PREVAIL I Cluster Vaccination Study With rVSVΔG-ZEBOV-GP as Part of a Public Health Response in Liberia.

OBJECTIVE: In November 2015, a 15-year-old boy received a diagnosis of Ebola virus disease (EVD) at the John F. Kennedy Medical Center in Monrovia, Liberia. Two additional family members received a diagnosis of EVD. The protocol for a phase 2 placebo-controlled trial of 2 Ebola vaccines was amended and approved; in 4 days, a single-arm cluster vaccination trial using the Merck rVSVΔG-ZEBOV-GP vaccine was initiated. Here, we evaluate the safety and immunogenicity of the vaccine and discuss challenges for its implementation in a small Ebola outbreak. METHOD: We conducted a ring vaccination study among contacts and contacts of close contacts of EVD cases a in Monrovia. Participants were evaluated 1 and 6 months after vaccination. RESULTS: Among 650 close contacts and contacts of close contacts of EVD cases, 210 (32%) consented and were vaccinated with rVSVΔG-ZEBOV-GP. Of those vaccinated, 189 (90%) attended the month 1 follow-up visit; 166 (79%) attended the month 6 visit. No serious adverse events were reported. Among 88 participants without an elevated antibody level at baseline, 77.3% (95% confidence interval, 68.5-86.1) had an antibody response at 1 month. CONCLUSIONS: The Merck rVSVΔG-ZEBOV-GP vaccine appeared to be safe and immunogenic among the vaccinated individuals. However, fewer than one third of eligible individuals consented to vaccination. These data may help guide implementation decisions for of cluster vaccination programs in an Ebola cluster outbreak response situation.

A review of strategies used to retain participants in clinical research during an infectious disease outbreak: The PREVAIL I Ebola vaccine trial experience.

INTRODUCTION: This article describes a retrospective review of participant follow-up and retention strategies in the Partnership for Research on the Ebola Virus in Liberia (PREVAIL) I Vaccine Trial. It illustrates and analyzes strategies used to retain participants in an emergency clinical research response vaccine trial conducted during the 2014 Ebola outbreak in Liberia. METHODS: An anecdotal review of participant retention strategies developed and employed during the PREVAIL I vaccine trial. RESULTS: Though other factors likely contributed to the high retention rate of trial participants, the unique PREVAIL I follow-up process described resulted in an exceptionally high participant retention rate (97.8%) through 12 months of follow-up, increased the ability to obtain meaningful trial results, and provided a platform through which to respond to social issues in an emergency clinical research response setting. CONCLUSION: Successful strategies were developed and employed in the PREVAIL I vaccine trial that resulted in extraordinarily high participant retention and follow-up rates during an infectious disease outbreak. This review illustrates that employing host country social mobilization concepts within a modified clinical research management framework is highly correlated to elevated rates of retention and minimal loss to follow-up. These strategies also contributed to increased data quality and enhanced adherence to protocol requirements. The increased ability to respond to social issues such as stigma, job retention and relationship conflicts was an additional and significant benefit of this follow-up methodology.

Phase 2 Placebo-Controlled Trial of Two Vaccines to Prevent Ebola in Liberia.

