Abstract
BackgroundDuring the 2014 Ebola virus disease (EVD) outbreak, policy-makers were confronted with difficult decisions on how best to test the efficacy of EVD vaccines. On one hand, many were reluctant to withhold a vaccine that might prevent a fatal disease from study participants randomized to a control arm. On the other, regulatory bodies called for rigorous placebo-controlled trials to permit direct measurement of vaccine efficacy prior to approval of the products. A stepped-wedge cluster study (SWCT) was proposed as an alternative to a more traditional randomized controlled vaccine trial to address these concerns. Here, we propose novel “ordered stepped-wedge cluster trial” (OSWCT) designs to further mitigate tradeoffs between ethical concerns, logistics, and statistical rigor.Methodology/Principal FindingsWe constructed a spatially structured mathematical model of the EVD outbreak in Sierra Leone. We used the output of this model to simulate and compare a series of stepped-wedge cluster vaccine studies. Our model reproduced the observed order of first case occurrence within districts of Sierra Leone. Depending on the infection risk within the trial population and the trial start dates, the statistical power to detect a vaccine efficacy of 90% varied from 14% to 32% for standard SWCT, and from 67% to 91% for OSWCTs for an alpha error of 5%. The model’s projection of first case occurrence was robust to changes in disease natural history parameters.Conclusions/SignificanceOrdering clusters in a step-wedge trial based on the cluster’s underlying risk of infection as predicted by a spatial model can increase the statistical power of a SWCT. In the event of another hemorrhagic fever outbreak, implementation of our proposed OSWCT designs could improve statistical power when a step-wedge study is desirable based on either ethical concerns or logistical constraints.
Highlights
The 2014 Ebola virus disease (EVD) epidemic is the largest recorded outbreak of any filovirus infection, primarily affecting three major countries in West Africa: Guinea, Liberia, and Sierra Leone
The last of these is called a Phase III clinical trial, in which the vaccine is tested on a subset of the population before it is approved for general use
A randomized controlled trial (RCT) in which individuals are randomized to receive vaccine or placebo is the most direct and efficient trial design to assess the efficacy of a vaccine
Summary
The 2014 Ebola virus disease (EVD) epidemic is the largest recorded outbreak of any filovirus infection, primarily affecting three major countries in West Africa: Guinea, Liberia, and Sierra Leone. Many candidate vaccines were proposed for Phase III trials in the affected countries, with different vaccine trial designs suggested for each region. The design was a ring vaccination cluster-randomized trial, where the trial population was made up of clusters of all contacts and contacts of contacts of laboratory-confirmed Ebola cases. A stepped-wedge cluster study (SWCT) was proposed as an alternative to a more traditional randomized controlled vaccine trial to address these concerns. We propose novel “ordered stepped-wedge cluster trial” (OSWCT) designs to further mitigate tradeoffs between ethical concerns, logistics, and statistical rigor
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