Real-time dynamic modelling for the design of a cluster-randomized phase 3 Ebola vaccine trial in Sierra Leone.

BACKGROUND: Declining incidence and spatial heterogeneity complicated the design of phase 3 Ebola vaccine trials during the tail of the 2013-16 Ebola virus disease (EVD) epidemic in West Africa. Mathematical models can provide forecasts of expected incidence through time and can account for both vaccine efficacy in participants and effectiveness in populations. Determining expected disease incidence was critical to calculating power and determining trial sample size. METHODS: In real-time, we fitted, forecasted, and simulated a proposed phase 3 cluster-randomized vaccine trial for a prime-boost EVD vaccine in three candidate regions in Sierra Leone. The aim was to forecast trial feasibility in these areas through time and guide study design planning. RESULTS: EVD incidence was highly variable during the epidemic, especially in the declining phase. Delays in trial start date were expected to greatly reduce the ability to discern an effect, particularly as a trial with an effective vaccine would cause the epidemic to go extinct more quickly in the vaccine arm. Real-time updates of the model allowed decision-makers to determine how trial feasibility changed with time. CONCLUSIONS: This analysis was useful for vaccine trial planning because we simulated effectiveness as well as efficacy, which is possible with a dynamic transmission model. It contributed to decisions on choice of trial location and feasibility of the trial. Transmission models should be utilised as early as possible in the design process to provide mechanistic estimates of expected incidence, with which decisions about sample size, location, timing, and feasibility can be determined.

Canagliflozin improves glycaemic control over 28 days in subjects with type 2 diabetes not optimally controlled on insulin.

AIM: Canagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor that is being investigated for the treatment of type 2 diabetes mellitus (T2DM). METHODS: This was a randomized, double-blind, placebo-controlled, parallel-group, 28-day study conducted at two sites, in 29 subjects with T2DM not optimally controlled on insulin and up to one oral antihyperglycaemic agent. Subjects were treated with canagliflozin 100 mg QD or 300 mg twice daily (BID) or placebo. Safety, tolerability, pharmacokinetic characteristics and pharmacodynamic effects of canagliflozin were examined. Glucose malabsorption following a 75-g oral glucose challenge was also examined. RESULTS: Canagliflozin pharmacokinetics were dose-dependent, and the elimination half-life ranged from 12 to 15 h. After 28 days, the renal threshold for glucose excretion was reduced; urinary glucose excretion was increased; and A1C, fasting plasma glucose and body weight decreased in subjects administered canagliflozin (A1C reductions: 0.19% with placebo, 0.73% with 100 mg QD, 0.92% with 300 mg BID; body weight changes: 0.03 kg increase with placebo, 0.73 kg reduction with 100 mg QD, 1.19 kg reduction with 300 mg BID). Glucose malabsorption was not observed with canagliflozin treatment. There were no deaths, serious adverse events or severe hypoglycaemic episodes. The incidence of adverse events was similar across groups. There were no clinically meaningful changes in routine laboratory safety tests, vital signs or electrocardiograms. CONCLUSION: In subjects receiving insulin and oral antihyperglycaemic therapy, canagliflozin was well tolerated without evidence for glucose malabsorption, had pharmacokinetic characteristics consistent with once-daily dosing, and improved glycaemic control.

Causal proportional hazards models and time-constant exposure in randomized clinical trials.

The last decade saw enormous progress in the development of causal inference tools to account for noncompliance in randomized clinical trials. With survival outcomes, structural accelerated failure time (SAFT) models enable causal estimation of effects of observed treatments without making direct assumptions on the compliance selection mechanism. The traditional proportional hazards model has however rarely been used for causal inference. The estimator proposed by Loeys and Goetghebeur (2003, Biometrics vol. 59 pp. 100-105) is limited to the setting of all or nothing exposure. In this paper, we propose an estimation procedure for more general causal proportional hazards models linking the distribution of potential treatment-free survival times to the distribution of observed survival times via observed (time-constant) exposures. Specifically, we first build models for observed exposure-specific survival times. Next, using the proposed causal proportional hazards model, the exposure-specific survival distributions are backtransformed to their treatment-free counterparts, to obtain - after proper mixing - the unconditional treatment-free survival distribution. Estimation of the parameter(s) in the causal model is then based on minimizing a test statistic for equality in backtransformed survival distributions between randomized arms.

Correlation between type of adaptive immune response against porcine circovirus type 2 and level of virus replication.

Porcine circovirus 2 (PCV2) replication is characterized by high variation among infected pigs. This study investigated the role of immunologic responses in causing this variation. Twelve gnotobiotic pigs were inoculated with PCV2. Four of these pigs were treated with cyclosporin A (CysA) to monitor the effect of the adaptive immunity on the development of the PCV2 infection. Through lymph node biopsies at 10, 15, and 21 days postinoculation (DPI), PCV2 replication in lymphoid tissues was monitored. The production of total PCV2-specific and PCV2-neutralizing antibodies was followed, together with interferon-gamma (IFN-gamma) mRNA expression levels in peripheral blood monocytes as a marker for cellular immunity. In general, the CysA-treated pigs showed the highest PCV2 titers, indicating that the adaptive immunity is necessary to restrain PCV2 replication. Three different PCV2 replication patterns were observed in non-CysA-treated pigs. Pattern 1: In two pigs, PCV2 was not detected. They had the highest neutralizing antibody titers, appearing from 15 DPI. In these pigs a good cellular response was indicated by a peak in IFN-gamma mRNA at 15 DPI. Pattern 2: Five pigs contained low to moderate PCV2 titers at 15 DPI, remaining constant or decreasing towards 21 DPI. Lower neutralizing antibody titers were observed and no rise in IFN-gamma was detected. Pattern 3: In one pig, a low PCV2 titer at 15 DPI dramatically increased toward 21 DPI. Although an antibody response against PCV2 was mounted, no PCV2-neutralizing antibodies were detected. This pig also showed no rise in IFN-gamma. The study findings indicate that variation in the onset of the adaptive immunity may account for variation in PCV2 replication among pigs. Absence of PCV2-neutralizing antibodies may be an important factor in the development of an increased virus replication.

Acceptability of COL-1492, a vaginal gel, among sex workers in one Asian and three African cities.

OBJECTIVES: To evaluate the acceptability of COL-1492, a vaginal gel containing 52.5 mg nonoxynol-9, in an HIV prevention trial. METHODS: Sex workers participating in a phase II/III triple blind, randomised trial in Benin, Côte d'Ivoire, South Africa, and Thailand were interviewed on the gel's acceptability at monthly scheduled clinic visits. Safer sex counselling, male condoms, and study gels were given at each monthly visit; a gynaecological examination and HIV test were performed. Phase III interviews considered the participants' appreciation of the gel. On the first, second, and fifth follow up visits, the study volunteers completed more extensive questionnaires. RESULTS: Responses were similar between treatment arms. Women indicated not liking their gel in 1.8% of the visits; 98.1% of the women found the gel easy to apply; 30.1% said that it affected sexual intercourse. These effects were mostly improvements (92.6%) by facilitating intercourse (73.6%). Intercourse was more often affected in women reporting painful sexual intercourse (OR: 2.59 (95% CI 1.63 to 4.12)) and in older women. The latter effect differed among centres. CONCLUSION: Most participants found their assigned gel acceptable and the vast majority of reported effects on intercourse were favourable. The type of gel had no significant impact on the findings.