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TAJUDEEN RAJI, SILAIGWANA BLESSING, YAVLINSKY ALEXEI, EDWARDS SARAHJL. Research ethics during infectious disease outbreaks: A survey of African research stakeholders using the Ebola virus disease outbreak as a case. J Public Health Afr 2023; 14:1632. [PMID: 37881726 PMCID: PMC10594595 DOI: 10.4081/jphia.2023.1632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Abstract
Conducting research during disease outbreaks can be ethically challenging as evidenced in the 2014-2016 Ebola outbreak in West Africa and COVID-19 pandemic. Yet, there has been little empirical research conducted for understanding the views and perspectives of different stakeholders regarding ethical issues in conducting research during disease outbreaks. This preliminary study was conducted to empirically explore African public health research stakeholders' views about research ethics issues during infectious disease outbreaks in Africa. We conducted an online survey of 330 participants attending the International Conference on Re-emerging and Emerging Infectious Disease (ICREID) meeting that took place from 13-15 March 2019 in Addis Ababa, Ethiopia to elicit their views on various research ethics complexities experienced in the 2014 Ebola outbreak. Study results revealed some divergent views on several ethical themes including: ethics of using unregistered interventions in outbreaks; acceptable study design; ethics review processes; risks-benefit assessment; exclusion of pregnant women and children; and biological sample and data sharing. Majority (76.3%) of respondents felt that in the absence of available standard treatments or prevention modalities, the use of investigational interventions can be ethically justifiable if there is a strong scientific rationale and favorable risk-benefit ratio. Regarding conventional placebo-controlled trials during outbreaks with high case fatality rates, respondents that considered this unethical were more than three times those that felt such design were ethically justifiable. We were somewhat surprised that a majority (almost 60%) of respondents were satisfied with the exclusion of pregnant women and children in clinical trials during outbreaks. All respondents concurred with the prioritization of informed consent for research during an outbreak. Based on our findings, research ethics guidance is needed to equip research stakeholders in dealing with ethical complexities arising in the conduct of research during emerging disease outbreaks-especially regarding using experimental interventions; placebo trial design; inclusion or justified exclusion of pregnant women and children; and biological sample/data sharing. The findings will be used in ongoing efforts of developing a consultative and coherent African-centric framework to support ethical conduct of research for future emerging infectious disease outbreaks in Africa.
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Affiliation(s)
- RAJI TAJUDEEN
- African Union, Africa CDC, Division of Public Health Institutes and Research, Addis Ababa, Ethiopia
| | - BLESSING SILAIGWANA
- NIHR Group Tackling Infections to Benefit Africa (TIBA), University of Edinburgh
| | - ALEXEI YAVLINSKY
- University College London, Institute of Health Informatics, London, London NW1 2DA
| | - SARAH JL. EDWARDS
- University College London, Science & Technology Studies, Bloomsbury, London WC1H 0AW, UK
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Chongwe G, Ali J, Kaye DK, Michelo C, Kass N. Ethics of Adaptive Designs for Randomized Controlled Trials. Ethics Hum Res 2023; 45:2-14. [PMID: 37777976 PMCID: PMC10739783 DOI: 10.1002/eahr.500178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Over recent decades, adaptive trial designs have been used more and more often for clinical trials, including randomized controlled trials (RCTs). This rise in the use of adaptive RCTs has been accompanied by debates about whether such trials offer ethical and methodological advantages over traditional, fixed RCTs. This study examined how experts on clinical trial methods and ethics believe that adaptive RCTs, compared to fixed ones, affect the ethical character of clinical research. We conducted in-depth interviews with 17 researchers from bioethics, epidemiology, biostatistics, and/or medical backgrounds. While about half believed that adaptive trials are more complex and may thus threaten autonomy, these respondents also expressed that this challenge is not insurmountable. Most respondents expressed that efficiency and potential for participant benefit were the main justifications for adaptive trials. There was tension about whether adaptive randomization in response to increasing information disrupts clinical equipoise, with some respondents insisting that uncertainty still exists and therefore clinical equipoise is not disrupted. These findings suggest that further discussion is needed to increase the awareness and utility of these study designs.
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Affiliation(s)
- Gershom Chongwe
- School of Public Health, University of Zambia, Department
of Epidemiology and Biostatistics, Box 50110, Lusaka, Zambia
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
- Tropical Diseases Research Centre, Box 71769, Ndola,
Zambia
| | - Joseph Ali
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
| | - Daniel K. Kaye
- College of Health Sciences, Department of Obstetrics and
Gynaecology, Makerere University
| | - Charles Michelo
- School of Public Health, University of Zambia, Department
of Epidemiology and Biostatistics, Box 50110, Lusaka, Zambia
| | - Nancy Kass
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
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Abdul-Rahman T, Lawal L, Meale E, Ajetunmobi OA, Toluwalashe S, Alao UH, Ghosh S, Garg N, Aborode AT, Wireko AA, Mehta A, Sikora K. Inequitable access to Ebola vaccines and the resurgence of Ebola in Africa: A state of arts review. J Med Virol 2023; 95:e28986. [PMID: 37534818 DOI: 10.1002/jmv.28986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/29/2023] [Accepted: 07/13/2023] [Indexed: 08/04/2023]
Abstract
The Ebola virus, a member of the filoviridae family of viruses, is responsible for causing Ebola Virus Disease (EVD) with a case fatality rate as high as 50%. The largest EVD outbreak was recorded in West Africa from March 2013 to June 2016, leading to over 28 000 cases and 11 000 deaths. It affected several countries, including Nigeria, Senegal, Guinea, Liberia, and Sierra Leone. Until then, EVD was predominantly reported in remote villages in central and west Africa close to tropical rainforests. Human mobility, behavioral and cultural norms, the use of bushmeat, burial customs, preference for traditional remedies and treatments, and resistance to health interventions are just a few of the social factors that considerably aid and amplify the risk of transmission. The scale and persistence of recent ebola outbreaks, as well as the risk of widespread global transmission and its ability for bioterrorism, have led to a rethinking of public health strategies to curb the disease, such as the expedition of Ebola vaccine production. However, as vaccine production lags in the subcontinent, among other challenges, the risk of another ebola outbreak is likely and feared by public health authorities in the region. This review describes the inequality of vaccine production in Africa and the resurgence of EVD, emphasizing the significance of health equality.
