1 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal Agenda Item 3.1.4 Follow up Actions of 30 th SEA-ACHR: Research management in the countries by Prof. Ranjit Roy Chaundhry Thirty-first Session of WHO South-East Asia Advisory Committee on Health Research 21-23 July 2009, Kathmandu, Nepal 2 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal SOME OTHER ISSUES IN RESEARCH MANAGEMENT � Ethics in research � Twinning of research centres � Preparation of paper based on results � Dissemination of research results 3 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal ETHICS IN RESEARCH � Development of Institute Ethics Committees � Training of members of Ethics Committees � Weaknesses in functioning of Institute Ethics Committees 4 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal ISSUES OF CONCERN � Informed Consent of a poor and illiterate group of volunteers � Ownership of data � Rights of patients � Benefit to country 5 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal MORE IMPORTANT 1. Genuine desire of institute authorities to conform always to Ethical Principles in Research 2. Genuine desire of Chief Investigator to ensure that clinical trial subjects are not exposed to unjustifiable risk 3. Ethics Committees only a mechanism to achieve this 6 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal INSTITUTE ETHICS COMMITTEES NOT AN IMPEDIMENT TO RESEARCH � Many investigators regard Ethics Committees as a block to be overcome � This is a wrong attitude � Ethics Committees are a help to carry out good research � Protocol must be prepared keeping safety of trial subject in mind � Not prepared keeping in mind how to obtain rapid Ethical approval 7 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal MIND - SET � What is needed is a change in mind set � Both institute authorities and Chief Investigators need to think positively � Unjustifiable unethical research is the problem � Ethics Committees are a solution for the problem 8 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal TWINNING OF RESEARCH CENTRES This mechanism can be used more since there are developed and sophisticated research centres in the region and centres trying to establish themselves. Very often the problems of research interest are similar. Good opportunity for two institutes to work together. 9 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal BASIC CRITERIA FOR SUCCESS � Both centres must want this link-up � WHO-SEARO should be a partner � Both sides should benefit from this collaboration � Partnership in spirit of equality – Not that one centre “Gives” and the other centre “Takes” � Both sides to contribute financially to this joint activity 10 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal WHAT CAN BE DONE � Development of joint research proposals � Training of research workers � Exchange visits at all levels - Senior Researcher - Middle Level - Junior Level � Joint training programmes � Joint publications � Joint application for research grants 11 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal SOME SUCCESSFUL EXAMPLES 1. Postgraduate Medical Education and Research – Chandigarh and Royal Postgraduate Medical Hammersmith Hospital – London 2. Swiss Tropical Institute – Basel and BIFARA Tanzania 12 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal WRITING THE PAPER Common Scenario � Research project completed � Raw data available � Analysis of data carried out � Chief Investigator is very busy and has no time to write the paper � No other person in the team has competence or background to write the paper � Postponed and postponed and paper never written up 13 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal 1. There are very many scientists in countries of the region who have written many good research papers 2. Many are now retired and have time to help and would like to help and work again with WHO 3. SEARO should create database of such persons and offer to link up the two ONE APPROACH 14 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal BENEFITS OF SUCH COOPERATION � Results of research will be published as papers � Retired person would find an interest in doing something they can do well � Second level persons will work with the expert and learn the art and science of writing good papers � Benefit for all at very minimal cost � There is no point in carrying out or supporting research when results are not written up 15 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal DISSEMINATION OF RESEARCH RESULTS � To sponsor of research � To other research workers � To government department concerned � To bureaucrats and program managers � To Ministers and politicians � To media for public 16 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal FORMAT � Format of research paper written for one group will not be of interest to others � Report or format should be modified for the person reading it � Research