Better Labs for Better Health activity report 2018–2019 Document number: WHO/EURO:2022-4370-44133-62280 KEYWORDS LABORATORIES TRAINING EMERGENCY BIOSAFETY MENTORING EUROPE © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons license. 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All photos: ©WHO/Jeremy Ford Better Labs for Better Health activity report 2018–2019 4 / ACTIvITY REPORT2018–2019 ACTIVITY REPORT 2018–2019 iv ACKNOWLEDGEMENTS v ABBREVIATIONS vi INTRODUCTION 1 BETTER LABS FOR BETTER HEALTH ACTION AREAS 2 AREA 1: SUPPORTING NATIONAL LABORATORY SYSTEM REFORMS 6 < Country ownership through national laboratory working groups 7 < Establishing health laboratory licensing 8 < Training manual: Laboratory Test Costing Tool 8 AREA 2: IMPROVE NATIONAL TRAINING PROGRAMMES AND QMS 11 < Improving in-country training programmes 12 < In-country capacity building 12 < Mentoring in QMS 13 < National mentoring and knowledge sharing 16 AREA 3: ESTABLISHING LAB NETWORKS FOR EMERGENCY PREPAREDNESS AND RESPONSE 18 < European Regional Laboratory Task Force for High Threat Pathogens 19 AREA 4: ADVOCACY, PARTNERSHIP AND LEADERSHIP 22 < Advocacy 23 < Video - ‘We are Laboratory Workers’ 23 < Providing leadership for change 24 < Moving forward: Priorities for 2021 - 2023 24 REFERENCES ......................................................................................................................... 25 CONTENTS v ACTIvITY REPORT 2018–2019 This report was written by Maria Valerie Amante (WHO Regional Office for Europe) and Joanna Zwetyenga (WHO Regional Office for Europe). It was co-authored and designed by Jeremy Ford (WHO Regional Office for Europe). Support for Better Labs for Better Health activities in the period 2018–2019 was provided by the European Union (European Commission’s Directorate-General for International Co-operation and Development), as part of the project to strengthen health laboratories in order to minimize potential biological risks (contract IFS/2013/332312). This initiative has been funded thanks to the contributions from: • Assessed Contributions (AC); • Centers for Disease Control and Prevention (CDC), United States of America; • Directorate General for International Cooperation and Development (DEVCO); • European Commission; • Federal Ministry for Health, Social Affairs, Women and Family, Germany; • Ministry of Finance, Russian Federation; • Ministry of Health, Welfare and Sport, Netherlands. ACKNOWLEDGEMENTS ACTIVITY REPORT 2018–2019 v i ABBREvIATIONS AMR antimicrobial resistance Better Labs Better Labs for Better Health CDC Centers for Disease Control and Prevention, United States of America ECDC European Centre for Disease Prevention and Control HIV human immunodeficiency virus HTP high-threat pathogen IHR International Health Regulations (2005) LQMS laboratory quality management system LQSI Laboratory Quality Stepwise Implementation tool LTCT Laboratory Test Costing Tool MCH maternity and childhood hospital MoH ministry of health NLFP national laboratory focal point NLWG national laboratory working group QMS quality management system TB tuberculosis WHO World Health Organization ACTIvITY REPORT 2018–2019 – Gulmira Kalmambetova, mentor, Kyrgyzstan “Laboratory workers are always learning, always developing. The best laboratories are those that never lose the desire to strive to be better.” ACTIvITY REPORT 2018–2019 1 Strong laboratory services are fundamental to the improvement of health systems and health service delivery. Reliable laboratory evidence is vital for health care from day-to-day operations right through to emergency preparedness and response. Good laboratories are essential in order to protect patients and communities. They underpin disease prevention strategies through screening programmes, guide treatment and provide essential community health data. Better Labs was launched by World Health Organization (WHO) Regional Office for Europe in 2012. It supports all laboratories and advocates for the improvement of health through the provision of timely and accurate results that are trusted by the user and through early detection of acute public health events. Better Labs assists countries with laboratory reform with an emphasis on efficiency, rationalization, provision of human resources and overall laboratory capacity. To boost international networking and collaboration, the European Regional Laboratory Task Force (Lab Task Force) was