD(+) patients was 60.8% and highest in those aged <5 or >25 years (p<0.05). Death was significantly associated with malaria co-infection (OR = 2.5, p = 0.01). However, this observation was abrogated after adjustment to Ebola viral load (p = 0.1), potentially indicating a pathologic synergy between the infections. Similarly, referral-time interacted with viral load, and adjustment revealed referral-time as a significant determinant of mortality, thus quantifying the benefits of early reporting as a 12% mortality risk reduction per day (p = 0.012). Disorientation was the strongest unadjusted predictor of death (OR = 13.1, p = 0.014) followed by hiccups, diarrhoea, conjunctivitis, dyspnoea and myalgia. Including these characteristics in multivariate prognostic scores, we obtained a 91% and 97% ability to discriminate death at or after triage respectively (area under ROC curve). CONCLUSIONS/SIGNIFICANCE This study proposes highly predictive and easy-to-use prognostic tools, which stratify the risk of EVD mortality at or after EVD triage.
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Affiliation(s)
- Mary-Anne Hartley
- GOAL Global, Dublin, Ireland
- University of Lausanne, Lausanne, Switzerland
- * E-mail:
| | | | | | | | | | | | | | - Mohamed Faouzi
- Institute of Social and Preventive Medicine, Lausanne, Switzerland
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Pablo Beca J, Salas SP. [Ethical and health issues posed by the recent Ebola epidemic: What should we learn?]. Rev Med Chil 2017; 144:371-6. [PMID: 27299824 DOI: 10.4067/s0034-98872016000300013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/15/2016] [Indexed: 11/17/2022]
Abstract
The recent Ebola epidemic that affected several countries in Africa, with very high mortality and a pandemic threat, posed problems of justice, public health, prevention, treatment and research, each of which has relevant ethical issues. Despite severe initial difficulties, an effective international response was achieved, whose outcome has left significant teachings to be considered in order to deal with future epidemics or pandemics. In this article, the authors analyze the main problems faced during the Ebola epidemic, including the unequal distribution of health resources between countries, the need for international collaboration, the requirement for a review of the ethical standards of clinical trials in emergencies, and the necessity of an organized global system of prevention and timely response to these outbreaks. Authors conclude that at the present time health is a global issue without borders, that insufficient healthcare resources in some countries poses risks and affects all countries and that the confrontation of the threats of epidemics requires a solution based in universal solidarity. At the same time, a moral duty to investigate should be acknowledged, seeking a balance between sense of urgency, scientific rigor and involvement of local communities.
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21
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Richardson T, Johnston AM, Draper H. A Systematic Review of Ebola Treatment Trials to Assess the Extent to Which They Adhere to Ethical Guidelines. PLoS One 2017; 12:e0168975. [PMID: 28095476 PMCID: PMC5240928 DOI: 10.1371/journal.pone.0168975] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/11/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Objective: To determine to what extent each trial met criteria specified in three research frameworks for ethical trial conduct. Design: Systematic review and narrative analysis. METHODS AND FINDINGS Data sources: MEDBASE and EMBASE databases were searched using a specific search strategy. The Cochrane database for systematic reviews, the PROSPERO database and trial registries were examined. A grey literature search and citation search were also carried out. Eligibility criteria for selecting studies: Studies were included where the intervention was being used to treat Ebola in human subjects regardless of study design, comparator or outcome measured. Studies were eligible if they had taken place after the 21st March 2014. Unpublished as well as published studies were included. Included studies: Sixteen studies were included in the data synthesis. Data was extracted on study characteristics as well as any information relating to ten ethical areas of interest specified in the three research frameworks for ethical trial conduct and an additional criterion of whether the study received ethics approval from a research ethics committee. Synthesis of results: Eight studies were judged to fully comply with all eleven criteria. The other eight studies all had at least one criteria where there was not enough information available to draw any conclusions. In two studies there were ethical concerns regarding the information provided in relation to at least one ethical criteria. Description of the effect: One study did not receive ethical approval as the authors argued that treating approximately one hundred patients consecutively for compassionate reasons did not constitute a clinical trial. Furthermore, after the patients were treated, physicians in Sierra Leone did not release reports of treatment results and so study conclusions had to be made based on unpublished observations. In another study the risk-benefit ratio of the trial drug does not appear to be favourable and the pre-trial evidence base for its effectiveness against Ebola is speculative. CONCLUSIONS Some limited and appropriate deviation from standard research expectations in disaster situations is increasingly accepted. However, this is not an excuse for poor ethics oversight and international regulations are in place which should not be ignored. New guidelines are needed that better define the boundaries between using medicines for compassionate use and conducting a clinical trial. Greater support should be offered for local research ethics committees in affected areas so that they can provide robust ethical review. Further systematic reviews should be carried out in epidemics of any novel infectious diseases to assess if comparable findings arise.