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Affiliation(s)
- Toufik Abdul-Rahman
- Medical Institute, Sumy State University, Sumy, Ukraine
- ICORMed Collaborative, Sumy, Ukraine
| | - Lukman Lawal
- Faculty of Clinical Sciences, University of Ilorin, Ilorin, Nigeria
| | - Emily Meale
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | | | - Soyemi Toluwalashe
- Lagos State University of College of Medicine, Faculty of Clinical Sciences, Ikeja, Nigeria
| | - Uthman Hassan Alao
- Department of Biomedical Laboratory Science, Faculty of Basic Medical Sciences, University of Ibadan, Ibadan, Nigeria
| | - Shankhaneel Ghosh
- Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan, Bhubaneswar, India
| | - Neil Garg
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | | | - Andrew Awuah Wireko
- Medical Institute, Sumy State University, Sumy, Ukraine
- ICORMed Collaborative, Sumy, Ukraine
| | - Aashna Mehta
- Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Wilhelmy S, Müller R, Gross D. Identifying the scope of ethical challenges caused by the Ebola epidemic 2014-2016 in West Africa: a qualitative study. Philos Ethics Humanit Med 2022; 17:16. [PMID: 36575529 PMCID: PMC9794467 DOI: 10.1186/s13010-022-00128-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 12/01/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The West African Ebola virus epidemic from 2014 to 2016 is unprecedented in its scale, surpassing all previous and subsequent Ebola outbreaks since 1976. This epidemic provoked a humanitarian emergency that extended to different spheres of life, making visible ethical challenges in addition to medical, economic, and social ones. The present article aims to identify and differentiate the scope of ethical issues associated with the Ebola epidemic. METHODS An online media analysis was performed on articles published from March 2014 to September 2015 in ten preselected academic journals (scientific press) and two online newspapers (lay press). Two methodological approaches were combined: a systematic literature search and a qualitative content analysis. An additional keyword search was conducted on the PubMed database for the period after the end of the Ebola epidemic (2016-2020) to obtain an overview of research dealing with medical ethics due to the epidemic and to compare these results with the identified ethical challenges. RESULTS A total of 389 articles dealing with the subject fields "Ebola epidemic" and "ethics" were researched. For qualitative content analysis, the time span with the highest article density was selected and a total of 64 articles were included (15 scientific articles, 49 popular articles). Five core ethical challenges of the Ebola epidemic emerged: 1. Responsibility and Accountability, 2. Spillover Effects, 3. Research and Development, 4. Health Communication, and 5. Resource Allocation. Articles in academic journals were dominated by the discussion of normative aspects in the area of "research and development", while newspaper articles focused on aspects of "responsibility and accountability". CONCLUSION An ethical discussion of the Ebola epidemic requires an examination of as many of the ethical dimensions involved as possible. The presented investigation of the two types of media with regard to the Ebola epidemic offers this possibility of a more comprehensive insight into this diversity as a basis for ethical discussions.
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Affiliation(s)
- Saskia Wilhelmy
- Institute for History, Theory and Ethics of Medicine, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074 Aachen, Germany
| | - Regina Müller
- Institute of Philosophy, University of Bremen, Enrique-Schmidt-Str. 7, 28359 Bremen, Germany
| | - Dominik Gross
- Institute for History, Theory and Ethics of Medicine, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074 Aachen, Germany
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Grenier C, Loniewski M, Plazy M, Onaisi R, Doucet MH, Joseph JP, Duvignaud A, Malvy D, Anglaret X, Orne-Gliemann J. Implementing an outpatient clinical trial on COVID-19 treatment in an emergency epidemic context: a mixed methods study among operational and research stakeholders within the Coverage trial, Bordeaux (France). Arch Public Health 2022; 80:245. [PMID: 36463300 PMCID: PMC9719237 DOI: 10.1186/s13690-022-00999-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 11/09/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The emergency set-up and implementation of outpatient clinical trials on epidemic emerging infectious diseases such as COVID-19 raise many issues in terms of research structuration, regulations, and health systems organization. We aimed to describe the experience and points of view of different stakeholders involved in a French home-based outpatient trial on COVID-19 and to identify the early barriers and facilitators to the trial implementation. METHODS We conducted a mixed-methods study in July 2020. A self-administered questionnaire was emailed to 213 clinical, operational and research stakeholders involved in the Coverage trial; individual semi-directed interviews were conducted among 14 stakeholders. Questionnaire data and written interview notes are presented together by key theme. RESULTS One hundred fifty six stakeholders responded to the questionnaire. 53.4% did not have prior experience in clinical research. The motivation of most stakeholders to participate in the Coverage trial was to feel useful during the pandemic. 87.9% agreed that the trial had an unusual set-up timeframe, and many regretted a certain lack of regulatory flexibility. Mobile medical teams and specific professional skills were perceived as instrumental for outpatient research. CONCLUSIONS The implementation of a home-based outpatient clinical trial on COVID-19 was perceived as relevant and innovative although requiring important adaptations of usual professional responsibilities and standard research procedures. Lessons learned from the Coverage trial underline the need for improved networks between hospital and community medicine, and call for a dedicated and reactive outpatient research platform on emerging or threatening infectious diseases.
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Affiliation(s)
- Carine Grenier
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Bordeaux, France ,grid.508062.90000 0004 8511 8605National Institute for Health and Medical Research (INSERM) UMR 1219, Bordeaux Population Health Research Centre, Bordeaux, France ,Research Institute for Sustainable Development (IRD) EMR 271, GHiGS, Bordeaux, France
| | - Macha Loniewski
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Bordeaux, France ,grid.508062.90000 0004 8511 8605National Institute for Health and Medical Research (INSERM) UMR 1219, Bordeaux Population Health Research Centre, Bordeaux, France ,Research Institute for Sustainable Development (IRD) EMR 271, GHiGS, Bordeaux, France
| | - Mélanie Plazy
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Bordeaux, France ,grid.508062.90000 0004 8511 8605National Institute for Health and Medical Research (INSERM) UMR 1219, Bordeaux Population Health Research Centre, Bordeaux, France ,Research Institute for Sustainable Development (IRD) EMR 271, GHiGS, Bordeaux, France
| | - Racha Onaisi
- grid.412041.20000 0001 2106 639XDepartment of General Practice, University of Bordeaux, Bordeaux, France
| | - Marie-Hélène Doucet
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Bordeaux, France ,grid.508062.90000 0004 8511 8605National Institute for Health and Medical Research (INSERM) UMR 1219, Bordeaux Population Health Research Centre, Bordeaux, France ,Research Institute for Sustainable Development (IRD) EMR 271, GHiGS, Bordeaux, France
| | - Jean-Philippe Joseph
- grid.412041.20000 0001 2106 639XDepartment of General Practice, University of Bordeaux, Bordeaux, France
| | - Alexandre Duvignaud
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Bordeaux, France ,grid.508062.90000 0004 8511 8605National Institute for Health and Medical Research (INSERM) UMR 1219, Bordeaux Population Health Research Centre, Bordeaux, France ,Research Institute for Sustainable Development (IRD) EMR 271, GHiGS, Bordeaux, France ,grid.42399.350000 0004 0593 7118Department of Infectious Diseases and Tropical Medicine, Division of Tropical Medicine and Clinical International Health, CHU Bordeaux, Bordeaux, France
| | - Denis Malvy