BACKGROUND: The safety and efficacy of vaccines to prevent Ebola virus disease (EVD) were unknown when the incidence of EVD was peaking in Liberia. METHODS: We initiated a randomized, placebo-controlled, phase 3 trial of the chimpanzee adenovirus 3 vaccine (ChAd3-EBO-Z) and the recombinant vesicular stomatitis virus vaccine (rVSV∆G-ZEBOV-GP) in Liberia. A phase 2 subtrial was embedded to evaluate safety and immunogenicity. Because the incidence of EVD declined in Liberia, the phase 2 component was expanded and the phase 3 component was eliminated. RESULTS: A total of 1500 adults underwent randomization and were followed for 12 months. The median age of the participants was 30 years; 36.6% of the participants were women. During the week after the administration of vaccine or placebo, adverse events occurred significantly more often with the active vaccines than with placebo; these events included injection-site reactions (in 28.5% of the patients in the ChAd3-EBO-Z group and 30.9% of those in the rVSV∆G-ZEBOV-GP group, as compared with 6.8% of those in the placebo group), headache (in 25.1% and 31.9%, vs. 16.9%), muscle pain (in 22.3% and 26.9%, vs. 13.3%), feverishness (in 23.9% and 30.5%, vs. 9.0%), and fatigue (in 14.0% and 15.4%, vs. 8.8%) (P<0.001 for all comparisons); these differences were not seen at 1 month. Serious adverse events within 12 months after injection were seen in 40 participants (8.0%) in the ChAd3-EBO-Z group, in 47 (9.4%) in the rVSV∆G-ZEBOV-GP group, and in 59 (11.8%) in the placebo group. By 1 month, an antibody response developed in 70.8% of the participants in the ChAd3-EBO-Z group and in 83.7% of those in the rVSV∆G-ZEBOV-GP group, as compared with 2.8% of those in the placebo group (P<0.001 for both comparisons). At 12 months, antibody responses in participants in the ChAd3-EBO-Z group (63.5%) and in those in the rVSV∆G-ZEBOV-GP group (79.5%) remained significantly greater than in those in the placebo group (6.8%, P<0.001 for both comparisons). CONCLUSIONS: A randomized, placebo-controlled phase 2 trial of two vaccines that was rapidly initiated and completed in Liberia showed the capability of conducting rigorous research during an outbreak. By 1 month after vaccination, the vaccines had elicited immune responses that were largely maintained through 12 months. (Funded by the National Institutes of Allergy and Infectious Diseases and the Liberian Ministry of Health; PREVAIL I ClinicalTrials.gov number, NCT02344407 .).

Conventional Wisdom versus Actual Outcomes: Challenges in the Conduct of an Ebola Vaccine Trial in Liberia during the International Public Health Emergency.

Clinical trials are challenging endeavors. Planning and implementing an investigational vaccine trial in Liberia, in the midst of an Ebola virus disease (EVD) epidemic that World Health Organization classified a public health emergency of international concern, presented extraordinary challenges. Normally, years of preparation and a litany of tasks lay the groundwork for a successful, randomized, blinded, placebo-controlled trial focused on safety and efficacy. Difficult research settings, unpredictable events, and other unique circumstances can add complexity. The setting in Liberia was especially problematic due to an infrastructure still badly damaged following a lengthy civil war and a very fragile health-care system that was further devastated by the EVD outbreak. The Partnership for Research on Vaccines in Liberia I EVD vaccine trial was planned and implemented in less than 3 months by a Liberian and U.S. research partnership, and its Phase II substudy was fully enrolled 3 months later. Contrasting conventional wisdom with trial outcomes offers an opportunity to compare early assumptions, barriers encountered, and adaptive strategies used, with end results. Understanding what was learned can inform future trial responses when disease outbreaks, especially in resource-poor locations with minimal infrastructure, pose a significant threat to public health.

Implementation of an Ebola virus disease vaccine clinical trial during the Ebola epidemic in Liberia: Design, procedures, and challenges.

The index case of the Ebola virus disease epidemic in West Africa is believed to have originated in Guinea. By June 2014, Guinea, Liberia, and Sierra Leone were in the midst of a full-blown and complex global health emergency. The devastating effects of this Ebola epidemic in West Africa put the global health response in acute focus for urgent international interventions. Accordingly, in October 2014, a World Health Organization high-level meeting endorsed the concept of a phase 2/3 clinical trial in Liberia to study Ebola vaccines. As a follow-up to the global response, in November 2014, the Government of Liberia and the US Government signed an agreement to form a research partnership to investigate Ebola and to assess intervention strategies for treating, controlling, and preventing the disease in Liberia. This agreement led to the establishment of the Joint Liberia-US Partnership for Research on Ebola Virus in Liberia as the beginning of a long-term collaborative partnership in clinical research between the two countries. In this article, we discuss the methodology and related challenges associated with the implementation of the Ebola vaccines clinical trial, based on a double-blinded randomized controlled trial, in Liberia.