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Affiliation(s)
- Thomas Richardson
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Andrew McDonald Johnston
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Heather Draper
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
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22
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Malvy D. [Science in a crisis. Medical countermeasures in Ebola virus disease, 2016: lessons learned and perspectives]. ACTA ACUST UNITED AC 2016; 109:262-271. [PMID: 27848225 DOI: 10.1007/s13149-016-0527-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 09/13/2016] [Indexed: 11/30/2022]
Abstract
In 2013, the world began to witness an unprecedented Ebola epidemic in West Africa that was smoldering by early 2016. Under this urgent circumstance, the global scientific community organized and made progress in identifying potential preventive countermeasures and therapeutics and accelerated the development of those promising interventions. Trials of experimental interventions soon emerged as a key component of the global response. Hence, an interdisciplinary issue ensued concerning how best to assess clinical safety and effectiveness of potential interventions prior to or concurrent with their broad use in humans. Key issues rely on the close collaboration between research and clinical teams involved in care in the field. Indeed, it is of prime importance to consider cultural dimensions when aiming to build trust within communities and flexibility to adapt trial procedures to field constraints. Trials implemented during the outbreak crisis illustrates challenging inputs for producing scientific and ethical gains for the benefits of vulnerable populations in the context of an international emerging or re-emerging infectious disease event. This includes rapid implementation of clinical research studies from the early phase of the next global outbreak on the basis of practical and ready-to-apply innovative methodological framework built during interepidemic periods.
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Affiliation(s)
- D Malvy
- Secteur de médecine tropicale et santé internationale clinique, Service des maladies infectieuses et tropicales, CHU Pellegrin de Bordeaux, place Amélie-Raba-Léon, 33075, Bordeaux, France. .,Inserm U 1219, université de Bordeaux, 33076, Bordeaux, France.
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23
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Davey RT, Dodd L, Proschan MA, Neaton J, Neuhaus Nordwall J, Koopmeiners JS, Beigel J, Tierney J, Lane HC, Fauci AS, Massaquoi MBF, Sahr F, Malvy D. A Randomized, Controlled Trial of ZMapp for Ebola Virus Infection. N Engl J Med 2016; 375:1448-1456. [PMID: 27732819 PMCID: PMC5086427 DOI: 10.1056/nejmoa1604330] [Citation(s) in RCA: 361] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Data from studies in nonhuman primates suggest that the triple monoclonal antibody cocktail ZMapp is a promising immune-based treatment for Ebola virus disease (EVD). METHODS Beginning in March 2015, we conducted a randomized, controlled trial of ZMapp plus the current standard of care as compared with the current standard of care alone in patients with EVD that was diagnosed in West Africa by polymerase-chain-reaction (PCR) assay. Eligible patients of any age were randomly assigned in a 1:1 ratio to receive either the current standard of care or the current standard of care plus three intravenous infusions of ZMapp (50 mg per kilogram of body weight, administered every third day). Patients were stratified according to baseline PCR cycle-threshold value for the virus (≤22 vs. >22) and country of enrollment. Oral favipiravir was part of the current standard of care in Guinea. The primary end point was mortality at 28 days. RESULTS A total of 72 patients were enrolled at sites in Liberia, Sierra Leone, Guinea, and the United States. Of the 71 patients who could be evaluated, 21 died, representing an overall case fatality rate of 30%. Death occurred in 13 of 35 patients (37%) who received the current standard of care alone and in 8 of 36 patients (22%) who received the current standard of care plus ZMapp. The observed posterior probability that ZMapp plus the current standard of care was superior to the current standard of care alone was 91.2%, falling short of the prespecified threshold of 97.5%. Frequentist analyses yielded similar results (absolute difference in mortality with ZMapp, -15 percentage points; 95% confidence interval, -36 to 7). Baseline viral load was strongly predictive of both mortality and duration of hospitalization in all age groups. CONCLUSIONS In this randomized, controlled trial of a putative therapeutic agent for EVD, although the estimated effect of ZMapp appeared to be beneficial, the result did not meet the prespecified statistical threshold for efficacy. (Funded by the National Institute of Allergy and Infectious Diseases and others; PREVAIL II ClinicalTrials.gov number, NCT02363322 .).