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Bordeaux, France ,grid.508062.90000 0004 8511 8605National Institute for Health and Medical Research (INSERM) UMR 1219, Bordeaux Population Health Research Centre, Bordeaux, France ,Research Institute for Sustainable Development (IRD) EMR 271, GHiGS, Bordeaux, France ,grid.42399.350000 0004 0593 7118Department of Infectious Diseases and Tropical Medicine, Division of Tropical Medicine and Clinical International Health, CHU Bordeaux, Bordeaux, France
| | - Xavier Anglaret
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Bordeaux, France ,grid.508062.90000 0004 8511 8605National Institute for Health and Medical Research (INSERM) UMR 1219, Bordeaux Population Health Research Centre, Bordeaux, France ,Research Institute for Sustainable Development (IRD) EMR 271, GHiGS, Bordeaux, France
| | - Joanna Orne-Gliemann
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Bordeaux, France ,grid.508062.90000 0004 8511 8605National Institute for Health and Medical Research (INSERM) UMR 1219, Bordeaux Population Health Research Centre, Bordeaux, France ,Research Institute for Sustainable Development (IRD) EMR 271, GHiGS, Bordeaux, France
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Lasco G, Yu VG. Pharmaceutical messianism and the COVID-19 pandemic. Soc Sci Med 2021; 292:114567. [PMID: 34794852 PMCID: PMC8734002 DOI: 10.1016/j.socscimed.2021.114567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/12/2021] [Accepted: 11/12/2021] [Indexed: 12/04/2022]
Abstract
As part of their populist performances during disease outbreaks, public officials and politicians tend to offer ‘miracle cures’ or ‘wonder drugs’ that can supposedly treat or prevent the disease in question. This article analyzes contemporary instances of what we call ‘pharmaceutical messianism’ and proposes four characteristics for this phenomenon, namely, that it: (1) emerges during times of extraordinary health crisis; (2) builds on pre-existing knowledge, practices, and sentiments; (3) borrows from medical, often heterodox, authority; and (4) involves accessible, affordable, and/or familiar substances. Demonstrating the analytic value of our framework, we present three case studies, constructed using academic and journalistic sources, during the COVID-19 pandemic: hydroxychloroquine in France, ivermectin in the Philippines, and Covid-Organics in Madagascar. We conclude by identifying some implications of our findings on public health and avenues for future research.
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Affiliation(s)
- Gideon Lasco
- Department of Anthropology, University of the Philippines Diliman, Philippines; Development Studies Program, Ateneo de Manila University, Philippines.
| | - Vincen Gregory Yu
- Development Studies Program, Ateneo de Manila University, Philippines; Social Medicine Unit, College of Medicine, University of the Philippines Manila, Philippines
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Pepe VLE, Novaes HMD, Osorio-de-Castro CGS. COVID-19 and the medicines regulation challenges in times of pandemic. CIENCIA & SAUDE COLETIVA 2021; 26:4693-4702. [PMID: 34730655 DOI: 10.1590/1413-812320212610.11472021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/26/2021] [Indexed: 09/03/2023] Open
Abstract
The SARS-CoV-2 pandemic has brought challenges related to prevention, protection and care. Coping strategies, such as social distancing, individual protection for the population and workers, increase in the number of intensive care beds, provision of human resources and equipment are necessary actions. However, there are yet no specific effective and safe medicines that justify their use. The challenge imposed on the regulatory framework for medicines is aimed at providing timely access to medicines capable of modifying the course of the disease and leading to better treatment outcomes, with health safety. Regulatory agencies must protect the health by assessing the actual benefits and harms of the medicines under these specific conditions. The article discusses the main regulatory challenges and response of regulatory agencies to the demands imposed by the COVID-19 pandemic, especially, drug development strategies and regulatory strategies related to off-label use. Emergency drug use authorization and alternatives for extended/compassionate use are addressed, as well as clinical trials, safety assessment and monitoring of adverse events.
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Affiliation(s)
- Vera Lúcia Edais Pepe
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde de Saúde Pública Sergio Arouca (ENSP), Fundação Oswaldo Cruz (Fiocruz). R. Leopoldo Bulhões 1480, 7º andar, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
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Fenton E, Chillag K. Conditions of Global Health Crisis Decision-Making-An Ethical Analysis. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:395-402. [PMID: 33860895 PMCID: PMC8050628 DOI: 10.1007/s11673-021-10100-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/10/2021] [Indexed: 06/12/2023]
Abstract
The circumstances of a public health emergency (PHE) shape reasoning and decision-making in ways that deviate from routine circumstances, where adherence to established values, principles, and methodologies is expected. Understanding what drives these deviations is critical to assessing their ethical consequences. In this paper we describe four conditions that influence decision-making during PHEs, in particular regarding the deployment and conduct of research on experimental or novel biomedical interventions. These four conditions are politicization, urgency, uncertainty, and fear. We argue that taken together these four conditions create pressure to address the most visible targets of immediate crisis events, driving emphasis on research and development of biomedical interventions. However, this emphasis raises ethical concerns regarding the extent to which attention to and investment in the underlying causes of PHEs, particularly impoverished global public health infrastructure, is diminished as a result.
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Affiliation(s)
- Elizabeth Fenton
- Bioethics Centre, University of Otago, 71 Frederick Street, Dunedin, New Zealand.
| | - Kata Chillag
- Department of Public Health, Davidson College, Davidson, NC, USA
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Osorio-de-Castro CGS, O’Mathúna D, Fernandes Esher Moritz A, Silva Miranda E. Conflicts surrounding individual and collective aspects of ethics in health emergencies. ETHICS & BEHAVIOR 2021. [DOI: 10.1080/10508422.2021.1929233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Donal O’Mathúna
- College of Nursing and Center for Bioethics and Medical Humanities, Ohio State University College of Nursing
| | - Angela Fernandes Esher Moritz
- Department of Medicines Policy and Pharmaceutical Services, Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation,
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Saleh BM, Aly EM, Hafiz M, Abdel Gawad RM, El Kheir-Mataria WA, Salama M. Ethical Dimensions of Public Health Actions and Policies With Special Focus on COVID-19. Front Public Health 2021; 9:649918. [PMID: 34409003 PMCID: PMC8365183 DOI: 10.3389/fpubh.2021.649918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/24/2021] [Indexed: 01/10/2023] Open
Abstract
During pandemics, the ethicists, public health professionals, and human rights advocates raise a red flag about different public health actions that should, at best, be addressed through integrated, global policies. How to rationalize the healthcare resources and prioritize the cases is not a recent challenge but the serious concern about that is how to achieve this while not increasing the vulnerability of the disadvantaged population. Healthcare professionals use different scoring systems as a part of their decision-making so the medical teams and triage committees can allocate resources for predictable health outcomes and prognosis as well as to appropriately triage the patients accordingly. However, the value of the existing scoring systems to manage COVID-19 cases is not well-established yet. Part of this problem includes managing non-COVID patients with chronic medical conditions like non-communicable diseases and addressing their medical needs during the pandemic complex context in a way to avoid worsening their conditions and, on the other hand, avoid hindering the establishment of comprehensive standards for dealing with COVID-19. In this article, we discuss this dilemma as well as how preexisting ethical standards were challenged by COVID-19. We also discuss how monitoring the consistent application of ethical standards during the medical trials of new medications, vaccines, or unproven medical interventions is also a critical issue.