paper published in scientific journal if sent to politician means very little 17 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal FOR BUREAUCRATS 1. Simple reader friendly summary 2. Not more than two pages 3. No medical terms 4. Describe relevance of work 5. How the results help policy decisions 6. What could be done in future 7. Time frame of future studies 18 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal FUTURE TIME FRAME � This is important because bureaucrat himself/herself has a fixed time period generally in that department � Would generally be Interested in any activity which could be carried out during his stay in the department � Main interest is to get things done fast 19 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal REPORT FOR MINISTERS AND POLITICIANS � Report should be prepared with great care � Not easy to write. Take help from others like communication experts � Relevance / benefit of research � If changes introduced could result in better health care or reduction in costs to public or government then say so 20 Thirty-first Session of WHO SEA ACHR, 21-23 July 2009, Kathmandu, Nepal MEDIA � Cannot ignore media � Powerful agent for change � Report for media must be very carefully written � Tendency to exaggerate � Should be a continuing relationship � Should be with few selected media persons � Can be a great help for research
Thirty-first session of WHO South-East Asia Advisory Committee on Health Research Kathmandu, Nepal, 21-23 July 2009 SEA/ACHR/31/8 18 July 2009 Agenda Item 3.1.4 FOLLOW-UP ACTIONS ON THE RECOMMENDATIONS OF THE THIRTIETH SESSION OF WHO SEA-ACHR: PROMOTION OF RESEARCH AND DEVELOPMENT IN AREAS OF DRUGS AND VACCINES
CONTENTS 1. Challenges for addressing Millennium Development Goals: .............................1 2. Burden of major diseases in SEAR:.......................................................................2 3. Research and development in drugs collaborative network in promoting research on drugs ....................................................................................................4 3.1 Anti-leishmania Combinations developed as DNDi and (ICMR) collaboration: ...................................................................................................5 3.2 TB alliance:.......................................................................................................5 3.3 National Efforts in Drug and Vaccine Development ..................................5 4. Promoting clinical trials in the Region:...................................................................8 5. Promoting Research and development in Traditional Medicines:.....................8 6. Promotion of research and development in vaccines: ......................................10 6.1 Development of tetravlet dengue vaccine:................................................10 6.2 Development of Vaccine against H1N5 at H1N1 of flu ...........................10 7. Areas in vaccine research where there are gaps: .............................................11 8. Annexures: ...............................................................................................................12 FOLLOW-UP ACTIONS ON THE RECOMMENDATIONS OF THE THIRTIETH SESSION OF WHO SEA-ACHR: PROMOTION OF RESEARCH AND DEVELOPMENT IN AREAS OF DRUGS AND VACCINES The South-East Asia region (SEAR) has witnessed a spurt in economic growth over the last few decades. Despite the economic growth, this part of the world is burdened with the highest incidence of infectious and non- communicable diseases. Moreover, the major share of neglected diseases can also be found in this part of the globe. The disease burden, as represented by disability adjusted life years (DALYs) in the low- and middle- income countries account for 125 million DALYs for the “big three” (HIV, TB and malaria), 165 million DALYs for pneumonia and diarrhoeal diseases, 12 million DALYs for helminth infections, 4 million DALYs for kinetoplastid diseases such as leishmaniasis, and 600,000 DALYs for dengue in 2004. (Moran et al., 2009). Moreover, as has been highlighted by Moran et al., (2009), the funding for R&D on these diseases was not correlated with the disease burden as deduced from DALYs. 1. Challenges for addressing Millennium Development Goals: Three out of eight Millennium Development Goals (MDGs), 8 of 16 MDG targets and 18 of 48 MDG indicators are health-related. These health-related goals can be achieved with increasing access to and effective use of drugs and vaccines. For example, development of a vaccine for HIV/AIDS, more effective diagnostics for tuberculosis (TB), and better treatments for leishmaniasis and malaria would greatly improve health in the developing countries. Hence, promotion of research and development in drugs and vaccines can contribute immensely to timely achievement of the Millennium Development Goals of the United Nations. 