Accuracy of vertical radial plume mapping technique in measuring lagoon gas emissions.

UNLABELLED: Recently, the U.S. Environmental Protection Agency (EPA) posted a ground-based optical remote sensing method on its Web site called Other Test Method (OTM) 10 for measuring fugitive gas emission flux from area sources such as closed landfills. The OTM 10 utilizes the vertical radial plume mapping (VRPM) technique to calculate fugitive gas emission mass rates based on measured wind speed profiles and path-integrated gas concentrations (PICs). This study evaluates the accuracy of the VRPM technique in measuring gas emission from animal waste treatment lagoons. A field trial was designed to evaluate the accuracy of the VRPM technique. Control releases of methane (CH4) were made from a 45 m×45 m floating perforated pipe network located on an irrigation pond that resembled typical treatment lagoon environments. The accuracy of the VRPM technique was expressed by the ratio of the calculated emission rates (QVRPM) to actual emission rates (Q). Under an ideal condition of having mean wind directions mostly normal to a downwind vertical plane, the average VRPM accuracy was 0.77±0.32. However, when mean wind direction was mostly not normal to the downwind vertical plane, the emission plume was not adequately captured resulting in lower accuracies. The accuracies of these nonideal wind conditions could be significantly improved if we relaxed the VRPM wind direction criteria and combined the emission rates determined from two adjacent downwind vertical planes surrounding the lagoon. With this modification, the VRPM accuracy improved to 0.97±0.44, whereas the number of valid data sets also increased from 113 to 186. IMPLICATIONS: The need for developing accurate and feasible measuring techniques for fugitive gas emission from animal waste lagoons is vital for livestock gas inventories and implementation of mitigation strategies. This field lagoon gas emission study demonstrated that the EPA's vertical radial plume mapping (VRPM) technique can be used to accurately measure lagoon gas emission with two downwind vertical concentration planes surrounding the lagoon.

Optimal sensor locations for the backward lagrangian stochastic technique in measuring lagoon gas emission.

This study evaluated the impact of gas concentration and wind sensor locations on the accuracy of measuring gas emission rates from a lagoon environment using the backward Lagrangian stochastic (bLS) inverse-dispersion technique. Path-integrated concentrations (PICs) and three-dimensional (3D) wind vector data were collected at different locations within the lagoon landscape. A floating 45 m × 45 m perforated pipe network on an irrigation pond was used as a synthetic distributed emission source for the controlled release of methane. A total of 961 15-min datasets were collected under different atmospheric stability conditions over a 2-yr period. The PIC location had a significant impact on the accuracy of the bLS technique. The location of the 3D sonic anemometer was generally not a factor for the measured accuracies with the PIC positioned on the downwind berm. The PICs across the middle of the pond consistently produced the lowest accuracy with any of the 3D anemometer locations (<69% accuracy). The PICs located on the downwind berm consistently yielded the best bLS accuracy regardless of whether the 3D sonic anemometer was located on the upwind, side, or downwind berm (accuracies ranged from 79 to 108%). The accuracies of the emission measurements with the berm PIC-berm 3D setting were statistically similar to that found in a more ideal homogeneous grass field. Considering the practical difficulties of setting up equipment and the accuracies associated with various sensor locations, we recommend that wind and concentration sensors be located on the downwind berm.

Oxygen transfer in marsh-pond-marsh constructed wetlands treating swine wastewater.

