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Eckstein L, Rid A, Kamuya D, Shah SK. The Essential Role of Data and Safety Monitoring Boards (DSMBs) in Ensuring the Ethics of Global Vaccine Trials to Address Coronavirus Disease 2019 (COVID-19O). Clin Infect Dis 2021; 73:2126-2130. [PMID: 33758912 PMCID: PMC8083612 DOI: 10.1093/cid/ciab239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Indexed: 11/13/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) vaccines are being developed and implemented with unprecedented speed. Accordingly, trials considered ethical at their inception may quickly become concerning. We provide recommendations for Data and Safety Monitoring Boards (DSMBs) on monitoring the ethical acceptability of COVID-19 vaccine trials, focusing on placebo-controlled trials in low- and middle-income countries.
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Affiliation(s)
- Lisa Eckstein
- School of Law, University of Tasmania, Hobart, Australia
| | - Annette Rid
- Clinical Center Department of Bioethics & Division of AIDS, National Institutes of Health, Bethesda, MarylandUSA
| | - Dorcas Kamuya
- Health Systems and Research Ethics (HSRE) Department, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Seema K Shah
- Department of Pediatrics, Chicago, IllinoisUSA
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation (SCHORE) Center; Stanley Manne Children’s Research Institute; Lurie Children’s Hospital, Chicago, IllinoisUSA
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Shah SK, London AJ, Mofenson L, Lavery JV, John-Stewart G, Flynn P, Theron G, Bangdiwala SI, Moodley D, Chinula L, Fairlie L, Sekoto T, Kakhu TJ, Violari A, Dadabhai S, McCarthy K, Fowler MG. Ethically designing research to inform multidimensional, rapidly evolving policy decisions: Lessons learned from the PROMISE HIV Perinatal Prevention Trial. Clin Trials 2021; 18:681-689. [PMID: 34524048 DOI: 10.1177/17407745211045734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Research in rapidly evolving policy contexts can lead to the following ethical challenges for sponsors and researchers: the study's standard of care can become different than what patients outside the study receive, there may be political or other pressure to move ahead with unproven interventions, and new findings or revised policies may decrease the relevance of ongoing studies. These ethical challenges are considerable, but not unprecedented. In this article, we review the case of a multinational, randomized, controlled perinatal HIV prevention trial, the "PROMISE" (Promoting Maternal Infant Survival Everywhere) study. PROMISE compared the relative efficacy and safety of interventions to prevent mother to child transmission of HIV. The sponsor engaged an independent international ethics panel to address controversy about the study's standard of care and relevance as national and international guidelines changed. This ethics panel concluded that continuing the PROMISE trial as designed was ethically permissible because: (1) participants in all arms received interventions that were effective, and there was insufficient evidence about whether one intervention was more effective or safer than the other, and (2) data from PROMISE could be useful for a diverse range of stakeholders. In general, trials designed to inform rapidly evolving policy issues should develop mechanisms to revisit social value while recognizing that the value of research varies for diverse stakeholders with legitimate reasons to weigh evidence differently. We conclude by providing four reasons that trials may depart from the standard of care after a change in policy, while remaining ethically justifiable, and by suggesting how to improve existing trial oversight mechanisms to address evolving social value.
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Affiliation(s)
- Seema K Shah
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation (SCHORE) Center, Stanley Manne Children's Research Institute, Lurie Children's Hospital, Northwestern Pritzker School of Law, by courtesy, Chicago, IL, USA
| | - Alex John London
- Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - James V Lavery
- Global Health Ethics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Patricia Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
| | | | - Dhayendre Moodley
- Centre for AIDS Research in South Africa and Department of Obstetrics and Gynecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Tumalano Sekoto
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Tebogo J Kakhu
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Sufia Dadabhai
- Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | | | - Mary Glenn Fowler
- Johns Hopkins University Research Collaboration, Makerere University, Kampala, Uganda
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Tannock LR, Barton-Baxter M, Stoops WW. Creation of an institutional semi-independent data monitoring committee. Clin Trials 2019; 16:523-530. [PMID: 31257918 DOI: 10.1177/1740774519859876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A major goal of the National Institutes of Health's Clinical and Translational Science Award program is to facilitate clinical research and enhance the transition of basic to clinical research. As such, a number of Clinical and Translational Science Award centers have developed services to facilitate the conduct of clinical research, including support with fulfilling regulatory requirements. METHODS The University of Kentucky sought to establish an institutional semi-independent monitoring committee to provide oversight for clinical research studies per National Institutes of Health requirements and recommendations. Our semi-independent monitoring committee was initiated in 2010. RESULTS Since the inception of our semi-independent monitoring committee we have restructured its operations and protocols to improve efficiency. This article discusses our experiences with semi-independent monitoring committee creation and growth. CONCLUSION This article summarizes our experience in creating and maturing an institutional data monitoring committee.
