Balasingam S, Horby P, Wilder-Smith A
Correspondence: Ms Shobana Balasingam, shoba35@hotmail.com
ABSTRACT
For over 100 years, controlled human infection (CHI) studies have been performed to advance the understanding of the pathogenesis, treatment and prevention of infectious diseases. This methodology has seen a resurgence, as it offers an efficient model for selecting the most promising agents for further development from available candidates. CHI studies are utilised to bridge safety and immunogenicity testing and phase II/III efficacy studies. However, as this platform is not currently utilised in Asia, opportunities to study therapeutics and vaccines for infections that are important in Asia are missed. This review examines the regulatory differences for CHI studies between countries and summarises other regulatory differences in clinical trials as a whole. We found that the regulations that would apply to CHI studies in Singapore closely mirror those in the United Kingdom, and conclude that the regulatory and ethical guidelines in Singapore are compatible with the conduct of CHI studies.
Keywords: challenge studies, controlled human infections, ethics, experimental infections, GCP
Singapore Med J 2014; 55(9): 456-461; http://dx.doi.org/10.11622/smedj.2014114
REFERENCES
1. Pollard AJ, Savulescu J, Oxford J, et al. Human microbial challenge: the ultimate animal model. Lancet Infect Dis 2012; 12:903-5. http://dx.doi.org/10.1016/S1473-3099(12)70292-X | ||||
2. Riedel S. Edward Jenner and the history of smallpox and vaccination. Proc (Bayl Univ Med Cent) 2005; 18:21-5. | ||||
3. Clinical trials: Steps in malaria vaccine development. In: Malaria Vaccine Initiative [online]. Available in: http://www.malariavaccine.org/rd-clinical-trials.php. Accessed August 25, 2014. | ||||
4. Lillie PJ, Berthoud TK, Powell TJ, et al. Preliminary assessment of the efficacy of a T-cell-based influenza vaccine, MVA-NP+M1, in humans. Clin Infect Dis 2012; 55:19-25. http://dx.doi.org/10.1093/cid/cis327 | ||||
5. Youngner JS, Treanor JJ, Betts RF, Whitaker-Dowling P. Effect of simultaneous administration of cold-adapted and wild-type influenza A viruses on experimental wild-type influenza infection in humans. J Clin Microbiol 1994; 32:750-4. PMid:8195389 PMCid:PMC263119 | ||||
6. Jones S, Evans K, McElwaine-Johnn H, et al. DNA vaccination protects against an influenza challenge in a double-blind randomised placebo?controlled phase 1b clinical trial. Vaccine 2009; 27:2506-12. http://dx.doi.org/10.1016/j.vaccine.2009.02.061 | ||||
7. Hayden FG, Jennings L, Robson R, et al. Oral oseltamivir in human experimental influenza B infection. Antivir Ther 2000; 5:205-13. PMid:11075941 | ||||
8. Wilkinson TM, Li CK, Chui CS, et al. Preexisting influenza-specific CD4+ T cells correlate with disease protection against influenza challenge in humans. Nat Med 2012; 18:274-80. http://dx.doi.org/10.1038/nm.2612 | ||||
9. Treanor JJ, Kotloff K, Betts RF, et al. Evaluation of trivalent, live, cold-adapted (CAIV-T) and inactivated (TIV) influenza vaccines in prevention of virus infection and illness following challenge of adults with wild-type influenza A (H1N1), A (H3N2), and B viruses. Vaccine 1999; 18:899-906. http://dx.doi.org/10.1016/S0264-410X(99)00334-5 | ||||
10. Hayden FG, Fritz R, Lobo MC, et al. Local and systemic cytokine responses during experimental human influenza A virus infection. Relation to symptom formation and host defense. J Clin Invest 1998; 101:643-9. http://dx.doi.org/10.1172/JCI1355 | ||||
11. Zaas AK, Chen M, Varkey J, et al. Gene expression signatures diagnose influenza and other symptomatic respiratory viral infections in humans. Cell Host Microbe 2009; 6:207-17. http://dx.doi.org/10.1016/j.chom.2009.07.006 | ||||
12. Verhage DF, Telgt DS, Bousema JT, et al. Clinical outcome of experimental human malaria induced by Plasmodium falciparum-infected mosquitoes. Neth J Med 2005; 63:52-8. PMid:15768480 | ||||
13. Thompson FM, Porter DW, Okitsu SL, et al. Evidence of blood stage efficacy with a virosomal malaria vaccine in a phase IIa clinical trial. PLoS One 2008; 3:e1493. http://dx.doi.org/10.1371/journal.pone.0001493 | ||||
14. Webster DP, Dunachie S, Vuola JM, et al. Enhanced T cell-mediated protection against malaria in human challenges by using the recombinant poxviruses FP9 and modified vaccinia virus Ankara. Proc Natl Acad Sci U S A 2005; 102:4836-41. http://dx.doi.org/10.1073/pnas.0406381102 | ||||
15. Kester KE, Cummings JF, Ofori-Anyinam O, et al. Randomized, double-blind, phase 2a trial of falciparum malaria vaccines RTS,S/AS01B and RTS,S/AS02A in malaria-naive adults: safety, efficacy, and immunologic associates of protection. J Infect Dis 2009; 200:337-46. http://dx.doi.org/10.1086/600120 | ||||
16. Porter DW, Thompson FM, Berthoud TK, et al. A human Phase I/IIa malaria challenge trial of a polyprotein malaria vaccine. Vaccine 2011; 29:7514?22. http://dx.doi.org/10.1016/j.vaccine.2011.03.083 | ||||
17. DeVincenzo J, Lambkin-Williams R, Wilkinson T, et al. A randomized, double-blind, placebo-controlled study of an RNAi-based therapy directed against respiratory syncytial virus. Proc Natl Acad Sci U S A 2010; 107:8800-5. http://dx.doi.org/10.1073/pnas.0912186107 | ||||
18. DeVincenzo JP, Wilkinson T, Vaishnaw A, et al. Viral load drives disease in humans experimentally infected with respiratory syncytial virus. Am J Respir Crit Care Med 2010; 182:1305-14. http://dx.doi.org/10.1164/rccm.201002-0221OC | ||||
19. Gunther VJ, Putnak R, Eckels KH, et al. A human challenge model for dengue infection reveals a possible protective role for sustained interferon gamma levels during the acute phase of illness. Vaccine 2011; 29:3895?904. http://dx.doi.org/10.1016/j.vaccine.2011.03.038 | ||||
20. Statler J, Mammen M, Lyons A, Sun W. Sonographic findings of healthy volunteers infected with dengue virus. J Clin Ultrasound 2008; 36:413-7. http://dx.doi.org/10.1002/jcu.20476 | ||||
21. Sun W, Eckels KH, Putnak JR, et al. Experimental dengue virus challenge of human subjects previously vaccinated with live attenuated tetravalent dengue vaccines. J Infect Dis 2013; 207:700-8. http://dx.doi.org/10.1093/infdis/jis744 | ||||
22. Atmar RL, Bernstein DI, Harro CD, et al. Norovirus vaccine against experimental human Norwalk Virus illness. N Engl J Med 2011; 365:2178?87. http://dx.doi.org/10.1056/NEJMoa1101245 | ||||
23. Atmar RL, Opekun AR, Gilger MA, et al. Norwalk virus shedding after experimental human infection. Emerg Infect Dis 2008; 14:1553-7. http://dx.doi.org/10.3201/eid1410.080117 | ||||
24. García L, Jidy MD, García H, et al. The vaccine candidate Vibrio cholerae 638 is protective against cholera in healthy volunteers. Infect Immun 2005; 73:3018-24. http://dx.doi.org/10.1128/IAI.73.5.3018-3024.2005 | ||||
25. Glickman SW, McHutchison JG, Peterson ED, et al. Ethical and scientific implications of the globalization of clinical research. N Engl J Med 2009; 360:816-23. http://dx.doi.org/10.1056/NEJMsb0803929 | ||||
26. [No authors listed]. Medical Ethics: The Japanese Version: Unit 731. In: Psychiatry, It's A Killing [online]. Available at: http://psychroaches.blogspot.sg/2009/07/medicalethics-japanese-version-u.... Accessed June 5, 2014. | ||||
27. Hornblum AM. They were cheap and available: prisoners as research subjects in twentieth century America. BMJ 1997; 315:1437-41. http://dx.doi.org/10.1136/bmj.315.7120.1437 | ||||
28. Chernin E. Richard Pearson Strong and the iatrogenic plague disaster in Bilibid Prison, Manila, 1906. Rev Infect Dis 1989; 11:996-1004. http://dx.doi.org/10.1093/clinids/11.6.996 | ||||
29. Shuster E. Fifty years later: the significance of the Nuremberg Code. N Engl J Med 1997; 337:1436-40. http://dx.doi.org/10.1056/NEJM199711133372006 | ||||
30. World Medical Association Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects [online]. Available at: http://www.wma.net/en/30publications/10policies/b3/17c.pdf. Accessed June 5 2014. | ||||
31. Vijayananthan A, Nawawi O. The importance of Good Clinical Practice guidelines and its role in clinical trials. Biomed Imaging Interv J 2008; 4:e5. http://dx.doi.org/10.2349/biij.4.1.e5 | ||||
32. Miller FG, Grady C. The ethical challenge of infection-inducing challenge experiments. Clin Infect Dis 2001; 33:1028-33. http://dx.doi.org/10.1086/322664 | ||||
33. Lynch HF. The rights and wrongs of intentional exposure research: contextualising the Guatemala STD inoculation study. J Med Ethics 2012; 38:513-5. http://dx.doi.org/10.1136/medethics-2011-100379 | ||||
34. Hope T, McMillan J. Challenge studies of human volunteers: ethical issues. J Med Ethics 2004; 30:110-6. http://dx.doi.org/10.1136/jme.2003.004440 | ||||
35. The Academy of Medical Sciences. Microbial Challenge Studies of Human Volunteers. A guidance document from the Academy of Medical Science [online]. Available at: http://www.acmedsci.ac.uk/viewFile/publicationDownloads/1127728424.pdf. Accessed November 5, 2013. | ||||
36. European Medicines Agency. Committee for Human Medicinal Products (CHMP). Note for Guidance on the Clinical Evaluation of Vaccines. 17 May 2005 [online]. Available at http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guidelin.... Accessed November 5, 2013. | ||||
37. US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research (CDER), Center for Biologics Evaluation and Research (CBER), Center for Food Safety and Applied Nutrition (CFSAN). Guidance for Clinical Investigators, Sponsors, and IRBS. Investigational New Drug Applications (INDs)– Determining Whether Human Research Studies Can Be Conducted Without an IND [online]. Available at: http://www.fda.gov/downloads/Drugs/Guidances/UCM229175.pdf. Accessed October 7, 2013. | ||||
38. European Medicines Agency. ICH Topic E 6 (R1) Guidance for Good Clinical Practice. Note for Guidance on Good Clinical Practice. CPMP/ICH/135/95). Step 5 [online]. Available at: http://www.edctp.org/fileadmin/documents/EMEA_ICHGCP_Guidelines_July_200.... Accessed November 5, 2013. | ||||
39. Burgess LJ, Pretorius D. FDA abandons the Declaration of Helsinki: The effect on the ethical aspects of clinical trial conduct in South Africa and other developing countries. S Afr J Bioethics Law 2012; 5:87-90. | ||||
40. World Medical Association. WMA Published its Revised Declaration of Helsinki [online]. Available at: http://www.wma.net/en/40news/20archives/2013/2013_28//. Accessed June 4, 2014. | ||||
41. TMQA. TMQA Regulatory News Update - July 2014 [online]. Available at: www.tmqa.co.uk/Pages/regulatory_news_1407.html. Accessed September 8, 2014. | ||||
42. Health Sciences Authority. Clinical Drug Trials in Singapore [online]. Available at: http://www.hsa.gov.sg/content/hsa/en/Health_Products_Regulation/Clinical.... Accessed August 25, 2014. | ||||
43. US Department of Health and Human Services, Food and Drug Administration, Center for Biologics Evaluation and Research. Guidance for Industry. Characterization and Qualification of Cell Substrates and Other Biological Materials Used in the Production of Viral Vaccines for Infectious Disease Indications [online]. Available at: http://www.fda.gov/downloads/biologicsbloodvaccines/guidancecompliancere.... Accessed October 7, 2013. | ||||
44. European Commission Health and Consumers Directorate-General. The Rules Governing Medical Products in the European Union Volume 10 – Guidance Documents Applying to Clinical Trials. Guidance on Investigational Medicinal Products (IMPs) and 'Non Investigational Medicinal Products' (NIMPs)(Rev, 1 March 2011)[online]. Available at: http://ec.europa.eu/health/files/eudralex/vol-10/imp_03-2011.pdf. Accessed October 7, 2013. | ||||
45. European Commission Enterprise Directorate-General. Working Party on Control of Medicines and Inspections. Final Version of Annex 16 to the EU Guide to Good Manufacturing Practice. Certification by a Qualified Person and Batch Release [online]. Available at: http://ec.europa.eu/health/files/eudralex/vol-4/pdfs-m/v4_an16_200408_en.... Accessed November 7, 2013. | ||||
46. US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research (CDER). Guidance for Industry Influenza: Developing Drugs for Treatment and/or Prophylaxis [online]. Available at: http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformati.... Accessed November 7, 2013. | ||||
47. Singapore Guideline for Good Clinical Practice (SGGCP). Adapted from the ICH Harmonised Tripartite Guideline E6: Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95)[online]. Available at: file:///C:/Users/Faizzah/Downloads/SG_Good_Clinical_Practice_Oct_1999.pdf. Accessed November 5, 2013. | ||||
48. Fenty A. Clinical Trial Requirements. Similarities and Differences US vs. EU [online]. Available at: http://www.slideshare.net/RETIRE/clinical-trial-requirements-us-vs-eusim.... Accessed October 10, 2013. |