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New drugs uptake in WHO EURO
Dr Ogtay Gozalov,
Medical officer,
WHO EURO
Dr Maya Kavtaradze,
Regional Technical Adviser,
Stop TB Partnership's GDF
Dr Elmira Gurbanova,
rGLC/Europe consultant,
Dr Gunta Dravniece,
Senior TB Adviser, KNCV
18th Wolfheze Workshops and 15th WHO National TB Programme Managers’ Meeting
The Hague, Netherlands
June 2017
Analysis of rGLC/Europe reports on
new drugs / new treatment regimens
Methodology
18 regional GLC mission reports from 15 sites were analyzed
against elements needed to be addressed for introduction of
new TB drugs (Bdq and Dlm), as per the Policy
Implementation Package
Year
of
the
asse
ssm
ent
Arm
enia
Aze
rbai
jan
Bel
aru
s
Geo
rgia
Kaz
akh
stan
Serb
ia (
UN
AT
Ko
sovo
)
Kyr
gyzs
tan
FYR
Mac
ed
on
ia
Mo
ldo
va
Ro
man
ia
Rep
ub
lic o
f M
old
ova
(T
ran
stri
stri
a)
Taji
kist
an
Turk
men
ista
n
Ukr
ain
e
Uzb
ekis
tan
2016
2017
Availability of Bdq and/or Dlm in the country
101
4
Available in Armenia, Belarus, Georgia,Kazakhstan, Serbia (UN AT Kosovo),Moldova, Romania, Moldova(Transnistria), Ukraine, Uzbekistan
No information on Tajikistan
Not available in Azerbaijan, FYRMacedonia, Kyrgyzstan, Turkmenistan
Out of 15 countries assessed, 10 introduced Bdq
and/or DlmNumber of countries that introduced
new TB drugsCumulative number of patients receiving new TB drugs
2013 2014 2015 2016
2 2
810
845
137
33 Bdq-basedtreatment
Dlm-basedtreatment
Bdq+Dlm-basedtreatment
National implementation plan for introduction of new TB
drugs
7
3
5
Availability of the National Implementation Plan
Available in Armenia, Belarus,Georgia, Kyrgyzstan, Moldova,Tajikistan, UzbekistanNo information on Kazakhstan,Turkmenistan, Ukraine
Not available in Azerbaijan, Serbia(UN AT Kosovo), FYR Macedonia,Romania, Moldova (Transnistria)
Minimum requirements for country preparedness and
planning: National health context
14
1
Availability of the National Strategy to fight TB up to 2020
Available in Azerbaijan, Armenia, Belarus,Georgia, Kazakhstan, Serbia (UN ATKosovo), Kyrgyzstan, FYR Macedonia,Moldova, Romania, Tajikistan,Turkmenistan, Ukraine, Uzbekistan
No information on Moldova (Transnistria)
Minimum requirements for country preparedness and
planning: Laboratory
Drug susceptibility testing (DST) to first-line drugs (FLD) Quality assurance for DST to FLD
14
1
Available in Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan,Serbia (UN AT Kosovo), FYR Macedonia, Moldova, Romania,Moldova (Transnistria), Tajikistan, Turkmenistan, Ukraine,Uzbekistan
No information on Kyrgyzstan
9
5
1
Passed in Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, FYRMacedonia,Tajikistan, Ukraine, UzbekistanNo information on Kyrgyzstan, Moldova, Romania, Moldova (Transnistria),TurkmenistanNot passed in Serbia (UN AT Kosovo)
Minimum requirements for country preparedness and
planning: Laboratory
Drug susceptibility testing (DST) to second-line drugs (SLD)
Quality assurance for DST to SLD
12
1
2
Available in Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan,Moldova, Romania, Moldova (Transnistria), Tajikistan, Turkmenistan,Ukraine, UzbekistanNo information on Kyrgyzstan
Not available in Serbia (UN AT Kosovo), FYR Macedonia
12
21
Passed in Azerbaijan, Armenia, Belarus, Georgia, Moldova,Kazakhstan, Romania, Tajikistan, Moldova (Transnistria),Turkmenistan, Uzbekistan, Ukraine
Not passed in Serbia (UN AT Kosovo), FYR Macedonia
No information on Kyrgyzstan
Minimum requirements for country preparedness and
planning: Drug supply and management
• Registration of Clofazimin (Cfz) is problematic at all countries.