Oxygen transfer efficiencies of various components of the marsh-pond-marsh (M-P-M) and marsh-floating bed-marsh (M-FB-M) wetlands treating swine wastewater were determined by performing oxygen mass balance around the wetlands. Biological oxygen demand (BOD) and total nitrogen (TN) loading and escaping rates from each wetland were used to calculate carbonaceous and nitrogenous oxygen demands. Ammonia emissions were measured using a wind tunnel. Oxygen transfer efficiencies of the aerated ponds were estimated by conducting the ASCE standard oxygen transfer test in a tank using the same aeration device. Covering pond water surface with the floating bed slightly decreased oxygen transfer efficiency. The diffused membrane aeration (26.7 kg O2 ha-1 d-1) of M-P-M was surprisingly not as effective as plant aeration in the marsh (38.9 to 42.0 kg O2 ha-1 d-1). This unusually low oxygen transfer efficiency of the diffused aeration was attributed to its low submergence depth of 0.8 m compared to typical depth of 4.5 m. The wetlands consisting entirely of marsh removed similar amounts of C and N without investing additional equipment and energy costs of aerating ponds in the middle of wetlands.

Measurement of greenhouse gas emissions from agricultural sites using open-path optical remote sensing method.

Improved characterization of distributed emission sources of greenhouse gases such as methane from concentrated animal feeding operations require more accurate methods. One promising method is recently used by the USEPA. It employs a vertical radial plume mapping (VRPM) algorithm using optical remote sensing techniques. We evaluated this method to estimate emission rates from simulated distributed methane sources. A scanning open-path tunable diode laser was used to collect path-integrated concentrations (PICs) along different optical paths on a vertical plane downwind of controlled methane releases. Each cycle consists of 3 ground-level PICs and 2 above ground PICs. Three- to 10-cycle moving averages were used to reconstruct mass equivalent concentration plum maps on the vertical plane. The VRPM algorithm estimated emission rates of methane along with meteorological and PIC data collected concomitantly under different atmospheric stability conditions. The derived emission rates compared well with actual released rates irrespective of atmospheric stability conditions. The maximum error was 22 percent when 3-cycle moving average PICs were used; however, it decreased to 11% when 10-cycle moving average PICs were used. Our validation results suggest that this new VRPM method may be used for improved estimations of greenhouse gas emission from a variety of agricultural sources.

Definitive N-terminal protein sequence and further characterization of the novel apolipoprotein A5 in human serum.

BACKGROUND: Apolipoprotein A5 (ApoA5) originally gained attention as a regulator of serum triglyceride concentrations through transgenic mouse studies. Our group recently developed the first assay to quantify serum ApoA5 protein concentrations and demonstrated that they are increased by administration of a potent peroxisome proliferator-activated receptor-alpha agonist. METHODS: To better characterize the circulating ApoA5, the protein was purified from human serum, and a definitive N-terminal protein sequence was obtained. In light of previous observations that ApoA5 was present in VLDL and not LDL, plasma infranatant and intermediate-density lipoprotein (IDL) were analyzed for ApoA5. Because the mature protein contains a single unpaired cysteine, ApoA5 in human serum was immunoprecipitated, and its migration pattern was examined via Western blotting under reducing and nonreducing conditions to determine whether the protein circulates as a disulfide-linked homodimer or heterodimer. RESULTS: Definitive N-terminal protein sequences obtained from ApoA5 purified from human serum indicated that cleavage of the signal peptide occurs in vivo at the predicted site. We found ApoA5 in VLDL, HDL, and chylomicrons but not in LDL, IDL, or plasma infranatant. Under both reducing and nonreducing conditions, ApoA5 migrated mainly as a single band with a relative molecular mass (Mr) of approximately 39,000, indicating that the protein exists in serum as a monomer and not as a disulfide-linked homodimer or heterodimer. CONCLUSIONS: Our data help characterize ApoA5 by defining its lipoprotein particle distribution, by determining its N-terminal protein sequence, and by demonstrating that the mature protein circulates mainly as a monomer and not as a disulfide-linked homodimer or heterodimer.