1 There is a need to identify and map the major diseases in the South-East Asia Region. The major diseases in this region are (1) HIV/AIDS (2) Tuberculosis (3) Malaria (4) Leprosy (5) leishmaniasis (6) helminthiasis (7) respiratory infections (8) diarrhoreal diseases and (9) the virus infections. 2. Burden of major diseases in SEAR: Actual disease burden prevalence, DALYs, mortality numbers are difficult to report from the region as the surveillance system is not appropriate and rigorous enough. The need for dedicated units for surveillance with appropriately trained manpower and sufficiently equipped laboratory infrastructure is required very urgently. Tuberculosis: One-third of the global burden of TB is seen in SEAR, with approximately 4.88 million prevalent cases and 3.17 million annual incidences of TB cases. Among the 22 high-burden countries, five are from SEAR and India has over 20% of the world’s cases. The age group that is affected the most is 15-54 years. HIV/AIDS: Of the approximately 31.6 million people infected with HIV till the end of 2007, more than 3.6 million cases were in the SEAR. To date, India has 2.4 million people living with HIV. Malaria: Ten of the member countries are malaria endemic. SEAR shares estimated 40% of the global population at risk of malaria of which 8.5% of the global burden of the disease and around 4.1% of the global mortality caused by malaria. SEAR bears around 1.34 million DALYs due to malaria where the global occurrence is 33.96 million as per (WHO Source: The global burden of disease: 2004 update). Malaria disease burden was in the range of 2.43 -2.77 millions in SEAR in the period of 2000-2006. Morbidity due to malaria was significantly reduced in DPR Korea, Bhutan, Sri Lanka and Thailand, other countries maintained status quo. 245 million laboratory confirmed malaria cases and 4515 million malaria deaths were reported in the SEAR in 2006, (GDB unit, WHO HQ 2004). There were highest number of laboratory confirmed 1,765,371 cases were reported from India, 347,197 from Indonesia- 2 and - 200,679 from Myanmar. Sri Lanka had 591, Bhutan-1,868 and Nepal- 5,349 reported cases in the same year. Leprosy: SEAR countries have achieved the leprosy elimination goal at the beginning of 2006, except Nepal and Timor-Leste; which have a plan for that within two more years. The prevalence rate from India was 0.95/10,000 population at the end of December 2005. 12.8 million cases were reported to be cured from the SEAR with MDT, more than 11.8 million from India in comparison with the worldwide 15 million cured cases helping to reduce the global leprosy burden. Most of the countries achieved the elimination at the national level; the persisting reported ones from Maldives and Bhutan were of multibacillary cases. The effort is sustained for achieving the goal in 2006-10. Leishmania: Bangladesh, India and Nepal are disease endemic, with 200 million people of the SEAR are reported to be at risk from Leishmaniasis. Fifty-two districts in India, 45 in Bangladesh, and 12 in Nepal are currently affected with the disease. Kala-azar is reported from more than 109 districts. 100,000 individuals from the Region are infected each year, as compared to 500,000 globally. A national steering committee with a technical task force has been firmed up in Bangladesh. Medical colleges, IEDCR and NIPSOM have interlinked. Disease burden mapping with entomological spot checks are also in place for better management of the disease. Soil-transmitted Helminthiasis (STH): Eleven SEAR countries are disease endemic with the most vulnerable people are women of childbearing age and school going children. Regionally, estimated 500 million people show chronic infection with the disease. Bhutan, Maldives, Myanmar, Sri Lanka and Thailand are focusing nationwide for de-worming of all school-age children. This will be subsequently adopted by DPR Korea, India and Indonesia. The current aim is 50% reduction of morbidity and mortality from the STH and 75% of all school-age children at risk to be treated by 2010. This will decrease the prevalence rate, magnitude of infections among the at-risk population, which in turn will arrest anaemia and other clinical complications arising from STH infections. 3 Non-communicable diseases: The non-communicable diseases like cancer, cardiovascular diseases, diabetes and chronic lung diseases are responsible for 54% of all deaths in the SEA Region according to the WHO estimates( Source: National capacity strengthening workshop for programme managers on integrated prevention and control of non-communicable diseases in Nay- Pyi-Taw, Myanmar on 8 December 2008). Antimicrobial resistance and its surveillance: The issue of antimicrobial resistance (AMR) is one of the most pressing problems in public health in the modern era. Most of the microorganisms have developed resistance against the commonly available antibiotics. A concerted effort is required to address this issue as otherwise the situation could very well deteriorate to that which was present before the antibiotic era. The epidemiological surveillance for AMR needs to be stepped up on a global basis. Epidemiological patterns of AMR distribution varies, depending on the type of community and other demographic parameters. A National Reference Microbiological Laboratory as well as an interconnected network of laboratories is essential for determining, assessing and analyzing the true magnitude of the problem. The nationwide surveillance systems for AMR need to be properly interconnected, linked-up and the networking should be extended throughout the South-East Asian region. 