• Bdq and Dlm are imported based on one-time license, mainly
because these drugs are still on a clinical trial
• TB drugs procured with the support from the Global Fund are
quality assured.
• However, drugs procured through local budget, mainly do not
hold GMP or WHO-prequalification
Minimum requirements for country preparedness and
planning: Drug supply and management
9
1
5
Shortage of TB drugs reported during the last 2 years
No shortage reported in Armenia,Georgia, Kazakhstan, Serbia (UN ATKosovo), FYR Macedonia, Moldova,Tajikistan, Turkmenistan, Uzbekistan
No information on Kyrgyzstan
Shortage reported by Azerbaijan,Belarus, Romania, Moldova(Transnistria), Ukraine
Minimum requirements for country preparedness and
planning: Case management
3
1
11
National guidelines for the programmatic management of drug-resistant TB is updated as per the latest WHO recommendations
Updated in Belarus, Kazakhstan, Ukraine
No information on Kyrgyzstan
Not updated in Azerbaijan, Armenia, Georgia, Serbia (UNAT Kosovo), FYR Macedonia, Moldova, Romania,Moldova (Transnistria), Tajikistan, Turkmenistan,Uzbekistan
Minimum requirements for country preparedness and
planning: Monitoring and evaluation
• All countries use updated WHO definitions for TB (2013 update)
• Some countries still do not have functional electronic TB database
and execute paper-based reporting (Azerbaijan, Tajikistan,
Turkmenistan, Uzbekistan, Kyrgyzstan)
• Supportive supervisions in majority countries are performed by the
National TB Programs, but are heavily relying on the Global Fund
support
Minimum requirements for country preparedness and
planning: Pharmacovigilance
• Armenia, Belarus and Georgia established:
– Active pharmacovigilance (PV)
– Centralized PV data collection
– Cohort-event monitoring used as PV method
• In remaining 12 countries the PV is not duly implemented
New and companion drugs via
GDF
Access to New TB tools via Global Drug Facility
and reporting requirements
www.stoptb.org
Global Drug Facility (GDF)
An enterprise of the Stop TB Partnership, mainly funded by USAID, hosted in UNOPS and managed by the Partnership secretariat
GDF began supplying FLDs in 2001, and in 2007 added the supply of SLDs, pediatric TB medicines and diagnostics and is a major source for GeneXpert™
137 countries benefited from GDF procurement / bundled mechanism
> 27 M Adult FLDs treatments> 1,59 M pediatric treatments> 239,321 SLDs patient treatments
US$ 1.63 billion of TB commodities procured since GDF inception in 2001
GDF Goal: Facilitate equitable and timely access to affordable, quality-assured, medicines and diagnostics, including new tools.
(as of December 2016)
GDF order placed by Product Line
www.stoptb.orgwww.stoptb.org
The Product List and Catalogue http://www.stoptb.org/gdf/drugsupply/drugs_available.asp
New Diagnostics
www.stoptb.orgwww.stoptb.org
Equipment and accessories, diagnostics and consumables, microbiological tests and test systems for:
• Equipment Kit for Microscopy laboratory Diagnostics and consumables kits for ZN or Auramine staining techniques
• Liquid Culture and DSTs Becton Dickinson BACTEC MGIT 960 system MGIT Tubes, OADC Supplement, SIRE Kits and Rapid Diagnostic Test SD BIOLINE TB Ag MPT64
• Lyophilized drug for laboratory use (Amikacin, Capreomycin, Kanamycin, Moxifloxacin, Ofloxacin)
• Solid culture and DST Loewenstein-Jensen-Medium
• Molecular line probe assays for 1st-line anti-TB drugs HAIN LifescienceGT-Blot 48, Twincubator, GenoType MTBDRplus and services
• Automated real-time nucleic acid amplification - Xpert MTB/RIF system
• Laboratory instruments, consumables, chemicals and personal protective equipment
Access to Laboratory and Diagnostic Products All products for WHO’s recommended techniques including New rapid diagnostic and DST tests!