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Affiliation(s)
- Basma M. Saleh
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Eman Mohamed Aly
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Marwa Hafiz
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Rana M. Abdel Gawad
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Wafa Abu El Kheir-Mataria
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Mohamed Salama
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
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Kitonsa J, Ggayi AB, Anywaine Z, Kisaakye E, Nsangi L, Basajja V, Nyantaro M, Watson-Jones D, Shukarev G, Ilsbroux I, Robinson C, Kaleebu P. Implementation of accelerated research: strategies for implementation as applied in a phase 1 Ad26.ZEBOV, MVA-BN-Filo two-dose Ebola vaccine clinical trial in Uganda. Glob Health Action 2021; 13:1829829. [PMID: 33073737 PMCID: PMC7594841 DOI: 10.1080/16549716.2020.1829829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background The 2013–2016 Ebola epidemic in West Africa is the worst ever caused by Ebolaviruses with over 28,000 human cases and 11,325 deaths. The World Health Organisation (WHO) declared the epidemic a public health crisis that required accelerated development of novel interventions including vaccines. The Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit (MRC/UVRI & LSHTM Uganda Research Unit) was among the African research sites that implemented the VAC52150EBL1004 Ebola vaccine trial. Objective We report on the strategies utilised by the Unit and sponsor in ensuring expedited clinical trial approval and accelerated conduct. Methods Janssen Vaccines and Prevention B.V. conducted a phase 1 trial to evaluate the safety, tolerability, and immunogenicity of heterologous two-dose vaccination regimens using Ad26.ZEBOV and MVA-BN-Filo, in healthy adults in Africa. Accelerated implementation strategies are hereby presented. Results Strategies included: holding the African Vaccine Regulatory Forum (AVAREF) joint review meeting; expedited review by institutional ethics and country-specific regulatory bodies; competitive recruitment between sites; electronic data capture (EDC); frequent study monitoring schedule; involvement of a community advisory board (CAB); and utilization of a ‘phased’ study information-sharing approach in community engagement and participant recruitment. These strategies enabled the site to acquire approvals within 2 months and enrol 47 participants within a spurn of five. The same milestone is usually acquired in at least 1 year without accelerated implementation. Conclusion The use of well-thought strategies by sponsors and research sites can enable the implementation of accelerated research. We recommend the use of similar strategies in other settings.
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Affiliation(s)
- Jonathan Kitonsa
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit , Entebbe, Uganda
| | - Abu-Baker Ggayi
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit , Entebbe, Uganda
| | - Zacchaeus Anywaine
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit , Entebbe, Uganda
| | - Eva Kisaakye
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit , Entebbe, Uganda
| | - Laura Nsangi
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit , Entebbe, Uganda
| | - Vincent Basajja
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit , Entebbe, Uganda
| | - Mary Nyantaro
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit , Entebbe, Uganda
| | | | - Georgi Shukarev
- Janssen Vaccines and Prevention B.V., Clinical Development , Leiden, The Netherlands
| | - Ine Ilsbroux
- Janssen Research & Development, Portfolio Delivery Operations, Global Development , Beerse, Belgium
| | - Cynthia Robinson
- Janssen Vaccines and Prevention B.V., Clinical Development , Leiden, The Netherlands
| | - Pontiano Kaleebu
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit , Entebbe, Uganda
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Nichol AA, Antierens A. Ethics of emerging infectious disease outbreak responses: Using Ebola virus disease as a case study of limited resource allocation. PLoS One 2021; 16:e0246320. [PMID: 33529237 PMCID: PMC7853513 DOI: 10.1371/journal.pone.0246320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Emerging infectious diseases such as Ebola Virus Disease (EVD), Nipah Virus Encephalitis and Lassa fever pose significant epidemic threats. Responses to emerging infectious disease outbreaks frequently occur in resource-constrained regions and under high pressure to quickly contain the outbreak prior to potential spread. As seen in the 2020 EVD outbreaks in the Democratic Republic of Congo and the current COVID-19 pandemic, there is a continued need to evaluate and address the ethical challenges that arise in the high stakes environment of an emerging infectious disease outbreak response. The research presented here provides analysis of the ethical challenges with regard to allocation of limited resources, particularly experimental therapeutics, using the 2013–2016 EVD outbreak in West Africa as a case study. In-depth semi-structured interviews were conducted with senior healthcare personnel (n = 16) from international humanitarian aid organizations intimately engaged in the 2013–2016 EVD outbreak response in West Africa. Interviews were recorded in private setting, transcribed, and iteratively coded using grounded theory methodology. A majority of respondents indicated a clear propensity to adopt an ethical framework of guiding principles for international responses to emerging infectious disease outbreaks. Respondents agreed that prioritization of frontline workers’ access to experimental therapeutics was warranted based on a principle of reciprocity. There was widespread acceptance of adaptive trial designs and greater trial transparency in providing access to experimental therapeutics. Many respondents also emphasized the importance of community engagement in limited resource allocation scheme design and culturally appropriate informed consent procedures. The study results inform a potential ethical framework of guiding principles based on the interview participants’ insights to be adopted by international response organizations and their healthcare workers in the face of allocating limited resources such as experimental therapeutics in future emerging infectious disease outbreaks to ease the moral burden of individual healthcare providers.
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Affiliation(s)
- Ariadne A. Nichol
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
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Bhatt A. Consent concerns in clinical trials of investigational therapies for COVID-19: Vulnerability versus voluntariness. Perspect Clin Res 2021; 11:174-177. [PMID: 33489836 PMCID: PMC7819368 DOI: 10.4103/picr.picr_271_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/26/2020] [Indexed: 11/25/2022] Open
Abstract
Obtaining informed consent from vulnerable patients participating in clinical trials of investigational therapies for COVID-19 is a major ethical challenge. Ethical and operational considerations – voluntariness, waiver, timing, time, documentation, and responsibilities of the sponsor, the investigator, and the ethics committee – are discussed briefly.