established in 2018 with a focus on effective emergency preparedness and response to high-threat pathogens (HTP). INTRODUCTION Better Labs for Better Health (Better Labs) is a multi-pronged approach based on the global vision of laboratory strengthening. It focuses on improving laboratory standards at national and international level. This ranges from helping countries develop laboratory policies and networks to on-site mentoring and training of laboratory workers. Supporting national laboratory SyStem reformS 1 improve national training programmeS and QmS 2 BETTER LABS ACTIVITY AREAS 2 ACTIvITY REPORT 2018–2019 ACTIvITY REPORT 2018–2019 3 The Better Labs goal is to improve health through the provision of timely and accurate results that are trusted by the user, and by early detection of acute public health events eStabliShing laboratory networkS for emergency preparedneSS and reSponSe 3 advocacy, partnerShip and leaderShip 4
14 / ACTIvITY REPORT2018–2019 AREA 1: Supporting national laboratory system reforms ACTIvITY REPORT 2018–2019 7 National laboratory policy and strategy signal political commitment and country ownership in addition to providing a framework for implementation. Between 2018 and 2019, Armenia, Belarus and Kazakhstan joined the Better Labs initiative along with Kyrgyzstan, Republic of Moldova, Tajikistan, Turkmenistan and Ukraine. This brings the total number of committed countries to eight – all of which have established national laboratory working groups (NLWGs) that are the drivers for in-country reform. The Better Labs intersectoral approach involves collaborative activities with Member States working hand in hand with relevant ministries (agriculture, health, environment), WHO and other partners. This is carried out via a series of in-country workshops to help develop and implement national laboratory policy, strategy and action plans. In-country workshops facilitated by WHO involve a wide range of national laboratory stakeholders. These include public health laboratories, clinical diagnostics, chemical, radionuclear, food safety, toxicology, veterinary services experts, university professors, laboratory accreditation agencies and ministries of health. They identify core cross-cutting challenges that include human resources, infrastructure development and quality management systems (QMS). Turkmenistan endorsed its national strategy and action plan in 2018. In the same year, Ukraine integrated a laboratory-strengthening concept paper into its national health reform. In 2019 Armenia, Kazakhstan and Uzbekistan finalized their national policy, strategy and action plan. Kyrgyzstan and Tajikistan started to implement their national laboratory policy and strategy following endorsement by their respective ministries of health. Country ownership through national laboratory working groups ¢ Laboratory system optimization: four workshops were organized in each country. These were to determine the list of tests to be performed for priority pathogens at each level of the system. They also evaluated the required numbers of tests, equipment and personnel. ¢ Output: draft of reform proposals The first activities addressed the following priority areas. ¢ Building trust: meetings in Kyrgyzstan and Tajikistan to discuss clinicians’ views on the quality of national laboratory services. ¢ Output: initiated dialogue between clinicians and laboratory experts and increased trust in laboratory services ¢ Sample management and transport: an inter-country workshop was conducted with Kyrgyzstan, Tajikistan, and Uzbekistan to address issues related to sample management and transport. ¢ Output: development of sampling guideline for microbiology and draft guidelines for environmental and veterinary samples. The sampling guideline for microbiology was approved by the Ministry of Health of Uzbekistan for further use in the country. BETTER LABS ACTIvITY AREA 1 SUPPORTING NATIONAL LABORATORY SYSTEM REFORMS 8 ACTIvITY REPORT 2018–2019 BETTER LABS ACTIvITY AREA 1 SUPPORTING NATIONAL LABORATORY SYSTEM REFORMS A key identified gap when developing laboratory policies and strategic plans was to revise the governance and regulatory policies pertaining to health laboratories. Two workshops in Kyrgyzstan and Tajikistan were conducted on health laboratory licensing and a comparative analysis of health laboratory licensing legislation in more than 17 countries. The workshops analysed