Product coming to GDF portfolio in 2017 • TB LAMP (LoopampTM technology)• Digital X-Ray• DNA Genotek - OMNIgene•SPUTUM (OM-SPD)• Quiagen - QuantiFERON-TB Gold Plus (QFT®-Plus)
GDF diagnostics catalogue
www.stoptb.orgwww.stoptb.org
Repurposed medicines with increasing demand: Clofazimine, linezolid, amoxicillin clavulanate, imipenem/cilastatin
Substantial price decrease for: Linezolid
Price decrease for: Amoxicillin Clavulanate, Capreomycin,Imipenem/Cilastatin, Levofloxacin, Moxifloxacin and PAS Sodium Salt
Clofazimine 100mg from Novartis
Off label use in TB - disclaimer and quarterly A second manufacturer is expected in 2017
Application for inclusion in the WHO EML -March 2017
Access to WHO-recommended medicines
Full range of medicines for any type of TB treatment regimens available from the GDF!
Products price list online
New dispersible pediatric formulations2-FDC/RH-75/50; 3-FDC/RHZ-75/50/150 Treatment of Latent Tuberculosis Infection
Priftin® (rifapentine 150 mg tablet) from Sanofi
www.stoptb.org
Improve the service level to GDF clients:
• Decrease lead time between the countries’ orders and delivery by serving countries from available stock
• Ensure flexibility of supply in case of over stocking or stock-out situations in countries: Adapt client orders with consumption by pre or postponement of deliveries
Improve the service level to GDF suppliers :
• Improve the GDF order cycle by a better scheduling of orders to suppliers
• Adapt replenishment orders and production capacity to smooth peaks in the ordering pattern
• Provide to suppliers more reliable forecast and information on the market especially on policy changes
New GDF Strategic Rotating Stockpile (SRS): aimed to SRS Product Name
Amikacin 500mg/2ml injectable
Amoxicillin 500mg+Clavulanic acid 125mg
Amoxicillin 875mg+Clavulanic acid 125mg
Bedaquiline 100mg tablet
Clofazimine 100mg capsule
Capreomycin 1gram powder for injectable
Cycloserine 250mg capsule
Delamanid 50mg tablet
Ethionamide 250mg tablet
Kanamycin 1g injectable solution
Levofloxacin 250mg tablet
Levofloxacin 500mg tablet
Linezolid 600mg tablet
Moxifloxacin 400 mg tablet
PAS sodium sachet
Prothionamide 250 mg tablet
Pyrazinamide 400 mg tablet
Pyrazinamide 500 mg tablet
Syringe & needle (auto-disabling)
Water for injections
Isoniazid 300mg tablet
Ethambutol HCI 400 mg tablet
www.stoptb.org
Delivering-only does not work any more
GDF value-adding package of services
The Goal of the GDF Technical Assistance and Capacity Building Strategy is twofold
• To strengthen priority countries capacity to ensure timely equitable access to the GDF-supplied quality-assured medicines and products, including new TB products
• To provide country information and evidence on TB product demand and country TB control trends for the GDF strategic procurement planning and decision-making, and global forecasting exercises
www.stoptb.orgwww.stoptb.org
GDF TA and Capacity Strengthening
GDF tier 1 countries with core USAID support
Full package TA for expedited uptake of new TB tools managed by Regional Technical Advisors
• Development of Transition PSM plans• Assistance with functional EWS for monitoring uptake• Ongoing focused technical assistance and capacity
building for PSM systems strengthening • PSM tools implementation: QuanTB (quantification,
planning, Early Warning), data collection tools
Tier 2 countries with additional USAID support
Managed by GDF HQ and RTAsImplemented by pool of GDF-trained consultants
• Targeted TA for PSM plans of the Global Fund proposals
• Development of Transition PSM plans for new TB tools• Regional capacity building for forecasting and
quantification• Assistance with functional Early Warning System• Joint missions: rGLC, TGF, WHO, partners (e.g. KNCV,
UNION, etc.)• Best practices and knowledge sharing
GDF Regional Technical Advisers:Zaza Munez – SE Asia and W.Pacific [email protected]
Salama Mwatawala – Africa [email protected]
Maya Kavtaradze – Europe/CAR [email protected]
Erulappa Thanaraj – India [email protected]
Two additional RTAs to be hired forAfrica (Anglophone/Francophone)
SE Asia
Pool of trained regional consultants
www.stoptb.org
New TB tools
Shorter MDR-TB treatment regimen
New Paediatric Formulations