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Affiliation(s)
- Arun Bhatt
- Consultant - Clinical Research and Drug Development, Mumbai, Maharashtra, India
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Bhatt A. Clinical trials during the COVID-19 pandemic: Challenges of putting scientific and ethical principles into practice. Perspect Clin Res 2020; 11:59-63. [PMID: 32670829 PMCID: PMC7342332 DOI: 10.4103/picr.picr_77_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 03/28/2020] [Accepted: 03/30/2020] [Indexed: 12/27/2022] Open
Abstract
Global pandemic of COVID-19 is a serious unmet medical need requiring clinical research into effective therapies. Clinical trials during pandemics of infections face complex challenges of putting scientific and ethical principles into practice. Some of these issues – selection of investigational product and participants, study design, assessment of efficacy and safety, ethics review, informed consent and publication, sample size, and publications – require in-depth consideration in planning and implementation of clinical trials during pandemics.
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Affiliation(s)
- Arun Bhatt
- Consultant-Clinical Research and Drug Development, Mumbai, Maharashtra, India
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Kalra RS, Tomar D, Meena AS, Kandimalla R. SARS-CoV-2, ACE2, and Hydroxychloroquine: Cardiovascular Complications, Therapeutics, and Clinical Readouts in the Current Settings. Pathogens 2020; 9:E546. [PMID: 32645974 PMCID: PMC7400328 DOI: 10.3390/pathogens9070546] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 01/08/2023] Open
Abstract
The rapidly evolving coronavirus disease 2019 (COVID-19, caused by severe acute respiratory syndrome coronavirus 2- SARS-CoV-2), has greatly burdened the global healthcare system and led it into crisis in several countries. Lack of targeted therapeutics led to the idea of repurposing broad-spectrum drugs for viral intervention. In vitro analyses of hydroxychloroquine (HCQ)'s anecdotal benefits prompted its widespread clinical repurposing globally. Reports of emerging cardiovascular complications due to its clinical prescription are revealing the crucial role of angiotensin-converting enzyme 2 (ACE2), which serves as a target receptor for SARS-CoV-2. In the present settings, a clear understanding of these targets, their functional aspects and physiological impact on cardiovascular function are critical. In an up-to-date format, we shed light on HCQ's anecdotal function in stalling SARS-CoV-2 replication and immunomodulatory activities. While starting with the crucial role of ACE2, we here discuss the impact of HCQ on systemic cardiovascular function, its associated risks, and the scope of HCQ-based regimes in current clinical settings. Citing the extent of HCQ efficacy, the key considerations and recommendations for the use of HCQ in clinics are further discussed. Taken together, this review provides crucial insights into the role of ACE2 in SARS-CoV-2-led cardiovascular activity, and concurrently assesses the efficacy of HCQ in contemporary clinical settings.
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Affiliation(s)
- Rajkumar Singh Kalra
- AIST-INDIA DAILAB, DBT-AIST International Center for Translational & Environmental Research (DAICENTER), National Institute of Advanced Industrial Science & Technology (AIST), Higashi 1-1-1, Tsukuba 305 8565, Japan
| | - Dhanendra Tomar
- Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Avtar Singh Meena
- CSIR-Centre for Cellular and Molecular Biology (CCMB), Habsiguda, Uppal Road, Hyderabad 500 007, Telangana State, India;
| | - Ramesh Kandimalla
- Applied Biology, CSIR-Indian Institute of Chemical Technology (IICT), Uppal Road, Tarnaka, Hyderabad 500007, Telangana State, India;
- Department of Biochemistry, Kakatiya Medical College, Warangal 506007, Telangana State, India
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El Rhazi K, Adarmouch L. Ethical issues related to the hydroxychloroquine treatment prescription for Covid-19. ETHICS, MEDICINE, AND PUBLIC HEALTH 2020; 14:100547. [PMID: 32835062 PMCID: PMC7298480 DOI: 10.1016/j.jemep.2020.100547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 12/19/2022]
Abstract
The 2019-20 coronavirus pandemic (COVID-19) has led to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To date, no drugs have demonstrated safety and efficacy in randomized controlled trials for patients with COVID-19. Although the association between Hydroxychloroquine and Azithromycin efficacy lack of solid evidence-base, several governments have adopted it for all virology confirmed Covid-19 cases even for those who are asymptomatic. In the following, we aim to discuss some of the ethical issues associated with the use of this treatment association. We mainly tried to discuss the following controversial questions: Is it ethical not to treat a patient while a treatment exists and is used for other indications than Covid-19 for which it's not proven yet? If yes, is a randomized controlled trial to prove the hydroxychloroquine for the Covid-19 treatment, necessary, in the context of covid-19 pandemic? If no, is it the government's right to decide the hydroxychloroquine treatment for all covid-19 patients? And what should be the physicians' attitudes? Finally, what are the government, physicians, and patient's rights and responsibilities? The paper conclude that, since health authorities in some countries recommended this off-label use treatment, physicians are challenged by the requirement of veracity while providing care to their patients and the implications of such a requirement; they are facing the challenge of balancing this guideline and their own conviction. Furthermore, the fundamental principles of beneficence and non-maleficence, and respect for persons should underlie any reflection process to address this dilemma. In addition, in a pandemic context, the limits between the government's, practitioner's and patient's rights and obligations are not clear which could significantly endanger the universal ethical principles in clinical practice. It could also undermine any attempt to develop serious clinical trials to prove the considered off-label drug.
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Affiliation(s)
- K El Rhazi
- Department of Epidemiology and Public Health, Faculty of Medicine of Fez, Sidi Mohamed Ben-Abdillah University, Hassan II University hospital Center, 30000 Fez, Morocco
| | - L Adarmouch
- Clinical research unit, School of medicine of Marrakech, Cadi-Ayyad University, Mohammed VI, Morocco
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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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Ma X, Wang Y, Gao T, He Q, He Y, Yue R, You F, Tang J. Challenges and strategies to research ethics in conducting COVID-19 research. J Evid Based Med 2020; 13:173-177. [PMID: 32445288 PMCID: PMC7280675 DOI: 10.1111/jebm.12388] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/27/2020] [Indexed: 12/13/2022]
Abstract
The number of research involving human subjects on coronavirus disease 2019 (COVID-19) is surging, bringing challenges to the ethical review committee (ERC) in terms of reviewing speed and special ethical considerations under the pandemic. However, the existing ethical review system and regulations have their limitations to meet the demand for a prompt and efficient epidemic control. Since the research under the public health emergency is different from that carried out in familiar situations to design and implementation, the strategy for a satisfactory ERC response should balance the duty of protecting individual participants as well as the special public needs derived from the disease control. It is suggested that the ethical review-related regulations need to be updated, and a unified supervision system to the overall ERC is required. ERC collaboration, capacity-improving and efficiency-improving measures need to be taken. With respect to the reviewing guidelines, it is suggested that the international norms should be explained with more consideration of the local condition and the exceptional circumstances in this public health emergency. A joint effort needs to be taken for better research conduction.