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Non-randomised Ebola trials--lessons for optimal outbreak research. THE LANCET. INFECTIOUS DISEASES 2016; 16:407-8. [PMID: 27036341 DOI: 10.1016/s1473-3099(16)00132-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/26/2016] [Accepted: 02/26/2016] [Indexed: 11/24/2022]
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McClure LA, Szychowski JM, Benavente O, Hart RG, Coffey CS. A post hoc evaluation of a sample size re-estimation in the Secondary Prevention of Small Subcortical Strokes study. Clin Trials 2016; 13:537-44. [PMID: 27094488 DOI: 10.1177/1740774516643689] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIMS The use of adaptive designs has been increasing in randomized clinical trials. Sample size re-estimation is a type of adaptation in which nuisance parameters are estimated at an interim point in the trial and the sample size re-computed based on these estimates. The Secondary Prevention of Small Subcortical Strokes study was a randomized clinical trial assessing the impact of single- versus dual-antiplatelet therapy and control of systolic blood pressure to a higher (130-149 mmHg) versus lower (<130 mmHg) target on recurrent stroke risk in a two-by-two factorial design. A sample size re-estimation was performed during the Secondary Prevention of Small Subcortical Strokes study resulting in an increase from the planned sample size of 2500-3020, and we sought to determine the impact of the sample size re-estimation on the study results. METHODS We assessed the results of the primary efficacy and safety analyses with the full 3020 patients and compared them to the results that would have been observed had randomization ended with 2500 patients. The primary efficacy outcome considered was recurrent stroke, and the primary safety outcomes were major bleeds and death. We computed incidence rates for the efficacy and safety outcomes and used Cox proportional hazards models to examine the hazard ratios for each of the two treatment interventions (i.e. the antiplatelet and blood pressure interventions). RESULTS In the antiplatelet intervention, the hazard ratio was not materially modified by increasing the sample size, nor did the conclusions regarding the efficacy of mono versus dual-therapy change: there was no difference in the effect of dual- versus monotherapy on the risk of recurrent stroke hazard ratios (n = 3020 HR (95% confidence interval): 0.92 (0.72, 1.2), p = 0.48; n = 2500 HR (95% confidence interval): 1.0 (0.78, 1.3), p = 0.85). With respect to the blood pressure intervention, increasing the sample size resulted in less certainty in the results, as the hazard ratio for higher versus lower systolic blood pressure target approached, but did not achieve, statistical significance with the larger sample (n = 3020 HR (95% confidence interval): 0.81 (0.63, 1.0), p = 0.089; n = 2500 HR (95% confidence interval): 0.89 (0.68, 1.17), p = 0.40). The results from the safety analyses were similar to 3020 and 2500 patients for both study interventions. Other trial-related factors, such as contracts, finances, and study management, were impacted as well. CONCLUSION Adaptive designs can have benefits in randomized clinical trials, but do not always result in significant findings. The impact of adaptive designs should be measured in terms of both trial results, as well as practical issues related to trial management. More post hoc analyses of study adaptations will lead to better understanding of the balance between the benefits and the costs.
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Affiliation(s)
- Leslie A McClure
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeff M Szychowski
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Oscar Benavente
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Robert G Hart
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Experimental Treatment with Favipiravir for Ebola Virus Disease (the JIKI Trial): A Historically Controlled, Single-Arm Proof-of-Concept Trial in Guinea. PLoS Med 2016; 13:e1001967. [PMID: 26930627 PMCID: PMC4773183 DOI: 10.1371/journal.pmed.1001967] [Citation(s) in RCA: 313] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/21/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ebola virus disease (EVD) is a highly lethal condition for which no specific treatment has proven efficacy. In September 2014, while the Ebola outbreak was at its peak, the World Health Organization released a short list of drugs suitable for EVD research. Favipiravir, an antiviral developed for the treatment of severe influenza, was one of these. In late 2014, the conditions for starting a randomized Ebola trial were not fulfilled for two reasons. One was the perception that, given the high number of patients presenting simultaneously and the very high mortality rate of the disease, it was ethically unacceptable to allocate patients from within the same family or village to receive or not receive an experimental drug, using a randomization process impossible to understand by very sick patients. The other was that, in the context of rumors and distrust of Ebola treatment centers, using a randomized design at the outset might lead even more patients to refuse to seek care. Therefore, we chose to conduct a multicenter non-randomized trial, in which all patients would receive favipiravir along with standardized care. The objectives of the trial were to test the feasibility and acceptability of an emergency trial in the context of a large Ebola outbreak, and to collect data on the safety and effectiveness of favipiravir in reducing mortality and viral load in patients with EVD. The trial was not aimed at directly informing future guidelines on Ebola treatment but at quickly gathering standardized preliminary data to optimize the design of future studies. METHODS AND FINDINGS Inclusion criteria were positive Ebola virus reverse transcription PCR (RT-PCR) test, age ≥ 1 y, weight ≥ 10 kg, ability to take oral drugs, and informed consent. All participants received oral favipiravir (day 0: 6,000 mg; day 1 to day 9: 2,400 mg/d). Semi-quantitative Ebola virus RT-PCR (results expressed in "cycle threshold" [Ct]) and biochemistry tests were performed at day 0, day 2, day 4, end of symptoms, day 14, and day 30. Frozen samples were shipped to a reference biosafety level 4 laboratory for RNA viral load measurement using a quantitative reference technique (genome copies/milliliter). Outcomes were mortality, viral load evolution, and adverse events. The analysis was stratified by age and Ct value. A "target value" of mortality was defined a priori for each stratum, to guide the interpretation of interim and final analysis. Between 17 December 2014 and 8 April 2015, 126 patients were included, of whom 111 were analyzed (adults and adolescents, ≥13 y, n = 99; young children, ≤6 y, n = 12). Here we present the results obtained in the 99 adults and adolescents. Of these, 55 had a baseline Ct value ≥ 20 (Group A Ct ≥ 20), and 44 had a baseline Ct value < 20 (Group A Ct < 20). Ct values and RNA viral loads were well correlated, with Ct = 20 corresponding to RNA viral load = 7.7 log10 genome copies/ml. Mortality was 20% (95% CI 11.6%-32.4%) in Group A Ct ≥ 20 and 91% (95% CI 78.8%-91.1%) in Group A Ct < 20. Both mortality 95% CIs included the predefined target value (30% and 85%, respectively). Baseline serum creatinine was ≥110 μmol/l in 48% of patients in Group A Ct ≥ 20 (≥300 μmol/l in 14%) and in 90% of patients in Group A Ct < 20 (≥300 μmol/l in 44%). In Group A Ct ≥ 20, 17% of patients with baseline creatinine ≥110 μmol/l died, versus 97% in Group A Ct < 20. In patients who survived, the mean decrease in viral load was 0.33 log10 copies/ml per day of follow-up. RNA viral load values and mortality were not significantly different between adults starting favipiravir within <72 h of symptoms compared to others. Favipiravir was well tolerated. CONCLUSIONS In the context of an outbreak at its peak, with crowded care centers, randomizing patients to receive either standard care or standard care plus an experimental drug was not felt to be appropriate. We did a non-randomized trial. This trial reaches nuanced conclusions. On the one hand, we do not conclude on the efficacy of the drug, and our conclusions on tolerance, although encouraging, are not as firm as they could have been if we had used randomization. On the other hand, we learned about how to quickly set up and run an Ebola trial, in close relationship with the community and non-governmental organizations; we integrated research into care so that it improved care; and we generated knowledge on EVD that is useful to further research. Our data illustrate the frequency of renal dysfunction and the powerful prognostic value of low Ct values. They suggest that drug trials in EVD should systematically stratify analyses by baseline Ct value, as a surrogate of viral load. They also suggest that favipiravir monotherapy merits further study in patients with medium to high viremia, but not in those with very high viremia. TRIAL REGISTRATION ClinicalTrials.gov NCT02329054.
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Walsh GM, Shih AW, Solh Z, Golder M, Schubert P, Fearon M, Sheffield WP. Blood-Borne Pathogens: A Canadian Blood Services Centre for Innovation Symposium. Transfus Med Rev 2016; 30:53-68. [PMID: 26962008 PMCID: PMC7126603 DOI: 10.1016/j.tmrv.2016.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 02/18/2016] [Indexed: 12/19/2022]
Abstract
Testing donations for pathogens and deferring selected blood donors have reduced the risk of transmission of known pathogens by transfusion to extremely low levels in most developed countries. Protecting the blood supply from emerging infectious threats remains a serious concern in the transfusion medicine community. Transfusion services can employ indirect measures such as surveillance, hemovigilance, and donor questioning (defense), protein-, or nucleic acid based direct testing (detection), or pathogen inactivation of blood products (destruction) as strategies to mitigate the risk of transmission-transmitted infection. In the North American context, emerging threats currently include dengue, chikungunya, and hepatitis E viruses, and Babesia protozoan parasites. The 2003 SARS and 2014 Ebola outbreaks illustrate the potential of epidemics unlikely to be transmitted by blood transfusion but disruptive to blood systems. Donor-free blood products such as ex vivo generated red blood cells offer a theoretical way to avoid transmission-transmitted infection risk, although biological, engineering, and manufacturing challenges must be overcome before this approach becomes practical. Similarly, next generation sequencing of all nucleic acid in a blood sample is currently possible but impractical for generalized screening. Pathogen inactivation systems are in use in different jurisdictions around the world, and are starting to gain regulatory approval in North America. Cost concerns make it likely that pathogen inactivation will be contemplated by blood operators through the lens of health economics and risk-based decision making, rather than in zero-risk paradigms previously embraced for transfusable products. Defense of the blood supply from infectious disease risk will continue to require innovative combinations of surveillance, detection, and pathogen avoidance or inactivation. A symposium on blood-borne pathogens was held September 26, 2015, in Toronto, Canada. Transmission-transmitted infections remain a threat to the blood supply. The residual risk from established pathogens is small; emerging agents are a concern. Next generation sequencing and donor-free blood are not yet practical approaches. Pathogen inactivation technology is being increasingly used around the world. Health economic concerns will likely guide future advances in this area.
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Affiliation(s)
- Geraldine M Walsh
- Centre for Innovation, Canadian Blood Services, Hamilton, Ottawa, and Vancouver, Canada
| | - Andrew W Shih
- Medical Services and Innovation, Canadian Blood Services, McMaster University, Hamilton, Canada; Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Ziad Solh
- Medical Services and Innovation, Canadian Blood Services, McMaster University, Hamilton, Canada; Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Mia Golder
- Centre for Innovation, Canadian Blood Services, Hamilton, Ottawa, and Vancouver, Canada
| | - Peter Schubert
- Centre for Innovation, Canadian Blood Services, Hamilton, Ottawa, and Vancouver, Canada; Centre for Blood Research, University of British Columbia, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Canada
| | - Margaret Fearon
- Medical Services and Innovation, Canadian Blood Services, McMaster University, Hamilton, Canada; Pathology and Laboratory Medicine, University of Toronto, Canada
| | - William P Sheffield
- Centre for Innovation, Canadian Blood Services, Hamilton, Ottawa, and Vancouver, Canada; Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.
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Yazdanpanah Y, Horby P, van Griensven J, Mentre F, Nguyen VK, Malvy JMD, Dunning J, Sissoko D, Delfraissy JF, Levy Y. Drug assessment in the Ebola virus disease epidemic in west Africa. THE LANCET. INFECTIOUS DISEASES 2016; 15:1258. [PMID: 26531030 DOI: 10.1016/s1473-3099(15)00344-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/24/2015] [Accepted: 09/16/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Yazdan Yazdanpanah
- INSERM, IAME, UMR 1137, UFR de Médecine, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Infectious Diseases Department, Bichat-Claude Bernard Hospital, Paris, France.
| | | | | | - France Mentre
- INSERM, IAME, UMR 1137, UFR de Médecine, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Infectious Diseases Department, Bichat-Claude Bernard Hospital, Paris, France
| | - Vinh-Kim Nguyen
- Collège d'études Mondiales, Fondation Maison des Sciences de l'Homme, Paris, France; Ecole de santé publique de l'Université de Montréal, Montreal, Canada; University of Amsterdam, Amsterdam, Netherlands
| | - Jean Marie Denis Malvy
- INSERM 897, Tropical Medicine Branch, Bordeaux, France; Service des Maladies Infectieuses et Tropicales, CHU de Bordeaux, Bordeaux, France
| | | | - Daouda Sissoko
- INSERM 897, Tropical Medicine Branch, Bordeaux, France; Service des Maladies Infectieuses et Tropicales, CHU de Bordeaux, Bordeaux, France
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Gobat NH, Gal M, Francis NA, Hood K, Watkins A, Turner J, Moore R, Webb SAR, Butler CC, Nichol A. Key stakeholder perceptions about consent to participate in acute illness research: a rapid, systematic review to inform epi/pandemic research preparedness. Trials 2015; 16:591. [PMID: 26715077 PMCID: PMC4693405 DOI: 10.1186/s13063-015-1110-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/08/2015] [Indexed: 12/14/2022] Open
Abstract
Background A rigorous research response is required to inform clinical and public health decision-making during an epi/pandemic. However, the ethical conduct of such research, which often involves critically ill patients, may be complicated by the diminished capacity to consent and an imperative to initiate trial therapies within short time frames. Alternative approaches to taking prospective informed consent may therefore be used. We aimed to rapidly review evidence on key stakeholder (patients, their proxy decision-makers, clinicians and regulators) views concerning the acceptability of various approaches for obtaining consent relevant to pandemic-related acute illness research. Methods We conducted a rapid evidence review, using the Internet, database and hand-searching for English language empirical publications from 1996 to 2014 on stakeholder opinions of consent models (prospective informed, third-party, deferred, or waived) used in acute illness research. We excluded research on consent to treatment, screening, or other such procedures, non-emergency research and secondary studies. Papers were categorised, and data summarised using narrative synthesis. Results We screened 689 citations, reviewed 104 full-text articles and included 52. Just one paper related specifically to pandemic research. In other emergency research contexts potential research participants, clinicians and research staff found third-party, deferred, and waived consent to be acceptable as a means to feasibly conduct such research. Acceptability to potential participants was motivated by altruism, trust in the medical community, and perceived value in medical research and decreased as the perceived risks associated with participation increased. Discrepancies were observed in the acceptability of the concept and application or experience of alternative consent models. Patients accepted clinicians acting as proxy-decision makers, with preference for two decision makers as invasiveness of interventions increased. Research regulators were more cautious when approving studies conducted with alternative consent models; however, their views were generally under-represented. Conclusions Third-party, deferred, and waived consent models are broadly acceptable to potential participants, clinicians and/or researchers for emergency research. Further consultation with key stakeholders, particularly with regulators, and studies focused specifically on epi/pandemic research, are required. We highlight gaps and recommendations to inform set-up and protocol development for pandemic research and institutional review board processes. PROSPERO protocol registration number CRD42014014000 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1110-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina H Gobat
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Micaela Gal
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Nick A Francis
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Kerenza Hood
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, Wales, UK.