approaches to regulating license requirements for tests, facilities, equipment, quality control, biosafety and biosecurity among other things. The resulting document provides options for national health authorities and national health laboratory focal points in their efforts to strengthen laboratory systems. The associated tool is available online in English and Russian (1). Establishing health laboratory licensing The Laboratory Test Costing Tool (LTCT) evaluates costs and helps to promote cost-effectiveness across the laboratory system. It helps laboratories calculate the true cost of a specific laboratory test, justify the cost in a standard way and produce transparent price lists for laboratory tests. 50 experts in Armenia, Kyrgyzstan and Tajikistan have already been trained to use this tool. This was developed as Better Labs believes in better quality and optimization of laboratory systems. It encourages clear organization of laboratory systems at all administrative levels within a country, defining testing and methods at each level (national/regional/primary health care). The tool is available online in English and Russian (2). Laboratory Test Costing Tool BETTER LABS ACTIvITY AREA 1 SUPPORTING NATIONAL LABORATORY SYSTEM REFORMS 18 / ACTIvITY REPORT2018–2019 MAIN ACTIvITIES ARMENIA Joined Better Labs 2018 3 workshops on laboratory policy and strategic plan. Finalization of laboratory policy and strategic plan BELARUS Joined Better Labs 2019 2 workshops on laboratory policy and strategic plan KAZAKHSTAN Joined Better Labs 2019 2 workshops on laboratory policy and strategic plan KYRGYZSTAN Finalized proposal for public health laboratory reform in Chui Oblast (region), Dec 2018 4 workshops on laboratory system optimization Sample referral work for common routes with disease-specific programmes in Chui Oblast, Dec 2019 Quality of Care Thematic Meeting - Governance of Quality discussion, Nov 2019 TAJIKISTAN Ongoing work on laboratory system optimization (4 workshops) Ongoing work on legislation for laboratories under the Ministry of Health TURKMENISTAN Endorsed national strategic and action plan 2018 UKRAINE Integration of laboratory strengthening concept note into health plan 2018 Finalization of public health laboratory reform, Nov 2019 UZBEKISTAN Finalization of laboratory policy and strategic plan INTERCOUNTRY Joint Kyrgyzstan, Tajikistan, Uzbekistan workshop on sample referral – draft national sampling guidelines for veterinary, microbiology and environmental samples BETTER LABS ACTIvITY AREA 1 SUPPORTING NATIONAL LABORATORY SYSTEM REFORMS ACTIVITY REPORT2018–2019 / 19 AREA 2: Improving national training programmes and QMS 12 ACTIvITY REPORT 2018–2019 BETTER LABS ACTIvITY AREA 2 IMPROvE NATIONAL TRAINING PROGRAMMES AND QUALITY MANAGEMENT SYSTEMS In 2019, a best practices document and facilitators guidance document was published outlining actions required to review and revise laboratory curricula at national level. One identified gap was specialised training for lab experts/directors in laboratory leadership and management. This is to foster and mentor current and emerging laboratory leaders in order to build, strengthen and sustain national laboratory systems. The Global Laboratory Leadership training programme is now being developed with the support of six leading organisations. Better Labs and the MoH of Kazakhstan have agreed to the implementation of the first phase. In-country capacity building Better Labs provides training and mentoring in laboratory QMS implementation, biosafety and biosecurity and sample transport. Two training packages have been developed (Basic and Advanced) for QMS and two additional ones for national mentor training. A training programme for sample transport has also been developed and rolled out in Kyrgyzstan and Tajikistan. An essential function of Better Labs is supporting Member States to improve their national training programmes, especially in the area of QMS Improving in-country training programmes ¢ 5 different training courses delivered by Better Labs across 9 countries. Topics: QMS implementation, national mentors training, Laboratory Test Costing Tool, biosafety, national sample transport. ¢ 2018–2019: total number of laboratory staff trained = 245 ¢ 2016–2017: total number of laboratory staff trained = 382 ACTIvITY REPORT 2018–2019 13 BETTER LABS ACTIvITY AREA 2 IMPROvE NATIONAL TRAINING PROGRAMMES AND QUALITY MANAGEMENT