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Affiliation(s)
- Xitao Ma
- Hospital of Chengdu University of Traditional Chinese MedicineChengduP.R. China
| | - Yanqiao Wang
- Hospital of Chengdu University of Traditional Chinese MedicineChengduP.R. China
| | - Tian Gao
- Hospital of Chengdu University of Traditional Chinese MedicineChengduP.R. China
| | - Qing He
- Hospital of Chengdu University of Traditional Chinese MedicineChengduP.R. China
| | - Yan He
- Hospital of Chengdu University of Traditional Chinese MedicineChengduP.R. China
| | - Rensong Yue
- Hospital of Chengdu University of Traditional Chinese MedicineChengduP.R. China
| | - Fengming You
- Hospital of Chengdu University of Traditional Chinese MedicineChengduP.R. China
| | - Jianyuan Tang
- Hospital of Chengdu University of Traditional Chinese MedicineChengduP.R. China
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Bhimraj A, Morgan RL, Shumaker AH, Lavergne V, Baden L, Cheng VCC, Edwards KM, Gandhi R, Muller WJ, O’Horo JC, Shoham S, Murad MH, Mustafa RA, Sultan S, Falck-Ytter Y. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. Clin Infect Dis 2020:ciaa478. [PMID: 32338708 PMCID: PMC7197612 DOI: 10.1093/cid/ciaa478] [Citation(s) in RCA: 536] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There are many pharmacologic therapies that are being used or considered for treatment of COVID-19. There is a need for frequently updated practice guidelines on their use, based on critical evaluation of rapidly emerging literature. OBJECTIVE Develop evidence-based rapid guidelines intended to support patients, clinicians and other health-care professionals in their decisions about treatment and management of patients with COVID-19. METHODS IDSA formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise. Process followed a rapid recommendation checklist. The panel prioritized questions and outcomes. Then a systematic review of the peer-reviewed and grey literature was conducted. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations. RESULTS The IDSA guideline panel agreed on 7 treatment recommendations and provided narrative summaries of other treatments undergoing evaluations. CONCLUSIONS The panel expressed the overarching goal that patients be recruited into ongoing trials, which would provide much needed evidence on the efficacy and safety of various therapies for COVID-19, given that we could not make a determination whether the benefits outweigh harms for most treatments.
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Affiliation(s)
- Adarsh Bhimraj
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario
| | - Amy Hirsch Shumaker
- VA Northeast Ohio Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Valery Lavergne
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Vincent Chi-Chung Cheng
- Queen Mary Hospital, Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rajesh Gandhi
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - William J Muller
- Division of Pediatric Infectious Diseases, Northwestern University, Chicago, Illinois
| | - John C O’Horo
- Division of Infectious Diseases, Joint Appointment Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis VA Healthcare System, Minneapolis, Minnesota
| | - Yngve Falck-Ytter
- VA Northeast Ohio Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio
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COVID-19, Chloroquine Repurposing, and Cardiac Safety Concern: Chirality Might Help. Molecules 2020; 25:molecules25081834. [PMID: 32316270 PMCID: PMC7221598 DOI: 10.3390/molecules25081834] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
The desperate need to find drugs for COVID-19 has indicated repurposing strategies as our quickest way to obtain efficacious medicines. One of the options under investigation is the old antimalarial drug, chloroquine, and its analog, hydroxychloroquine. Developed as synthetic succedanea of cinchona alkaloids, these chiral antimalarials are currently in use as the racemate. Besides the ethical concern related to accelerated large-scale clinical trials of drugs with unproven efficacy, the known potential detrimental cardiac effects of these drugs should also be considered. In principle, the safety profile might be ameliorated by using chloroquine/hydroxychloroquine single enantiomers in place of the racemate.
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Siegfried N, Narasimhan M, Logie CH, Thomas R, Ferguson L, Moody K, Remme M. Prioritising gender, equity, and human rights in a GRADE-based framework to inform future research on self care for sexual and reproductive health and rights. BMJ Glob Health 2020; 5:e002128. [PMID: 32337081 PMCID: PMC7170423 DOI: 10.1136/bmjgh-2019-002128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/28/2020] [Accepted: 02/15/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction In January 2019, the WHO reviewed evidence to develop global recommendations on self-care interventions for sexual and reproductive health and rights (SRHR). Identification of research gaps is part of the WHO guidelines development process, but reliable methods to do so are currently lacking with gender, equity and human rights (GER) infrequently prioritised. Methods We expanded a prior framework based on Grading of Evidence, Assessment, Development and Evaluation (GRADE) to include GER. The revised framework is applied systematically during the formulation of research questions and comprises: (1) assessment of the GRADE strength and quality rating of recommendations; (2) mandatory inclusion of research questions identified from a global stakeholder survey; and (3) selection of the GER standards and principles most relevant to the question through discussion and consensus. For each question, we articulated: (1) the most appropriate and robust study design; (2) an alternative pragmatic design if the ideal design was not feasible; and (3) the methodological challenges facing researchers through identifying potential biases. Results We identified 39 research questions, 7 overarching research approaches and 13 discrete feasible study designs. Availability and accessibility were most frequently identified as the GER standards and principles to consider when planning studies, followed by privacy and confidentiality. Selection and detection bias were the primary methodological challenges across mixed methods, quantitative and qualitative studies. A lack of generalisability potentially limits the use of study results with non-participation in research potentially highest in more vulnerable populations. Conclusion A framework based on GRADE that includes stakeholders’ values and identification of core GER standards and principles provides a practical, systematic approach to identifying research questions from a WHO guideline. Clear guidance for future studies will contribute to an anticipated ‘living guidelines’ approach within WHO. Foregrounding GER as a separate component of the framework is innovative but further elaboration to operationalise appropriate indicators for SRHR self-care interventions is required.
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Affiliation(s)
- Nandi Siegfried
- Independent Clinical Epidemiologist, Cape Town, South Africa
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, including UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Rebekah Thomas
- Guideline Review Committee Secretariat (Science Division), World Health Organization, Geneva, Switzerland
| | - Laura Ferguson
- Institute on Inequalities in Global Health, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kevin Moody
- Independent Consultant, Amsterdam, The Netherlands
| | - Michelle Remme
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
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Bedford J, Farrar J, Ihekweazu C, Kang G, Koopmans M, Nkengasong J. A new twenty-first century science for effective epidemic response. Nature 2019; 575:130-136. [PMID: 31695207 PMCID: PMC7095334 DOI: 10.1038/s41586-019-1717-y] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/24/2019] [Indexed: 12/20/2022]
Abstract
With rapidly changing ecology, urbanization, climate change, increased travel and fragile public health systems, epidemics will become more frequent, more complex and harder to prevent and contain. Here we argue that our concept of epidemics must evolve from crisis response during discrete outbreaks to an integrated cycle of preparation, response and recovery. This is an opportunity to combine knowledge and skills from all over the world-especially at-risk and affected communities. Many disciplines need to be integrated, including not only epidemiology but also social sciences, research and development, diplomacy, logistics and crisis management. This requires a new approach to training tomorrow's leaders in epidemic prevention and response.