| | - Angela Watkins
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
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Lanini S, Portella G, Vairo F, Kobinger GP, Pesenti A, Langer M, Kabia S, Brogiato G, Amone J, Castilletti C, Miccio R, Zumla A, Capobianchi MR, Di Caro A, Strada G, Ippolito G. Blood kinetics of Ebola virus in survivors and nonsurvivors. J Clin Invest 2015; 125:4692-8. [PMID: 26551684 DOI: 10.1172/jci83111] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/28/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Infection with Ebola virus (EBOV) results in a life-threatening disease, with reported mortality rates between 50%-70%. The factors that determine patient survival are poorly understood; however, clinical observations indicate that EBOV viremia may be associated with fatal outcome. We conducted a study of the kinetics of Zaire EBOV viremia in patients with EBOV disease (EVD) who were managed at an Ebola Treatment Centre in Sierra Leone during the recent West African outbreak. METHODS Data from 84 EVD patients (38 survivors, 46 nonsurvivors) were analyzed, and EBOV viremia was quantified between 2 and 13 days after symptom onset. Time since symptom onset and clinical outcome were used as independent variables to compare EBOV viral kinetics in survivors and nonsurvivors. RESULTS In all patients, EBOV viremia kinetics was a quadratic function of time; however, EBOV viremia was 0.94 logarithm (log) copies per ml (cp/ml) (P = 0.011) higher in nonsurvivors than in survivors from day 2 after the onset of symptoms. Survivors reached peak viremia levels at an earlier time after symptom onset than nonsurvivors (day 5 versus day 7) and had lower mean peak viremia levels compared with nonsurvivors (7.46 log cp/ml; 95% CI, 7.17-7.76 vs. 8.60 log cp/ml; 95% CI, 8.27-8.93). Before reaching peak values, EBOV viremia similarly increased both in survivors and nonsurvivors; however, the decay of viremia after the peak was much stronger in survivors than in nonsurvivors. CONCLUSION Our results demonstrate that plasma concentrations of EBOV are markedly different between survivors and nonsurvivors at very early time points after symptom onset and may be predicative of outcome. Further studies focused on the early phase of the disease will be required to identify the causal and prognostic factors that determine patient outcome. FUNDING Italian Ministry of Health; Italian Ministry of Foreign Affairs; EMERGENCY's private donations; and Royal Engineers for DFID-UK.
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Petrosillo N, Nicastri E, Lanini S, Capobianchi MR, Di Caro A, Antonini M, Puro V, Lauria FN, Shindo N, Magrini N, Kobinger GP, Ippolito G. Ebola virus disease complicated with viral interstitial pneumonia: a case report. BMC Infect Dis 2015; 15:432. [PMID: 26471197 PMCID: PMC4608352 DOI: 10.1186/s12879-015-1169-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/30/2015] [Indexed: 11/26/2022] Open
Abstract
Background In the current Ebola epidemic in Western Africa, many healthcare workers have become infected. Some of these have been medically evacuated to hospitals in Europe and the USA. These clinical experiences provide unique insights into the course of Ebola virus disease under optimized condition within high level isolation units. Case presentation A 50-year-old Caucasian male physician contracted Ebola virus diseases in Sierra Leone and was medically evacuated to Italy. Few days after the admission the course of the illness was characterized by severe gastro-intestinal symptoms followed by respiratory failure, accompanied by pulmonary infiltration and high Ebola viral load in the bronchial aspirate and Plasmodium vivax co-infection. The patient received experimental antiviral therapy with favipiravir, convalescent plasma and ZMAb. Ebola viral load started to steadily decrease in the blood after ZMAb administration and became undetectable by day 19 after admission, while it persisted longer in urine samples. No temporal association was observed between viral load decay in plasma and administration of favipiravir. The patient completely recovered and was discharged 39 days after admission. Conclusions This is the first case of Ebola-related interstitial pneumonia documented by molecular testing of lung fluid specimens. This reports underlines the pivotal role of fluid replacement and advanced life support with mechanical ventilation in the management of patients with Ebola virus diseases respiratory failure. Beside our finding indicates a close temporal association between administration of cZMAb and Ebola virus clearance from blood. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1169-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicola Petrosillo
- National Institute for Infectious Diseases Lazzaro Spallanzani-INMI IRCCS, Rome, Italy.
| | - Emanuele Nicastri
- National Institute for Infectious Diseases Lazzaro Spallanzani-INMI IRCCS, Rome, Italy.
| | - Simone Lanini
- National Institute for Infectious Diseases Lazzaro Spallanzani-INMI IRCCS, Rome, Italy.
| | | | - Antonino Di Caro
- National Institute for Infectious Diseases Lazzaro Spallanzani-INMI IRCCS, Rome, Italy.
| | - Mario Antonini
- National Institute for Infectious Diseases Lazzaro Spallanzani-INMI IRCCS, Rome, Italy.
| | - Vincenzo Puro
- National Institute for Infectious Diseases Lazzaro Spallanzani-INMI IRCCS, Rome, Italy.
| | | | - Nakono Shindo
- Pandemic and Epidemic Diseases Department, World Health Organization, Geneva, Switzerland.
| | - Nicola Magrini
- Essential Medicines and Health Products Department, World Health Organization, Geneva, Switzerland.
| | - Gary P Kobinger
- Special Pathogens Program, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada.
| | - Giuseppe Ippolito
- National Institute for Infectious Diseases Lazzaro Spallanzani-INMI IRCCS, Rome, Italy.