New and repurposed drugs
New diagnostics
www.stoptb.orgwww.stoptb.org
Sirturo by J&J, Kemwell Biopharma, USFDA/EMAPacking size: HDPE container(s) of 188Shelf life: 36 months
USAID Bedaquiline Donation Program: free-of-charge to eligible countries following WHO interim recommendations
Bedaquiline 100 mg tablest As of April 2017: 10 705 treatment courses globally including MSF projects (delivered, orders placed withsuppliers or in process)Of which in Europe and CAR countries: 2 944 courses without MSF projects
Countries can request Technical Assistance from USAID and GDF ([email protected] ; [email protected]; [email protected])
Adverse events reported directly to Janssen or via GDF: [email protected]
Country BDQ Order Completed
BDQ Order placed with
supplier BDQ Total
Armenia 69 69
Azerbaijan 91 91
Belarus 386 139 525
Georgia 341 60 401
Kazakhstan 390 332 722
Kosovo 2 2
Kyrgyzstan 25 110 135
Republic of Moldova 89 67 156
Tajikistan 50 70 120
Turkmenistan 40 40
Ukraine 200 200
Uzbekistan 90 393 483
Grand Total 1440 1504 2944
www.stoptb.orgwww.stoptb.org
Deltyba by Otsuka, EMA/JapanPacking size: Box(s) of 672Shelf life: 60 monthsCountries eligible for TB Financing by The Global Fund and following WHO interim recommendations can access Delamanid via the GDFPrice USD 1,700 for a full treatment course (6 months)
Adverse events reported to Otsuka via the GDF: [email protected]
Delamanid 50mg tablets As of April 2017: 2 448 treatment courses globally including MSF projects (delivered, orders placed withsuppliers or in process)Of which in Europe and CAR countries: 626 courses without MSF projects
Country DLM Order Completed
DLM Order placed with supplier
DLM Total
Armenia MSF
Azerbaijan
Belarus 144 193 337
Georgia 35 35
Kazakhstan 130 80 210
Kosovo
Kyrgyzstan 8 8
Republic of Moldova 25 25
Tajikistan MSF
Turkmenistan
Ukraine
Uzbekistan 11 11 + MSF
Grand Total 309 317 626
www.stoptb.org
A. Countries/programs should ensure they follow the five WHO recommendations for optimal introduction of BDQ and DLM:
Effective treatment and monitoring Proper patient inclusion Informed consent Adherence to WHO recommendations Active pharmacovigilance and management of adverse events aDSM
─ Active and systematic clinical and laboratory assessment of patients on treatment with new anti-TB drugs, novel MDR-TB regimens or XDR-TB regimens to detect, manage and report suspected or confirmed drug toxicities and adverse events;
─ Systematic and standardized recording and reporting at least Serious Adverse Events (may also monitor other AEs that are of clinical significance or of special interest to the program and can be expanded to eventually cover TB patients on treatment with any second-line drugs)
aDSM is intended
─ to be an integral component of the programmatic management of drug-resistant TB(PMDT) and
─ to complement current capacities of national pharmacovigilance.
How to Access Bedaquiline and Delamanid via GDF (1)
www.stoptb.orgwww.stoptb.org
B. Review the background documentation on the program and the order form from the GDF (http://www.stoptb.org/gdf/drugsupply/procurement_forms.asp)
Annex: Adverse Drug Reaction / Serious
adverse event forms • BDQ Adverse events reported to Janssen via GDF: [email protected]
• DLM Adverse events reported to Otsuka via the GDF:
System for systematic and standardized
recording and reporting of AEs is required
How to Access Bedaquiline and Delamanid via GDF (2)
www.stoptb.org
D. Review the need for other second-line drugs that are needed to treat patients who will be receiving BDQ or DLM ─ data-driven need-based approach to forecasting /
quantification for all medicines (not cohort-based)─ Phase-in / phase-out planning: scenarios and
estimation of volumes and values of obsolete medicines for withdrawal and destruction
E. Review needs based on the above descriptions
How to Access Bedaquiline and Delamanid via GDF (3)
C. Estimate the number of patients who will benefit from the medicines:─ Planning and executing the supply for multiple concurrent new and
old regimens of different duration and at various implementation start dates
─ Mixed supply medicines in countries graduating from the GF support: maintaining quality and access
Out- and in-coming medicines
Increased individualization and number of treatment regimens
Standard M/XDR 20 month:
8Cm70%Km30%Lfx50% Mfx50% Pto90%Cs90% PAS60%Z100%/12Lfx50%
Mfx50% Pto90%Cs90% PAS60%Z100%
With new and repurposed drugs 20 months:
6Bdq90%/6Dlm30%/8Cm65%Imp\Cls35%Amx\Clv35%Cfz90%Lnz90%Mfx50%Lfx10% Pto30%Cs30%PAS4% Z50% /12Cfz90%Lnz90%Mfx50%Lfx10%
Pto30%Cs30%PAS4% Z50%
STR 9 - 12 months (composition and duration may vary):
(4-6)Km10% Cm80% Am10%Mfx20% Pto100% Cfz100% Hh100% Z100% E100% /(5 -6) Mfx100% Pto100% Cfz100% Z100% E100%
Forecasting and quantification for multiple regimens become too complex for the existing level of expertise
Lack of data-driven rational phase-in / phase-out transition planning with scenarios and cost estimations
Need for functional Early Warning System including patient data collection to manage transition without treatment interruptions
Km Mfx
Pto
PAS
Z
Cm
Lfx
EtoCs
AmCfz
AmCl
Bdq Dlm
Imp
Lnz
www.stoptb.orgwww.stoptb.org
Benefits from EWS (quarterly QuanTB reports):• Proactively monitor TB medicines supply and medicines orders: Early
action to prevent stock-out/overstock• Streamline medicine orders: Firm order schedules, streamlined supply to
countries • Ensure uninterrupted supply for smooth transition to new medicines and
regimens• Play scenarios for rational introduction of new TB tools• Reduce wastage of medicine: in-country reallocation of medicines where
possible and changing delivery schedule - GDF needs advance notification!• GDF will improve global and strategic procurement forecasting (Cheaper
medicines for countries)• Reports will also serve as foundation for evidence-based technical
assistance to countries for rapid and rational transition to new medicines and regimens
Quantification and Early Warning System
www.stoptb.orgwww.stoptb.org
F. Place order for new and other second-line drugs as the turn-around time is
likely to be several months, and TA activities can be carried out while awaiting
drug arrival:
─ Need to capacitate laboratories to conduct SL DST (LPA, automated,
conventional)
─ Development, approval and introduction of new treatment guidelines and
training of staff at all levels
─ Need for approved policy for expedited uptake of new medicines and
regimens, including for withdrawal and destruction of obsolete sub-optimal
medicines
G. Explore options to import new medicines in the country if they are not
registered yet:
─ Registration/waivers and importation approvals (Donor and Domestic
funded)
H. Review clinical cases and patient histories to see who would benefit from new
medicines.
How to Access Bedaquiline and Delamanid
via GDF (4)
• Delays in initiating orders…• Delays in approving quotes…• Delays in country to grant
dispatch authorization…• Last minute changes in
required shipping documents....
• Delays in country to import through customs, stock and deliver…
www.stoptb.org
1. All Medicines and diagnostic tools recommended by WHO, including STR and new drugs are available in GDF
2. Technical assistance and capacity strengthening for the introduction of new TB tools are available through the GDF and USAID-funded projects
3. NTPs should use current opportunities and should not delay the transition of use of new TB drugs, STR and new pediatric formulations
4. NTPs are requested to follow reporting requirements including ADRs and EWS reports
Message from WHO and GDF to NTP’s:
Introduction of new drugs and shorter DR-TB treatment regimen
KNCV’s approach
Gunta Dravniece, Michael Kimerling
KNCV
Wolfheze conference, May 31-June 2 2017
KNCV supports
programmatic introduction and evaluation of any innovation
• Diagnostics
• Regimen design
• Monitoring of safety
and efficacy
• Drug management
• Patient support
• Infection control
• Recording & reporting
• Digital health
Monitoring
Patient with presumptive TB
Standard TB treatment with First
Line Drugs
No TB
Rapid molecular test (e.g. Xpert MTB/RIF)
Rif susceptible TB Rif resistant TB
Appropriate referral/ treatment
Shorter DR-TB treatment regimen
Eligible
Individualized DR-TB treatment
regimen
Ineligible
START TREATMENT AFTER EVALUATION OF ELIGIBILITY FOR SHORTER REGIMEN
KNCV’s patient triage approach allows initiation of the most effective treatment regimen for
any TB patient in <5 days
Patient Triage Approach
Linking the
Bdq donation program
with introduction of the
STR
KNCV’s support in WHO Euro
Through USAID Challenge TB project (CTB)
Four countries in the region
• Ukraine (PATH and KNCV)
• Uzbekistan (WHO and KNCV)
• Kyrgyz Republic (KNCV)
• Tajikistan (KNCV)
Generic documents developed and adapted for country needs
1. Implementation planning tool 2. Programmatic and clinical guide3. Job aids (Use of Bdq; QTE)
4. Generic SOPs (under development)5. Generic Training materials (under development)
COUNTRY SUPPORT:EXAMPLE FROM KYRGYZ
REPUBLIC
Regulatory environment and policy I
1.Advocacy work resulted in support from MoH
2. Use of new drugs included in national guidelines
3. National plan for new drugs and regimens
developed and endorsed by MoH
Regulatory environment and policy II
4. Triage approach and implementation of proposed regimens
supported by inter-/national partners
5. Adverse event monitoring within MDR-TB program was revised
and linked with PV authority
Site preparation I
1. One functional diagnostic algorithm designed
and includes Xpert and HAIN SL tests
2. Specimen transportation, procurement of
consumables supported by other partners considering
KNCV approach
3. UNDP/GF supports triage approach – drugs for
shorter and individualized regimens procured
Site preparation II
1. Clinical guide and SOPs developed
2. Access to all necessary monitoring tests
supported by UNDP/GF in coordination with KNCV
3. Electronic data base developed
4. Training for clinical and laboratory staff provided
5. Patients’ enrolment for shorter regimen and regimen with
new drugs started in January 2017
6. Continuous on job training and supervision provided
Introduction timelines in Kyrgyz Republic
44
Q3 2015
Q4 2015
Q1 2016
Q2 2016
Q3 2016 Q4
2016
• Finalization of guide and SOPs• Training of clinical and
laboratory staff
• Site selection/assessment
• Development of National
plan
• Estimation of drug needs
• On job training
• Patient enrollment
• Adjustment of guidelines
• Design of diagnostic algorithm and treatment regimens
• Development of SOPs
• Endorsement of National plan
Development of guide
Enrollment started in January 2017
Short treatment regimen is introduced starting from two sites
(Bishkek city, Chui oblast)
• 58 patients enrolled, including 3 children and 7 adolescents
Individualized regimen containing new and repurposed drugs
is provided for patients from whole country.
• 58 patients enrolled, majority from the waiting list, many of them in
severe condition at the time of enrollment
Progress in other countries
Tajikistan
• Enrollment started in December 2016
• By the end of April 2017 24 patients enrolled in shorter regimen and 24 in individualized regimen
Ukraine
• Bdq ordered for 200 patients
• Enrollment will be started in June 2017
Uzbekistan
• CTB project just started
• Guidelines adjusted
• National plan developed
Lessons learned from CTB countries I
Treatment regimen
Treatment
monitoring
Diagnostics
1. Treatment regimen is only one of components in patient
management. TA should address the essential PMDT elements
2. Many PMDT components were not ready in countries
therefore preparation takes longer (around 12 months).
3. TA on ND&R provides an opportunity to strengthen MDR
program.
4. Political support is crucial
Treatment regimen
Treatment
monitoring
Diagnostics
Lessons learned from CTB countries II
5. Preparing national plan helps to identify all components and
dividing tasks among partners
6. Preparation of introduction sites should be simultaneous
with preparations at national level
7. Specific needs for children and adolescents with TB should be
considered
8. Coordination with partners is essential
• Common approach
• Coordinated procurement
• Complementary activities
Acknowledgements
KNCV
• Susan van den Hof
• Agnes Gebhard
• Ieva Leimane
• Nick Blok
• Maria Idrissova
• Bakyt Myrzaliev
• Sandra Kik
• Edine Tiemersma
• Fraser Wares
• Job van Rest
• Hadi Qawasmeh
• Marcela Tommasi
• Michael Kimerling
PATH
• Katya Gamazina
• Olga Pavlova
• Nina Zherebko
• Aleksey Bogdanov
Acknowledgements• rGLC/Europe
members and consultants
• NTP’s of Member States
• Stop TB partnership GDF
• KNCV and Challenge TB Project
• MSF