SYSTEMS Mentoring in QMS In those Member States where laboratories lacked QMS, Better Labs made it a priority to train laboratory experts. Better Labs established a mentoring programme in 2015 to support laboratories in QMS implementation QMS implementation is a lengthy and ongoing process. In order to enhance the effectiveness of training provided by WHO, Better Labs established a mentoring programme in 2015 to support public health laboratories in QMS. Mentors are laboratory quality experts who work with the laboratory staff in the facility on all aspects of laboratory services – whether managerial, administrative or technical (wet lab). Mentoring visits are scheduled for approximately one week every 3-4 months for every laboratory in the mentoring programme. Together, mentors and laboratory staff develop a common understanding of the gaps in QMS, which are identified and logged in an activity plan. QMS implementation can take up to five years. Progress is monitored and measured on each visit against a standard mentoring QMS activity checklist. 14 ACTIvITY REPORT 2018–2019 BETTER LABS ACTIvITY AREA 2 IMPROvE NATIONAL TRAINING PROGRAMMES AND QUALITY MANAGEMENT SYSTEMS Case study: intersectoral collaboration – the fight against antimicrobial resistance (AMR) supports efforts towards better laboratories Better Labs has been working closely with regional and national laboratories through the mentoring scheme and this has led to a collaborative approach to making it a priority to mentor laboratories involved in AMR work. The mentoring programme was expanded to investigate how the mentoring approach might be complementary to the proof-of-principle (PoP) AMR routine diagnostics surveillance project. PoP projects have demonstrated the value of AMR surveillance and rapid, reliable tests for the effective treatment of patients. Collaboration between teams that ensure AMR laboratory quality is shaping the foundation of a national AMR surveillance network. Four meetings were held in 2018–2019 to establish and support AMR laboratory QMS implementation projects. Eleven AMR laboratories in Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine, and Uzbekistan are being mentored for QMS implementation. These are based on the 12 quality system essentials defined by the Clinical and Laboratory Standards Institute that helped develop the Laboratory Quality Stepwise Implementation tool (LQSI) and activity checklist for monitoring progress. In Uzbekistan, the national mentors conducted four visits to three AMR laboratories. The average score rose from 2.6% to 42.7% after the fourth mentoring visit. ACTIvITY REPORT 2018–2019 15 BETTER LABS ACTIvITY AREA 2 IMPROvE NATIONAL TRAINING PROGRAMMES AND QUALITY MANAGEMENT SYSTEMS Dr Kiyal Ormokoeva, national mentor, Kyrgyzstan “Better Labs for Better Health is one of our guides in Kyrgyzstan. Thanks to the programme, our laboratory services have been vastly improved and our specialists are learning a comprehensive range of invaluable new techniques and practices. We were also introduced to ISO 15189:2012 for the first time, which will be invaluable for us moving forward.” Better Labs QMS mentoring programme National mentoring and knowledge- sharing 16 ACTIvITY REPORT 2018–2019 BETTER LABS ACTIvITY AREA 2 IMPROvE NATIONAL TRAINING PROGRAMMES AND QUALITY MANAGEMENT SYSTEMS 0 5 10 15 20 25 30 National mentoring progress in maternal and child health hospitals in Kyrgyzstan 0 5 10 15 20 25 30 8% Progress Visit 1 16% Progress Visit 2 23% Progress Visit 3 29% Progress Visit 4 Kyrgyzstan was the first country to endorse its national laboratory policy and strategic plan, which highlighted the need for further laboratory assessment. The MoH requested that all maternity and child hospital labs be assessed by the NLWG and this indicated weak overall QMS. International support for regional labs would have been costly and it was decided that a more cost-effective and sustainable solution would be to train a team of national mentors to support the 10 maternal and child health regional laboratories. In 2017, Better Labs carried out the initial training of mentors in Kyrgyzstan. After the first set of Kyrgyzstan missions, two national mentors were invited to attend the 2018 annual mentor meeting to present their results. Annual mentor meetings help the pool of experts exchange their experience and knowledge. Further training and continuous capacity-building in