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Zhou Y, Sullivan NJ. Immunology and evolvement of the adenovirus prime, MVA boost Ebola virus vaccine. Curr Opin Immunol 2015; 35:131-6. [PMID: 26247875 DOI: 10.1016/j.coi.2015.06.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 06/22/2015] [Indexed: 11/29/2022]
Abstract
The 2014 Ebola virus outbreak caused an order of magnitude more deaths in a single outbreak than all previous known outbreaks combined, affecting both local and international public health, and threatening the security and economic stability of the countries in West Africa directly confronting the outbreak. The severity of the epidemic lead to a global response to assist with patient care, outbreak control, and deployment of vaccines. The latter was possible due to the long history of basic and clinical research aimed at identifying a safe and effective vaccine to protect against Ebola virus infection. This review highlights the immunology, development, and progress of vaccines based on replication-defective adenovirus vectors, culminating in the successful launch of the first Phase III trial of an Ebola virus vaccine.
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Affiliation(s)
- Yan Zhou
- Biodefense Research Section, Vaccine Research Center, National Institute for Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20814, USA
| | - Nancy J Sullivan
- Biodefense Research Section, Vaccine Research Center, National Institute for Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20814, USA.
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Zumla A, Heymann D, Ippolito G. Be prepared: Europe needs Ebola outbreak consortium. Nature 2015; 523:35. [PMID: 26135440 DOI: 10.1038/523035b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | - David Heymann
- Chatham House Centre on Global Health Security, London, UK
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Ippolito G, Lanini S, Brouqui P, Di Caro A, Vairo F, Abdulla S, Fusco FM, Krishna S, Capobianchi MR, Kyobe-Bosa H, Lewis DJM, Puro V, Wolfel R, Avsic-Zupanc T, Dar O, Mwaba P, Bates M, Heymann D, Zumla A. Ebola: missed opportunities for Europe-Africa research. THE LANCET. INFECTIOUS DISEASES 2015; 15:1254-5. [PMID: 26231479 DOI: 10.1016/s1473-3099(15)00236-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 07/16/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Giuseppe Ippolito
- Lazzaro Spallanzani National Institute for Infectious Diseases, Via Portuense, Rome 00149, Italy.
| | - Simone Lanini
- Lazzaro Spallanzani National Institute for Infectious Diseases, Via Portuense, Rome 00149, Italy
| | - Philippe Brouqui
- Institut Hospitalo Universitaire Méditérranée Infection, Marseille, France
| | - Antonino Di Caro
- Lazzaro Spallanzani National Institute for Infectious Diseases, Via Portuense, Rome 00149, Italy
| | - Francesco Vairo
- Lazzaro Spallanzani National Institute for Infectious Diseases, Via Portuense, Rome 00149, Italy
| | | | - Francesco Maria Fusco
- Lazzaro Spallanzani National Institute for Infectious Diseases, Via Portuense, Rome 00149, Italy
| | - Sanjeev Krishna
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | | | | | | | - Vincenzo Puro
- Lazzaro Spallanzani National Institute for Infectious Diseases, Via Portuense, Rome 00149, Italy
| | - Roman Wolfel
- Bundeswehr Institute of Microbiology, Munich, Germany
| | - Tatjana Avsic-Zupanc
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Osman Dar
- Chatham House Centre on Global Health Security, London, UK
| | - Peter Mwaba
- UNZA-UCLMS Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Matthew Bates
- UNZA-UCLMS Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - David Heymann
- Chatham House Centre on Global Health Security, London, UK
| | - Alimuddin Zumla
- UNZA-UCLMS Research and Training Project, University Teaching Hospital, Lusaka, Zambia; Division of Infection and Immunity, University College London, London, UK; NIHR Biomedical Research Centre at UCL Hospitals NHS Foundation Trust, London, UK
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Wiwanitkit S, Wiwanitkit V. Simulation as a tool for managing Ebola infection. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2015. [DOI: 10.1016/s2222-1808(15)60845-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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