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Affiliation(s)
| | | | | | - Gagandeep Kang
- Translational Health Science and Technology Institute, Faridabad, India
| | - Marion Koopmans
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John Nkengasong
- Africa Centres for Disease Control and Prevention, African Union, Addis Ababa, Ethiopia
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Agrawal S, Vamadevan P, Mazibuko N, Bannister R, Swery R, Wilson S, Edwards S. A New Method for Ethical and Efficient Evidence Generation for Off-Label Medication Use in Oncology (A Case Study in Glioblastoma). Front Pharmacol 2019; 10:681. [PMID: 31316378 PMCID: PMC6610246 DOI: 10.3389/fphar.2019.00681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/27/2019] [Indexed: 12/23/2022] Open
Abstract
In oncology, preclinical and early clinical data increasingly support the use of a number of candidate "non-cancer" drugs in an off-label setting against multiple tumor types. In particular, metabolically targeted drugs show promise as adjuvant chemo and radiosensitizers, improving or restoring sensitivity to standard therapies. The time has come for large scale clinical studies of off-label drugs in this context. However, it is well recognized that high-cost randomized controlled trials may not be an economically viable option for studying patent-expired off-label drugs. In some cases, randomized trials could also be considered as ethically controversial. This perspective article presents a novel approach to generating additional clinical data of sufficient quality to support changes in clinical practice and relabeling of such drugs for use in oncology. Here, we suggest that a pluralistic evidence base and triangulation of evidence can support clinical trial data for off-label drug use in oncology. An example of an off-label drug protocol brought to the clinic for glioblastoma patients is presented, along with preliminary retrospective data from the METRICS study (NCT02201381). METRICS is a novel participant-funded, open-label, non-randomized, single-arm real-world study designed to gather high-quality evidence on the safety, tolerability, and effectiveness of four off-label metabolically targeted medicines as an adjunctive cancer treatment for glioblastoma patients.
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Affiliation(s)
- Samir Agrawal
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- St Bartholomew’s Hospital, Bart’s Health NHS Trust, London, United Kingdom
| | | | - Ndaba Mazibuko
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | | | | | | | - Sarah Edwards
- Department of Science and Technology Studies, University College London, London, United Kingdom
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Alenichev A, Peeters Grietens K, Gerrets R. Conceptions within misconceptions: Pluralisms in an Ebola vaccine trial in West Africa. Glob Public Health 2019; 15:13-21. [PMID: 31237180 DOI: 10.1080/17441692.2019.1632368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Ensuring that biomedical information about research procedures is adequately understood by participants and their communities is key for conducting ethical research. This article explores participants' understanding of trial procedures for an experimental vaccine against Ebola virus disease (EVD) in a West African context. We found that some trial participants believed there was a chance of contracting Ebola and other sicknesses from the vaccine, and others believed both the vaccine and the placebo control would be able to prevent other illnesses than EVD. While these beliefs might be understood as misconceptions about the vaccine trial, this paper shows that such a conclusion is problematic because it excludes local explanatory health models and logics of causality. The paper invites bioethicists to work with anthropologists to take seriously different models of health knowledge in global health research. Investigating and addressing such differences could be the key to understanding human subjects' motives for participation, and to creating space for studies of empirical ethics.
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Affiliation(s)
- Arsenii Alenichev
- Department of Anthropology, University of Amsterdam, Amsterdam, Netherlands.,The Barcelona Institute for Global Health, Barcelona, Spain
| | | | - René Gerrets
- Department of Anthropology, University of Amsterdam, Amsterdam, Netherlands
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25
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Pace J, Ghinea N, Kerridge I, Lipworth W. An ethical framework for the creation, governance and evaluation of accelerated access programs. Health Policy 2018; 122:984-990. [DOI: 10.1016/j.healthpol.2018.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 07/07/2018] [Accepted: 07/14/2018] [Indexed: 12/23/2022]
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26
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Brown B, Ortiz C, Dubé K. Assessment of the Right-to-Try Law: The Pros and the Cons. J Nucl Med 2018; 59:1492-1493. [PMID: 30097502 DOI: 10.2967/jnumed.118.216945] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/18/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Brandon Brown
- Center for Healthy Communities, Department of Social Medicine, Population, and Public Health, University of California Riverside School of Medicine, Riverside, California
| | - Camerin Ortiz
- Syracuse University, Department of Biology, Syracuse, New York; and
| | - Karine Dubé
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
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27
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Mooney T, Smout E, Leigh B, Greenwood B, Enria L, Ishola D, Manno D, Samai M, Douoguih M, Watson-Jones D. EBOVAC-Salone: Lessons learned from implementing an Ebola vaccine trial in an Ebola-affected country. Clin Trials 2018; 15:436-443. [PMID: 29895178 PMCID: PMC6136072 DOI: 10.1177/1740774518780678] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background/aims During the 2014–2016 West African Ebola epidemic, clinical trials were
fast-tracked in order to identify prophylactic vaccines and experimental
treatments that might be useful in preventing or treating Ebola. These
trials included the ongoing EBOVAC-Salone study, which was established and
implemented in Sierra Leone to assess the safety and immunogenicity of the
Ad26.ZEBOV/MVA-BN-Filo prime-boost Ebola vaccine regimen. Methods This article describes the experiences of the EBOVAC-Salone research team in
setting up and implementing the trial, and provides recommendations for
research teams aiming to conduct clinical trials in future outbreak
situations. Results Establishing a clinical trial during an outbreak brought some unique
challenges, including those related to trial design and the regulatory
environment, operational issues, and community engagement. The situation was
further complicated by the weak infrastructure and limited experience of
clinical trials in Sierra Leone. However, operating in an outbreak context
also brought some benefits to the research team, including strong
stakeholder support. The EBOVAC-Salone study recruited participants both
during and after the outbreak, leading to additional challenges to trial
implementation during the post-outbreak transition. Conclusion Many lessons have been learned about setting up and implementing a clinical
trial during a devastating Ebola epidemic, and some of the experiences of
the EBOVAC-Salone team were mirrored by those of other researchers operating
in the region. Common to several of these research groups is a
recommendation that research should be more closely incorporated into
outbreak response planning, which could expedite the establishment of timely
and appropriate research projects. We recommend that the lessons learned by
researchers during the West African Ebola epidemic are built into programmes
and strategies to improve the responses to future epidemics, wherever they
occur.
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Affiliation(s)
- Thomas Mooney
- 1 London School of Hygiene & Tropical Medicine, London, UK
| | | | - Bailah Leigh
- 2 College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | | | - Luisa Enria
- 1 London School of Hygiene & Tropical Medicine, London, UK.,3 University of Bath, Bath, UK
| | - David Ishola
- 1 London School of Hygiene & Tropical Medicine, London, UK
| | - Daniela Manno
- 1 London School of Hygiene & Tropical Medicine, London, UK
| | - Mohamed Samai
- 2 College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Macaya Douoguih
- 4 Janssen Pharmaceutical Companies of Johnson & Johnson, Leiden, The Netherlands
| | - Deborah Watson-Jones
- 1 London School of Hygiene & Tropical Medicine, London, UK.,5 Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
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28
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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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29
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Abstract
The recent Ebola and Zika epidemics demonstrate the need for the continuous surveillance, rapid diagnosis and real-time tracking of emerging infectious diseases. Fast, affordable sequencing of pathogen genomes - now a staple of the public health microbiology laboratory in well-resourced settings - can affect each of these areas. Coupling genomic diagnostics and epidemiology to innovative digital disease detection platforms raises the possibility of an open, global, digital pathogen surveillance system. When informed by a One Health approach, in which human, animal and environmental health are considered together, such a genomics-based system has profound potential to improve public health in settings lacking robust laboratory capacity.
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Affiliation(s)
- Jennifer L. Gardy
- British Columbia Centre for Disease Control, Vancouver, V5Z 4R4 British Columbia Canada
- School of Population and Public Health, University of British Columbia, Vancouver, V6T 1Z3 British Columbia Canada
| | - Nicholas J. Loman
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, B15 2TT UK
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30
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Haire B. Aspects of disaster research ethics applicable to other contexts. JOURNAL OF MEDICAL ETHICS 2018; 44:9-10. [PMID: 27872145 DOI: 10.1136/medethics-2016-103843] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/01/2016] [Indexed: 06/06/2023]
Abstract
In his article 'The Ebola Clinical Trials: a precedent for research ethics in disasters', Philippe Calain constructs a compelling case as to why and how experiences from the recent Ebola epidemic should be used to develop a framework for disaster research ethics. In particular, Calain proposes a useful model for assessing whether or not an unproven intervention could be suitable for human use in a disaster context, and makes a powerful argument against the separation of patient care from research goals. In this commentary, I argue that the separation of patient care goals from research goals is also unhelpful in the context of other forms of participant disadvantage even when that disadvantage is less severe than an ongoing public health emergency. I contend that recognising that research in disadvantaged populations is an intervention that could and should aim to produce positive outcomes for participants, just as it should in disaster contexts, therefore seems a well-justified lesson that can be extrapolated from the experience of the Ebola epidemic.
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31
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Rid A. Individual and public interests in clinical research during epidemics: a reply to Calain : In response to: Calain P. The Ebola clinical trials: a precedent for research ethics in disasters. JOURNAL OF MEDICAL ETHICS 2018; 44:11-12. [PMID: 28137997 DOI: 10.1136/medethics-2016-104120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/06/2017] [Indexed: 06/06/2023]
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32
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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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33
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Ganguli-Mitra A, Dove ES, Laurie GT, Taylor-Alexander S. Reconfiguring Social Value in Health Research Through the Lens of Liminality. BIOETHICS 2017; 31:87-96. [PMID: 28060429 PMCID: PMC5244658 DOI: 10.1111/bioe.12324] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 09/15/2016] [Accepted: 10/06/2016] [Indexed: 06/06/2023]
Abstract
Despite the growing importance of 'social value' as a central feature of research ethics, the term remains both conceptually vague and to a certain extent operationally rigid. And yet, perhaps because the rhetorical appeal of social value appears immediate and self-evident, the concept has not been put to rigorous investigation in terms of its definition, strength, function, and scope. In this article, we discuss how the anthropological concept of liminality can illuminate social value and differentiate and reconfigure its variegated approaches. Employing liminality as a heuristic encourages a reassessment of how we understand the mobilization of 'social value' in bioethics. We argue that social value as seen through the lens of liminality can provide greater clarity of its function and scope for health research. Building on calls to understand social value as a dynamic, rather than a static, concept, we emphasize the need to appraise social value iteratively throughout the entire research as something that transforms over multiple times and across multiple spaces occupied by a range of actors.
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34
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Higgs ES, Dubey SA, Coller BAG, Simon JK, Bollinger L, Sorenson RA, Wilson B, Nason MC, Hensley LE. Accelerating Vaccine Development During the 2013-2016 West African Ebola Virus Disease Outbreak. Curr Top Microbiol Immunol 2017; 411:229-261. [PMID: 28918539 DOI: 10.1007/82_2017_53] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Ebola virus disease outbreak that began in Western Africa in December 2013 was unprecedented in both scope and spread, and the global response was slower and less coherent than was optimal given the scale and pace of the epidemic. Past experience with limited localized outbreaks, lack of licensed medical countermeasures, reluctance by first responders to direct scarce resources to clinical research, community resistance to outside interventions, and lack of local infrastructure were among the factors delaying clinical research during the outbreak. Despite these hurdles, the global health community succeeded in accelerating Ebola virus vaccine development, in a 5-month interval initiating phase I trials in humans in September 2014 and initiating phase II/III trails in February 2015. Each of the three Ebola virus disease-affected countries, Sierra Leone, Guinea, and Liberia, conducted a phase II/III Ebola virus vaccine trial. Only one of these trials evaluating recombinant vesicular stomatitis virus expressing Ebola virus glycoprotein demonstrated vaccine efficacy using an innovative mobile ring vaccination trial design based on a ring vaccination strategy responsible for eradicating smallpox that reached areas of new outbreaks. Thoughtful and intensive community engagement in each country enabled the critical community partnership and acceptance of the phase II/III in each country. Due to the delayed clinical trial initiation, relative to the epidemiologic peak of the outbreak in the three countries, vaccine interventions may or may not have played a major role in bringing the epidemic under control. Having demonstrated that clinical trials can be performed during a large outbreak, the global research community can now build on the experience to implement trials more rapidly and efficiently in future outbreaks. Incorporating clinical research needs into planning for future health emergencies and understanding what kind of trial designs is needed for reliable results in an epidemic of limited duration should improve global response to future infectious disease outbreaks.
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Affiliation(s)
- Elizabeth S Higgs
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
| | | | | | | | - Laura Bollinger
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, MD, USA
| | - Robert A Sorenson
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Martha C Nason
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Lisa E Hensley
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, MD, USA
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