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Affiliation(s)
- Lisa R Tannock
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA.,Barnstable Brown Diabetes Center, University of Kentucky, Lexington, KY, USA.,Center for Clinical and Translational Science, University of Kentucky, Lexington, KY, USA
| | - Marietta Barton-Baxter
- Center for Clinical and Translational Science, University of Kentucky, Lexington, KY, USA
| | - William W Stoops
- Center for Clinical and Translational Science, University of Kentucky, Lexington, KY, USA.,Department of Behavioral Science, University of Kentucky, Lexington, KY, USA
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Abstract
Institutional review boards (IRBs) have become beleaguered by a growth in responsibilities related to research oversight in the past several decades. A number of regulatory bodies have appeared in response to these novel and complex responsibilities, seeking to respond to among other issues, conflicts of interest, new technologies, and the potential misuse of research findings. Here, we examine several examples of these novel regulatory bodies as well as a number of concerns related to them that have been largely unacknowledged. Evidence suggests that there can be disharmony and conflicts between these regulatory bodies and IRBs, a lack of clarity with regard to their roles and responsibilities, as well as shortcomings within these entities that, at times, look a lot like the worries that have long been raised in relation to IRBs. We offer a brief discussion of how some of these concerns might be ameliorated, either through a significant restructuring of the system of research oversight, or perhaps through smaller changes to these regulatory bodies.
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Affiliation(s)
- Phoebe Friesen
- 1 NYU Medical Center, Division of Medical Ethics, New York, NY, USA
| | - Barbara Redman
- 1 NYU Medical Center, Division of Medical Ethics, New York, NY, USA
| | - Arthur Caplan
- 1 NYU Medical Center, Division of Medical Ethics, New York, NY, USA
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Borg Debono V, Mbuagbaw L, Thabane L. Sharing interim trial results by the Data Safety Monitoring Board with those responsible for the trial's conduct and progress: a narrative review. Trials 2017; 18:120. [PMID: 28279205 PMCID: PMC5345177 DOI: 10.1186/s13063-017-1858-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/21/2017] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Sharing interim data, results or result extrapolations is an important issue that can affect trial integrity. The different ways in which Data Safety Monitoring Boards (DSMBs) share interim results with non-DSMB members and the acceptability of such practices are poorly understood. Our objective was to undertake a narrative review specifically on what kind of interim results, if any, should be shared by the DSMB with non-DSMB members and why. METHODS We conducted a narrative review using a systematic search strategy of several databases and major health research stakeholders. Literature was included if there was some discussion within the full text about sharing interim trial results with non-DSMB members. RESULTS About 79.6% (129/162) of included citations were based on author's views, 16.7% (27/162) on research guidelines and 3.7% (6/162) on surveys. The largest group of citations, 73/162 (45%), expresses the opinion or argument against sharing interim results with exceptions. Trailing closely, 71/162 (43.8%) of the included citations support the opinion or argument that interim results should not be shared and should remain confidential with the DSMB. Half of the six surveys support sharing in some capacity, while the other three do not. Eleven circumstances were found that potentially warrant interim result sharing by the DSMB; they relate to (1) usual practices by DSMBs, (2) trial completion threatened, (3) patient safety, (4) regulatory approval and (5) other circumstances. Dominant risks for sharing under these conditions are associated with introducing trial bias. DISCUSSION/CONCLUSION There was no majority view in the literature. However, the largest group of citations included express the idea that interim results should remain confidential with the DSMB but also acknowledge circumstances when they could be shared with non-DSMB members. Limitations of this review are that (1) the included literature predominately provides personal perspectives, not evidence, and (2) surveys found globally focus on trial monitoring practices lacking detailed information on what specifically to share, with whom and why. More research is needed with the use of a detailed survey of the clinical trial community focused on DSMB sharing interim results, to better understand and guide DSMB interim result sharing practices.
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Affiliation(s)
- Victoria Borg Debono
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario Canada
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Stanev R. Quantitative Framework for Retrospective Assessment of Interim Decisions in Clinical Trials. Med Decis Making 2016; 36:999-1010. [PMID: 27353825 PMCID: PMC5046159 DOI: 10.1177/0272989x16655346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/09/2016] [Indexed: 11/23/2022]
Abstract
This article presents a quantitative way of modeling the interim decisions of clinical trials. While statistical approaches tend to focus on the epistemic aspects of statistical monitoring rules, often overlooking ethical considerations, ethical approaches tend to neglect the key epistemic dimension. The proposal is a second-order decision-analytic framework. The framework provides means for retrospective assessment of interim decisions based on a clear and consistent set of criteria that combines both ethical and epistemic considerations. The framework is broadly Bayesian and addresses a fundamental question behind many concerns about clinical trials: What does it take for an interim decision (e.g., whether to stop the trial or continue) to be a good decision? Simulations illustrating the modeling of interim decisions counterfactually are provided.
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Affiliation(s)
- Roger Stanev
- Department of Philosophy, Ottawa Hospital Research Institute, University of Ottawa, Canada
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