quality management was given. In 2018–2019, these meetings involved national and international mentors working together on new processes and procedures to be implemented in mentored labs. They include contingency plans, which have become particularly relevant during the pandemic response. In Kyrgyzstan, a 16% average increase in QMS implementation was noted between the first and third mentoring visits in maternal and child health hospital regional laboratories (according to the LQSI activity checklist). Because of this, it was decided to roll out the national mentoring programme to an additional four countries. National mentoring schemes are now in place in Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan for all types of public health, AMR and clinical diagnostic laboratories. Pe rc en ta ge % ACTIVITY REPORT2018–2019 / 25 BETTER LABS ACTIvITY AREA 2 IMPROvE NATIONAL TRAINING PROGRAMMES AND QUALITY MANAGEMENT SYSTEMS National mentoring programme ¢ Established in: Kyrgyzstan, Tajikistan and Uzbekistan International mentoring programme ¢ 15 mentored laboratories in 9 countries ¢ 29% progress between 1st and 4th visit (according to LQSI activity checklist) ¢ 12 international mentors 26 / ACTIvITY REPORT2018–2019 AREA 3: Establishing laboratory networks for emergency preparedness and response ACTIvITY REPORT 2018–2019 19 International networks for laboratory surveillance, preparedness and response are essential for laboratory strengthening. They serve both as a platform for sharing information and expertise and a system for the referral of diagnostic specimens for primary and confirmatory testing for HTPs. The Lab Task Force was launched following a preparatory meeting held in Istanbul, Türkiye in January 2019 at which the terms of reference for the Lab Task Force were agreed upon. A laboratory tool to assess national laboratory diagnostic capacities for HTPs was also reviewed. Lab Task Force BETTER LABS ACTIvITY AREA 3 ESTABLISHING LAB NETWORKS FOR EMERGENCY PREPAREDNESS AND RESPONSE I. The assessments in all five countries indicated very little to no diagnostic capacity for several pathogens included in the questionnaire. II. For pathogens that countries are able to diagnose, manual methods are frequently used, often due to funding issues. III. Not all reagents are always available through local vendors or are only available at a high price due to the small quantity requested/required at any one time. IV. Concerns regarding lack of maintenance of equipment also emerged from the assessments, particularly regarding biosafety cabinets. V. Results highlighted that there is often no regular transport of samples between regional and reference laboratories. International shipment can often take up to 90 days. VI. Human resources – staff retention is clearly an issue in many regions, resulting in a lack of consistent expertise and knowledge in testing. NLFP* WHO CC** Organisations and Networks W H O R egional O ff ice for Europe Secretariat Lab Task Force Laboratory diagnostics for HTPs In 2019, five Member States went through the assessment process for the capacity to detect HTPs { *national laboratory focal points **WHO collaborating centres 28 / ACTIvITY REPORT2018–2019 BETTER LABS ACTIvITY AREA 3 ESTABLISHING LAB NETWORKS FOR EMERGENCY PREPAREDNESS AND RESPONSE ACTIVITY REPORT2018–2019 / 29 AREA 4: Advocacy, partnership and leadership 22 ACTIvITY REPORT 2018–2019 Advocacy The work conducted under Better Labs is made visible to its stakeholders through the WHO Laboratory Services website and publications in peer-reviewed journals. Sharing of information and experience is facilitated through inter-country meetings and the EZcollab online platform for laboratory experts. For example, national laboratory policies and strategic plans are shared between countries for inspiration and as a means to advocate change, to inform donors, and to enhance collaboration and the sharing of resources among national partners. Video – “We are laboratory workers” A 2019 video advocating for laboratory workers was viewed and shared over 3000 times on the internet. It touched the hearts of workers in health laboratories all over the world because it shows the importance of their day-to-day work (4). The WHO Country Office in Tajikistan has also developed and widely disseminated a video of Better Labs activities in the country. BETTER LABS ACTIvITY AREA 4 ADvOCACY, PARTNERSHIP AND LEADERSHIP