3. Research and development in drugs collaborative network in promoting research on drugs In 2003 DNDi, the Drugs for Neglected Diseases initiative was set up with inputs and cooperation from five public sector institutions – the Oswaldo Cruz Foundation (Fiocruz) from Brazil, the Indian Council for Medical Research (ICMR), the Kenya Medical Research Institute, the Ministry of Health of Malaysia and France’s Pasteur Institute; one humanitarian organisation, Médecins sans Frontières (MSF); and one international research organisation, the UNDP/World Bank/WHO’s Special Programme for Research and Training in Tropical Diseases (TDR). It fosters collaboration with a centralized management and decentralized operations and has clear project-specific 4 focus. It is also unique since it does not conduct research and scientific work itself but relies on the fragmented R&D capacity of developing countries and complements it with additional expertise needed. Under the DNDi umbrella regional network of scientists involved in drug discovery especially for neglected diseases are nurtured and meaningful collaborations are established with the pharma giants like GSK and Sanofi Pasteur. Anti-leishmania Combinations developed as DNDi and (ICMR) collaboration: Prolonged half-life (150-200 hrs) of conventional anti-leishmania treatment contributes to the emergence of drug resistance. The drugs have a high toxicity, become inactive rapidly and are costly. A combination of drugs can improve compliance and reduce cost and overcome the resistance produced by a single drug. Various combinations of drug are being evaluated in randomised, open-label, parallel-group, safety and efficacy studies. These combinations are AmBisome + Paromomycin, AmBisome + Miltefosine, Paromomycin + Miltefosine vs. Amphotericin B deoxycholate. Another study is being carried out on the clinical evaluation of Artemisinin+ Amodiaquin for the treatment of malaria. TB alliance: The global Alliance for T.B Drug development (TB Alliance) is developing new affordable TB drugs what will dramatically shorten treatment time and be effort also against drug resistant TB. National Efforts in Drug and Vaccine Development Considerable effort is being made in India in clinical evaluation of drug for TB and malaria. A recent approach that has been adopted at the Central Drug Research Institute (CDRI), Lucknow (India) for increasing anti- TB drug efficacy is by introducing the drug in particulate form so that it can be 5 administered by inhalation. The drug gets deposited on the alveolar surface and uptake occurs by phagocytosis by alveolar macrophages. Inhaled particles generate low drug concentrations of isoniazid and rifabutin in blood and high intracellular concentration in lung macrophages. The fluoroquinolones have a role in the management of MDR-TB, and possibly also TB in the face of severe drug intolerance, such as hepatotoxicity. However, their role as primary treatment for TB is uncertain. A randomized clinical trial (RCT) is being undergone at the Tuberculosis Research Center, Chennai (India) to study the tolerability and efficacy of moxifloxacin and gatifloxacin containing regimens for treating patients with smear-positive pulmonary tuberculosis being evaluated. Anti malarial: Several drugs are being evaluated for the treatment of malaria. Arteether has been registered and marketed. Bulaquine has undergone Phase III clinical trial in cases of malaria with P. vivax and is now registered and marketed. Other drugs and drug combinations being developed are: Atavaquone/Proguanil Primaquine and Tafenoquine Artemisin derivatives (Qinghaosu) Azithromycin Halofantrine Pyronaridine The endoperoxides are a new class of antimalarial agents, of which artemisinin (qinghaosu) is the prototype. Combinations of available derivatives and other antimalarial agents show promise both as first- line agents and in the treatment of severe disease. Other types of drug which are being developed and tested are drugs for dyslipidemia drug anti-diabetics and anti-cancer drugs. These are being developed in the private pharmaceutical sector and in national laboratories and institutes. Research on development on new drugs and vaccines is also being carried out at the National Institute of Malaria Research (NIMR), New Delhi and the International links for genetic engineering and 6 biotechnology, New Delhi. The NIMR is carrying out, amongst other activities a clinical trial to determine the safety and efficacy of Arterolane maleete and Piperaquine as a combination comparable to Coartem, the standard antimalaria available today for uncomplicated P. Palcefarum malaria. The “Polypill” A Polypill or Polycap is a medication in the form of a tablet or capsule, which contains a combination of active ingredients with the intention of reducing the number of tablets or capsules that need to be taken. The Indian Polycap Study : It has been indicated that the combination of three antihypertensives at low doses, with statin, aspirin, and folic acid (the polypill), could reduce cardiovascular risks by more than 80% in healthy individuals. The Indian Polycap Study (TIPS) carried out a double-blind trial in 50 centres in India with 2053 individuals (average age 54) without cardiovascular disease. During a 12-week treatment period, 400 of the study participants were given Polycap. The remainder were divided into eight groups of 200 who were given either individual components or groups of them. Three of the groups of 200 received only aspirin, simvastatin or thiazide respectively; Three groups received two of the three blood pressure medications; Another received all three blood pressure medications, while the last received all three combined with aspirin. The individuals who were given Polycap saw their blood pressure drop from six to seven points for both their systolic and diastolic levels. These reductions in blood pressure could cut the risk of heart disease by 62% and of stroke by 48% based on the results of other studies that showed risk reductions from cutting blood pressure levels. The combined pill was almost as effective as the individual pills with no increase in side effects. Tolerability of the Polycap was similar to that of other treatments, with no evidence of increasing intolerability with 7 increasing number of active components in one pill. The authors interpreted that the Polycap formulation could be conveniently used to reduce multiple risk factors and cardiovascular risk. 4. Promoting clinical trials in the Region: Manufacturers from US and Europe prefer to carry out clinical trials in Asian countries because of low cost of conducting clinical trials in Asia (except Japan) and availability of facilities of clinical evaluation and data analysis. Faster recruitment of subjects is another strength in Asia which has a genetically diverse population, many of whom have never received medication to treat their conditions. With such large numbers of naive subjects pharmaceutical companies can assess the strength of this new drug more accurately. Also, most countries in Asia have less complicated regulatory regimes (excluding Japan) and therefore take less time for regulatory approvals. While Malayasia is a prefered desitination for clinical trials in the SEAR because of its good hospital infrastructure, India is preferred for its vast geographical exapanse, genetic diversity of the population, availability of existing pharmaceutical know-how and well trained human resource. Schedule Y which provided legislative framework for clinical trials in India, was amended in 2005 to keep up with the times Having a high quality clinical trial set up in the country, a network of well equipped national control laboratories and fully functional national regulatory authority can attract more manufacturers in the SEAR region thereby indirectly promoting the manufacture of generic drugs as well. 5. Promoting Research and development in Traditional Medicines: There is an ever increasing demand on the health system, particularly in the low- and middle-income countries, in spite of the fact that resources are scarce. Due to these constraints, there has been a change in thinking with regard to how the health system can function, without necessarily burdening 8 the already overburdened health system. Health planners have been considering the growing needs and potential of traditional medicine (TM) in conventional health care settings. Many developing countries already use TM to help meet health care needs. For example, in India, 70% of the population relies on TM for primary health care, particularly in the rural areas. On the other hand, in developed countries such as Australia, Europe and North America “complementary and alternative medicine” (CAM) has been increasingly used parallel to conventional allopathic medicine. A well-known TM licensed for clinical use is artemisinin and its derivatives for treatment of malaria. Moreover, the benefit of procedures such as acupuncture is now well established. TM testing for quality assurance (QA) and quality control (QC) is a difficult task, due to the sheer number of uncharacterized components present in these preparations, as opposed to the active ingredient in allopathic preparations. There is a need to encourage research and development in traditional medicine especially with regard to ensure quality, safety and efficacy and to generate data that facilitate development of standards for these evaluations of TM. Laboratories dedicated to TM testing need to be in place specifically for this function. Emphasis on early stage drug development, mechanism of action and pharmacokinetics is needed. There is a need to frame, develop and support effective policies that promote the development of capacities related to health innovation in this area. Rational use of quality-certified TM products is also a requirement, as is the qualification and standard of its practitioners. Communication between TM practitioners and allopaths is required if both types of medicines are being prescribed to the same patient simultaneously. Moreover, the dangers of many TMs should not be underestimated. There is a public misconception that TMs, since they are “non-chemical”, are devoid of all adverse drug reactions (ADRs). There is an urgent need to fill this communication lacunae between the experts and the people. Ethical issues that might arise during clinical trials of TM need to be addressed. 9 6. Promotion of research and development in vaccines: The manufacturers in the SEAR had initially included vaccines needed for the Expanded Programme on Immunization like BCG, DTP, TT etc. in their portfolio. The production methods for these vaccines were traditional and long out-of-patent. But with the advent of GAVI alliance with the aim to introduce new vaccines against priority diseases and flow of funds available for vaccine purchase, manufacturers are now concentrating on having a strong R&D pipeline and are strengthening their capacity in process development. Vaccine industry is gaining strength this region by way of acquisitions and joint ventures. One good example is the 80:20 joint-venture of Cadilla Pharmaceuticals and US based biotech firm Novavax has formed a to conduct research and commercializing virus-like-particle (VLP) based vaccines for seasonal influenza and HPV. Of the five WHO prequalified pentavalent vaccine suppliers viz, GSK. (Belgium), Berna biotech/Crucell/Novartis (Korea), Panacea Biotech, Shanta Biotechnics and Serum Institute, three are Indian companies. With more developing country manufacturers entering the foray, the vaccine manufacturing capacity in the region is on the rise. The updated list of developing country manufacturers those from SEAR and those having Development of tetravlet dengue vaccine: Research at Mahidol University Bangkok was carried out from 1980- 1993 on development of a live attenuated tetravalet vaccine for all form sero types of dengue vaccines. There are at least candidate dengue vaccines that are available or ready to be taken into Phase I and II clinical trial for safety and immunological evaluation. The development of a live attenuated tetravlet dengue vaccine has been reinitiated since 2005. Development of Vaccine against H1N5 at H1N1 of flu The Global Vaccine Institute has awarded grants of USD two million to: 1) The government pharmaceutical organization 10 2) Biofarma (Indonesia) for development and production of vaccines against Avian Influenza (H5N1) and Influenza 2009 (H1N1). 7. Areas in vaccine research where there are gaps: With more and more antigens being included in vaccines for EPI, need for combinations of antigens that could be given as one injection has increased. This also complicated the testing procedure for these vaccines and makes the regulatory clearance more difficult. Research on development of in vitro and in vivo assays that could facilitate the vaccine evaluation procedures should be encouraged. Another area which needs to be strengthened is that of adjuvant research. Globally there are only a few adjuvants that are in use in the vaccines. Stimulating research in SEAR on adjuvants, in the form of an Adjuvant Discovery Progamme, especially in institutions with strong basic immunology programmes can bridge the gap between researcher engaged in basic science and product development. Assistance from agencies like the Wellcome Trust and Grand Challenges in Global Health of Bill and Melinda Gates Foundation could boost research in this area. 11 8. Annexures: There are four annexures printed with this background paper. These are on: 1) New and Innovative source of funding to stimulate Research and Development in India (Annexure 1) 2) WHO prequalified HIV drug from manufactures in the South-East Asia Region (Annexure 2) 3) Developing countries vaccines manufacturers network (DCVMN) Members (Annexure 3) 4) Major needs of funding for vaccines research(Annexure 4) O:\EIP\RPC\ACHR\31 ACHR\ Final documents\SEA-ACHR-31-8_promotion of research and development in areas of drugs and vaccines_18 July09 at 1340 hrs 12