ACTIvITY REPORT 2018–2019 23 Providing leadership for change Better Labs is a unique cross-cutting initiative that works on many issues, such as quality and biosafety, policies and strategic plans, cost-effectiveness and reforms of laboratory systems, and regulatory frameworks, in addition to providing training and mentoring at the laboratory level. Better Labs also aims to address a wide audience that includes partners, laboratory staff at all levels, and public health administrators. BETTER LABS ACTIvITY AREA 4 ADvOCACY, PARTNERSHIP AND LEADERSHIP Moving forward: Priorities 2020–2021 Work on national sample transport and the related country legislations Laboratory Expenditure Tool that calculates the annual expenditure of a laboratory or institute has been piloted in several countries and will be published in 2021 Research on national selection and evaluation of reference laboratories and recognition mechanisms Development of a tool for evaluation of the sustainability of laboratory systems Development of WHO recognized TORs and related mechanisms for public health laboratories working with HTPs 32 / ACTIvITY REPORT2018–2019 ACTIvITY REPORT 2018–2019 25 < 1. Laboratory licensing: an essential part of the national laboratory regulatory framework Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/344485, accessed 5 May 2022). < 2. Laboratory test costing tool: user manual/training manual Copenhagen: WHO Regional Office for Europe; 2019 (https://apps.who.int/iris/handle/10665/346135, accessed 5 May 2022). < 3. Uzbek Agency for Technical Regulation [website] (https://www.standart.uz/en/page/view?id=131, accessed 5 May 2022). < 4. (video) ‘We are laboratory workers’ Copenhagen: WHO Regional Office for Europe; 2019 (https://www.youtube.com/watch?v=zI5NPKCL4jw, accessed 5 May 2022). < The “Better Labs for Better Health” initiative to strengthen laboratory systems in the WHO European Region: activity report: January 2013–December 2015 Copenhagen: WHO Regional Office for Europe; 2016 (https://apps.who.int/iris/handle/10665/353744, accessed 5 May 2022). < Better Labs for Better Health Second Partners’ Meeting, December 2016: report, April 2017 Copenhagen: WHO Regional Office for Europe; 2017 (https://apps.who.int/iris/handle/10665/353740, accessed 5 May 2022). < Development of a national laboratory strategic plan: best practices document and facilitators’ guide, December 2016 Copenhagen: WHO Regional Office for Europe; 2017 (https://apps.who.int/iris/handle/10665/353746, accessed 5 May 2022). < Development of national laboratory policies – Best practices document and facilitators’ guide Copenhagen: WHO Regional Office for Europe; 2017 (https://apps.who.int/iris/handle/10665/355631, accessed 5 May 2022). < WHO manual for organizing a national external quality assessment programme for health laboratories and other testing sites Copenhagen: WHO Regional Office for Europe; 2016 (https://apps.who.int/iris/handle/10665/250117, accessed 5 May 2022). < Laboratory core capacities to be improved in two countries of Central Asia through addressing national sample referral mechanisms Copenhagen: WHO Regional Office for Europe; 2019 (https://apps.who.int/iris/handle/10665/325061, accessed 5 May 2022). Additional resources References 34 / ACTIvITY REPORT2018–2019 ABBREvIATIONS < AMR - Antimicrobial resistance < CC - Collaborating Centre < CDC - Centers for Disease Control and Prevention, United States of America < ECDC - European Centre for Disease Prevention and Control < GF - The Global Fund to Fight AIDS, Tuberculosis and Malaria < HIV - Human immunodeficiency virus < HTP - High threat pathogen < IHR - International Health Regulations (2005) < LQMS - Laboratory Quality Management System < LQSI - Laboratory Quality Stepwise Implementation tool < MoH - Ministry of HealthMS - Member States < NLFP - National Laboratory Focal Point < NLWG - National laboratory working group < PHL - Public health laboratory < QMS - Quality Management System < QSE - Quality system essential < TB - Tuberculosis < WHO - World Health Organization The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States: Lithuania Luxembourg North Macedonia Malta Monaco Montenegro Netherlands Norway North Macedonia Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Türkiye Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.who.int/europe WHO/EURO:2022-4370-44133-62280 Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia