FIRST INTERTB/LATIN AMERICAN REGIONAL SEMINAR

Transcripción

1 FIRST INTERTB/LATIN AMERICAN REGIONAL SEMINAR DEVELOPMENT OF A REGIONAL CAPACITY IN THE COUNTRIES OF LATIN AMERICA FOR CLINICAL TRIALS IN TUBERCULOSIS: AN ASSESSMENT OF FACILITIES, RESOURCES AND NEEDS Santiago de Cali,. March 7-9, 2005 Final Report Sponsored by: Cali, March 7 9, 2005 seminario-intertb@cideim.org.co; hildegard79@cideim.org.co; josef_garcía@cideim.org.co

2 DEVELOPMENT OF A REGIONAL CAPACITY IN THE COUNTRIES OF LATIN AMERICA FOR CLINICAL TRIALS IN TUBERCULOSIS: AN ASSESSMENT OF FACILITIES, RESOURCES AND NEEDS Santiago de Cali,. March 7-9, 2005 Final Report 1. Introduction Objectives Workshops specific conclusions Final Discussion Appendix a. Topics b. Speakers c. Latin-American Participants d. s Participants 14 e. CIDEIM Participants f. Participants to workshops g. Participants addresses 16 2

3 1. Introduction Randomized controlled clinical trials have long been recognized as the definitive method for assessing the efficacy of a particular medical intervention. Clinical trials have played a pivotal role in identifying chemotherapy regimens for the treatment of tuberculosis, which have achieved high rates of cure with low levels of toxicity and reasonable duration of chemotherapy. While the development of effective chemotherapy has had an important impact in industrialized countries, rapidly reducing morbidity and mortality caused by tuberculosis, the disease remains a major health burden in low income countries. The cost of the standard short-course chemotherapy of 6 month duration, with efficacy rates of almost 100%, is less than US$ 10 per patient, approximately 5 cents a day. However, even this low cost is proving a challenge for the provision of treatment, especially in the 22 listed poorest countries of the world, four of which (Bolivia, Honduras, Guyana and Nicaragua) are in the Latin American Region. The rising rates in the incidence of tuberculosis in the Latin American Region are of concern the regional NTPs. It is, thus, reasonable to plan the development of a regional coordinating centre and the inclusion of at least some of the most affected countries in such a network with a view to developing research capacity in the area and enable these nations to respond adequately to their own health needs. Experience in international studies has shown the advantages of establishing regional coordinating centers for such trials, not the least of which is the rapid recruitment of sufficient numbers of patients for the trials. The process of training in operations research, and of capacity strengthening to do such research, will require a sustained effort over a period of, at least, five years. Activities will be coordinated with the Pan American Health Organization (PAHO) tuberculosis activities in the region. These activities will consist of repeated workshops on research issues, especially statistical procedures and protection of human subjects and discussions of specific research protocols. The training will, therefore, have to be a continuous process. 2. Objectives 1. To develop an international network of clinical trials centers in Latin America. Participating centers must fulfill the following criteria: They are in a country with an established National Tuberculosis Programme (NTP) that is implementing the recommended DOTS Strategy in the areas where randomized clinical trials (RCT s) are going to be implemented. The NTP offers an uninterrupted supply of drugs and diagnostic materials, free of charge, for all patients. An established recording and reporting system, following the IUATLD/WHO guidelines, providing all the information necessary for a cohort analysis. They have access to a laboratory capable of microscopy, culture and susceptibility testing with a system of quality assurance. 3

4 They have personnel who can be trained in the conduct of clinical trials and who are capable of supervising treatment and monitoring progress. This should include a clear protocol for defaulter tracing. Knowledge from the Ministry of Health for the possible participation in clinical trials. 2. To strengthen capacity of clinical trials centers in operations research through Training in the conduct of controlled clinical trials Data management Quality assurance in laboratories Develop and enlarge the local ethical principles guiding trials in human subjects. Site visits Attendance of participants at workshops and courses on tuberculosis This first INTERTB/ LATIN AMERICAN REGIONAL SEMINAR were, therefore, held to discuss these issues. 3. WORKSHOP specific conclusions In addition,, to the topics covered in the course (see appendix), 2 workshops were held during lunch time to discuss the steps that are needed to be taken for management of new TB cases and cases that failed treatment or relapse. These workshops were lively and generated much discussion among the participants. The objectives of these workshops were: 1. Facilitate DOTS therapy 2. Improve the implementation of treatment The agenda was: Monday 12:30 14:30 Groups 1 and 2, and Tuesday 12:30 14:30 Groups 3 and 4. The four groups were given an outline to follow: 1. Introduction of the participants 2. Clinical trials to discuss during the workshop a. Intermittent treatment during the intensive phase (3 /week versus daily) and during the continuation phase (2/week versus 3/week) b. EBA (Early bactericidal activity): high doses of rifampicin during the intensive phase (600, 750, 900 and 1200). Follow up of the EBA study with a phase II study. c. 3 arm study: treatment during the intensive phase HRZE x 2 versus HRZS x 2 versus HRZQ x2. d. Other clinical trials 3. How can we advance? a. Requirements to participate b. Countries that may participate c. Questions to resolve 4. Conclusions The conclusions of the groups were discussed at the end of the day with all the participants. 4

5 Conclusions Group 1: Leaders: Dra. Amina Jindani and Dra. Elsa Villarino 1. Clinical trials are necessary in Latin America, (they could be pilot studies) 2. Differences in the DOTS strategy implementation may be an obstacle in the development of the Latin American network 3. Intermittent treatment twice a week may not be an option (requires 100% of supervision) 4. Studies with the purpose of reducing the duration of the treatment should be the priority in this region. - Brasil: is conducting a study giving 4 months of treatment with negative cultures at the second month in patients without cavity (Problem: 70% of the patients have cavity.) as the primary end point. 5. If a protocol is developed, a central office should be organized. - Training and supervision are necessary for all countries except Brasil (Ex. Brasil already has an investigation network in TB) 6. There should be an improvement in the communication and information system, clinical training, together with the development of a protocol 7. State penitentiaries are not a potential study group 8. It is necessary that each country have the support of the Ministry of Health to develop clinical trials. Conclusions Group 2: Leaders: Dr William Burman and Dr. Stefan Goldberg 1. Intermittent treatment studies: Evaluate during the initial phase three times a week versus daily (Peru, Guatemala, ) Develop studies of intervention during the continuation phase two times a week versus three times a week (, Peru, Bolivia) 2. Reduce duration of treatment Phase I studies evaluating the administration of Moxifloxacin for 4 months HRZE, Vs. HRZQ (Peru, ). 3. Other studies Comparison between S vs. E during the initial phase of treatment (HRZEX2 Vs. HRZSX2) () Evaluate the risk factors for treatment abandonment and failure with the DOTs strategy (Argentina). Identify the predictor markers of MDRTB (Peru, ) Conclusions Group 3: Leaders: Dra. Carole Mitnick and Dr. Cesar Bonilla 1. All Latin American countries agree that drug resistance is a threat to the efficacy of the DOTS strategy 2. There is interest in developing clinical trials with MDRTB patients 3. Identify standardized regimens according to the resistance pattern 4. There is interest in developing clinical trials that evaluate treatment regimens and duration of treatment (Peru,, Argentina, Nicaragua) 5. In countries without susceptibility test capability, standardized regimens could be evaluated. 5

6 Conclusions Group 4: Leaders: Dra. Mercedes Becerra and Dr. Jaime Bayona 1. There is already experience in the management of MDRTB patients 2. Information about the epidemiology of each region is not complete. 3. Begin the network with a simple study : high probability of success Proposal: identify patients with failure to the first line treatment with resistance to 2 or 3 drugs Options: DR H &R One arm: evaluate cure rate 4 o 5 drugs: E, P, Q, Amg(duration?) Cs? Two arms: 4 drugs: E, P, Q, Amg (duration 6) 5 drugs: E, P, Q, Amg (duration 6) and CS Conclusions of the 4 workshops: 4 drugs: E, P, Q, Amg (duration 6) 4 drugs: E, P, Q, Amg (duration 9) 4 drugs: E, P, Cipro, Amg (duration 6) 4 drugs: E, P, Moxi, Amg (duration 6) 1. Participants agreed to take the collaboration forward and to build the capacity to participate in clinical trials 2. Three different committees were organized where all the participants could choose to which one they would like to participate: Clinical Trials Protocols, Diagnosis and Operational Committee, and they could choose whether or not to be a leader in the group. The list of participants is shown below: Committee: Clinical Trials Protocols Function: Formulation of the initial question and the further development of clinical trials protocols in TB standard treatment Name Country Leader Luis Chacón Nicaragua William Garay Peru Belkys Marcelino Republic Dominican Jaime Bayona Peru William Cárdenas Ethel Maciel Brasil Ana Maria Jimenez Costa Rica Jacobo Arguello Honduras Carlos Agudelo Julia Freer Costa Rica Instituto Nacional De Salud Rocío Verduga Ecuador Cesar Bonilla Peru Elsa Zerbini Argentina David Jamil Hadad Brasil 6

7 Committee: Diagnosis of tuberculosis Function: Formulation of questions about the improvement of the diagnosis and research of new methods for TB diagnosis. Name Country Leader Luis Chacón Nicaragua Nancy Ayala Guatemala William Garay Peru Leonarda Reyes Republic Dominican Gloria Yale Cajahuanca Peru Gladys Dominguez Carlos Agudelo Instituto Nacional de Salud Hilda Membreño Honduras Oriana Rivera Maria Delfina Sequeira Argentina Moises Palaci Brasil Committee: Operational Research Function: Find funds for the developed protocol; Help in the conduction of the protocol and its development Name Country Leader Jackeline Espinoza Jaime Bayona Peru William Cárdenas Gladys Dominguez Ana María Jimenez Costa Rica Julia Freer Costa Rica Jacobo Arguello Honduras José Antonio Mercado Bolivia Gloria Yale Cajahuanca Peru Instituto Nacional De Salud René Guevara El Salvador Claudia Figueroa Rodrigo Ordoñez Ernesto Moreno Mario Soto Villalta El Salvador Rocío Verduga Ecuador Horacio Espinoza Bolivia 7

8 3. All the speakers were invited to participate as members of an advisory committee. Happily, all accepted: Advisory Committee: Dra. Amina Jindani Dr. Marcos Burgos Dra. Mercedes Becerra Dra. Carole Mitnick Dra. Elsa Villarino Dr. William Burman Dr. Stefan Goldberg Dr. Ernesto Montoro Dr. José Becerra 4. There would be a link between the two URL: CIDEIM and INTERTB where everyone may find information of the seminars and other network activities: a. b For the continuation of the training of the countries, PERU will organize the II seminar to be held in October, 2005 and afterwards BRAZIL will organize the III seminar to be held in March, FINAL DISCUSSION On March 9, 2005 after the final discussions of the seminar, a meeting was held at CIDEIM with the Advisory Committee where it was discussed the most promising ideas to pursue as possible clinical trials: 1. EBA studies of high dose rifampin 2. Prepare a 2 arm study Phase II for high dose rifampin in the intensive phase. Those attending were: Dra, Amina Jindani Dr. Marcos Burgos Dra. Elsa Villarino Dr. William Burman Dr. Stefan Goldberg Dra. Carole Mitnick Dra. Mercedes Becerra Dr. José Becerra Dra. Nancy Saravia Dr. Juan Francisco Miranda Dr.- José Fernando Garcia Dra. Hildegard Piñeros Dr. Carlos Durán Dr. Juan Carlos Higuita 8

9 The conclusions were: 1. Identify organizations for funding: USAID, CDC, Dukes University (huge clinical trials), Fogarty, PAHO 2. Training persons for the development of clinical trials in tuberculosis 3. Advantages of the EBA studies: i. Ready availability of the drug ii. Blank the dose (ideally) iii. Field not crowded iv. There are persons interested in the area 4. Regarding the 2 arm study: proposal: EHZR 600 versus EHZR 900 for two months i. Placebo, (300mg extra) ii. Organize the proposal and send it to the Advisory Committee iii. Sample size (around 330 patients) 9

10 5. APPENDIX a. TOPICS In order to accomplish these objectives, a three day agenda was organized, and the following topics were covered: Why do we need RCTs? Essentials of the RCT Framing the research question Preparing the protocol Study procedures randomization enrolment treatment phase follow up phase Statistical considerations confidence significance power sample size sampling methods Drafting forms and questionnaires Data management Critical issues serious adverse events outcome events critical data or specimens when to stop Site requirements Site monitoring Trial oversight Steering Committee Data & Safety Monitoring Committee Analysis of data Basic approaches Impact of losses to follow up Impact of confounding Publication of data Laboratory procedures Resources available Enrolment capacity Follow up capacity Human subject protection Declaration of Helsinki GCP- ICH guideline Role of National Ethics Committee Responsibilities of investigators Intellectual property rights 10

11 Future clinical trials High dose rifapentin trial Treatment trial of MDRTB Prevention trial of MDRTB Trial of moxifloxacin Surrogate markers of relapse b. SPEAKERS Dra. Amina Jindani Honorary Senior Lecturer; St. George s Hospital Medical School; University of London Dr. William Burman Department of Medicine (Division of Infectious Diseases), U. of Colorado; Associate professor, Health Sciences Center, Denver CO; Attending physician - Infectious Diseases and Tuberculosis clinics, Medical director, Infectious Diseases Clinic, Denver Health and Hospitals; Medical Director, Title 3 HIV care program Dra. Elsa Villarino Team leader: TB Trials Consortium (TBTC); Clinical and Health Systems Research Branco; Division of Tuberculosis Elimination; National Center for HIV, STD, and TB Prevention; Center for Disease Control and Prevention; Atlanta, GA. Staff Physician; Tuberculosis Clinic; Country Board of Health; Decatur, Georgia. Instructor; TB/HIV; Mini- residency; Emory University School of Medicine and Georgia Department of Human Resources. Dra. Carole Mitnick Associate Researcher, Division of Social Medicine and Health Inequalities, Department of Medicine, Brigham and Women s Hospital, Boston, MA Dr. Marcos Burgos Assistant Professor, University of New Mexico, School of Medicine. Department of Internal medicine, Division of Infectious Diseases, Albuquerque, New Mexico. Dr. José Becerra Centers for Disease Control and Prevention (CDC), National Center for HIV, STD and TB Prevention (NCHSTP), Division of Tuberculosis Elimination (DTBE), Atlanta, GA. Chief, Information Technology and Statistics Branch (ITSB). ITSB provides information management, statistical, analytical, software programming, software development and support to the DTBE so that staff may accomplish the mission of promoting health and quality of life by preventing, controlling, and eventually eliminating TB from the United States. Dra. Mercedes Becerra Epidemiologist, Partners In Health, Boston, MA, and Socios En Salud, Lima, Peru Dr. Stefan Goldberg Medical Officer; CDC NCHSTP, Division of TB Elimination; Clinical and Health Systems Research Branch Dr. Ernesto Montoro 11

12 Chief of the National Laboratory of Reference and Research in Tuberculosis and Mycobacterium since Instituto de Medicina tropical, "Pedro Kourí" IPK Dr. William Cárdenas Investigator and Coordinator of the Contract Research Organization (CRO) Unit, CIDEIM, Cali -. Dra. Beatriz Ferro Investigator and leader of the Mycobacterium Laboratory at CIDEIM, Cali Dra. Nancy Saravia Scientific Director of CIDEIM, Cali Dra. María C. Miranda Investigator of bacterial resistance and secretary of the Ethics Committee at CIDEIM, Cali Argentina Bolivia Brasil Costa Rica Ecuador Elsa Zerbini Maria Sequeira Jose Mercado Horacio Espinoza Ethel Leonor Noia Maciel c. PARTICIPANTS from LATINAMERICAN Director of Instituto Nacional Enfermedades Respiratorios Dr. Emilio Coni Delfina Technical Assistant Director of Instituto Nacional de Enfermedades Respiratorias Dr. Emilio Coni Antonio Pneumologist - Hospital Viedma Technical Physician in tuberculosis, responsible of the Gabriel study TBC - VIH - AIDS. Servicio Departamental de Salud Pando Coordinator of Pesquisa Clínica Núcleo de Doenças Infecciosas UFES Pesquisa Clínica Núcleo de Doenças Infecciosas UFES David Jamil Hadad Julia Freer Vargas Attending physician, Coordinator of Epidemiology, responsible of the NTP. Ana María Jimenez Rocío Verduga Guatemala Dra Nancy Ayala Mario Rafael Soto El Salvador René Guevara Honduras Hilda Membreño Jacobo Arguello Nurse of the NTP. Caja Costarricense de Seguro Social. (Institution encharged of the NTP since 1999 Nurse of the NTP from Guayas. DPSG Office Supervisor of the Mycobacterium Area National Laboratory of Health Physician supervisor of the NTP from El Salvador National Laboratory Supervisor Chief of the Central Laboratory of Tuberculosis Chief of the NTP 12

13 Nicaragua Peru Luis Alberto Chacón Jaime Bayona William Ernesto Garay Cesar Bonilla Gloria Yale Cajahuanca Chief of the National Department of Mycobacterium. National center of Diagnosis and Reference Minsalud Physician, Director Chief of C.S. Magdalena Chief of the Public Health Laboratory Dominican Belkys Marcelino Epidemiologist of the NTP Republic Leonarda Reyes Chief of the Laboratory network Claudia Valencia Montero Associate Consultant PAHO Coordinator of the Mycobacterium group National María Consuelo network of Laboratories - Instituto Nacional de Salud Garzón d. PARTICIPANTS from COLOMBIA Cali Antonio José Triana Coordinator of the Local PNT of Cali Cali Gladys Domínguez Coordinator of the NTP - Hansen of the Valle del Cauca State Cali Maria Claudia Rojas Director of Liga Antituberculosa na Marta Gardner Bogotá Ernesto Moreno Naranjo Coordinator of NTP - Ministerio Protección Social Bogotá Rafael Romero Director of Instituto Nacional de Salud Bogotá Jacqueline Espinoza Bacteriologist from Instituto Nacional Salud Bogotá Claudia Llerena Instituto Nacional de Salud Physician from Corporation para Investigaciones Medellin Carolina Muñoz Biológicas - CIB Physician from Corporation para Investigaciones Biológicas - CIB Medellin Carlos Agudelo Medellin Elena del Corral Public Health Medellin Lizeth Paniagua Physician Research Assistant Medellin Carlos Rojas Physician PhD, Professor Universidad de Antioquia Popayan Oriana Rivera Microbiologist, Professor Universidad de Cauca Medellin Gustavo Montero Internist Physician Pasto Claudia Figueroa Fundación Universitaria San Martín Sede Pasto Pasto Rodrigo Ordoñez Fundación Universitaria San Martín Sede Pasto e. PARTICIPANTS from CIDEIM Cali Juan Francisco Miranda Executive Director of CIDEIM Cali Jose Fernando Garcia Coordinator of the Tuberculosis Group Cali Cesar Moreira Physician Research Assistance Tuberculosis group Cali Carlos Eduardo Durán Physician Research Assistance Tuberculosis group 13

14 Cali Hildegard Piñeros Physician Research Assistance Tuberculosis group Cali Margarita Chamorro Nurse Research Assistance Tuberculosis group Cali Lyda Osorio Epidemiologist Investigator Cali Juan Carlos Higuita Molecular Biologist Tuberculosis group Cali Ana Lucía Rodríguez Bacteriologist Tuberculosis group Cali Olga Barón Bacteriologist Tuberculosis group Cali Ernesto Martínez Coordinator Clinical Unit Cali Alisson Sombredero Physician Research Assistance Cali Adriana Cruz Dermatologist Investigator Cali Beatriz Porras Physician Research Assistance Cali Mauricio Pérez Statistical f. Participants in workshops The list of participants to each workshop is as follows: Committee: Monday New Cases Group: 1 Chair: Dra. Amina Jindani, Dra. Elsa Villarino NAME COUNTRY 1 William Garay Peru 2 Luis Chacón Nicaragua 3 Horacio Espinoza Bolivia 4 Claudia Valencia Brasil 5 Jackeline Espinoza 6 Gladys Dominguez 7 Elsa Zerbini Argentina 8 Mercedes Becerra EEUU 9 José Becerra EEUU 10 Amina Jindani UK 11 Hildegard Piñeros 12 Ethel Maciel Brasil 13 David Hamil Jadad Brasil 14 Jacobo Arguello Honduras 15 Lizeth Paniagua 16 Carolina Muñoz 17 Carlos Agudelo 18 Carlos Durán 19 Elsa Villarino EEUU 20 Julia Freer Costa Rica 21 Ana María Jimenez Costa Rica Committee: Monday New Cases Group: 2 Chair: Dr. William Burman, Dr. Stefan Goldberg 14

15 NAME COUNTRY 1 José Mercado Bolivia 2 Cesar Bonilla Peru 3 Ernesto Moreno 4 Maria Delfina Sequeira Argentina 5 Gloria Yale Peru 6 Hilda Membreño Honduras 7 Nancy Ayala Guatemala 8 William Cárdenas 9 Cesar Moreira 10 Carole Mitnick EEUU 11 Marcos Burgos EEUU 12 Nancy Saravia 13 José Fernando Garcia 14 Stefan Goldberg EEUU 15 Juan Carlos Higuita Committee: Tuesday MDRTB cases Group: 3 Chair: Dra. Carole Mitnick, Dr. Cesar Bonilla NAME COUNTRY 1 William Garay Peru 2 Cesar Bonilla Peru 3 Carole Mitnick EEUU 4 José Fernando Garcia 5 Maria Delfina Sequeira Argentina 6 Leonarda Reyes Dominican Republic 7 José Antonio Mercado Bolivia 8 William Burman EEUU 9 Luis Chacón Nicaragua 10 Carlos Agudelo 11 Nancy Ayala Guatemala 12 Hilda Membreño Honduras 13 Helena Del Corral 14 Amina Jindani UK Committee: Tuesday MDRTB cases Group: 4 Chair: Dra. Mercedes Becerra, Dr. Jaime Bayona NAME COUNTRY 1 Ernesto Moreno 2 Julia Freer Costa Rica 3 Marcos Burgos EEUU 4 Elsa Villarino EEUU 5 José Becerra EEUU 6 Stefan Goldberg EEUU 7 Ana María Jimenez Costa Rica 15

16 8 Jacobo Arguello Honduras 9 Horacio Espinoza Bolivia 10 Oriana Rivera 11 Gloria Yale Peru 12 Jaime Bayona Peru 13 Mercedes Becerra EEUU 14 Gladys Dominguez 15 Antonio José Triana 16 David Jamil Hadad Brasil 17 Ethel Maciel Brasil 18 Claudia Valencia Brasil 19 William Cárdenas 20 Carlos Rojas 21 Cesar Moreira 22 Maria Consuelo Garzón 23 Hildegard Piñeros 24 Carlos Durán g. Participants addresses P/Ciu Nombres correos Cali Antonio José Triana antoniojoset5@hotmail.com Cali Gladys Domínguez gobando@valledelcauca.gov.co Cali Maria Claudia Rojas ligatuber@hotmail.com Marta Gardner Bog Ernesto Moreno Naranjo emoreno@minproteccionsocial.gov.co Bog Rafael Romero rromero@ins.gov.co Bog Jacqueline Espinoza jespinosa@ins.gov.co Bog Claudia Llerena claudiallerena@yahoo.com Med Carolina Muñoz carito-mg-sp@yahoo.com Med Carlos Agudelo carlosagudelo@yahoo.com Med Elena del Corral elenadelco@udea.edu.co Med Lizeth Paniagua lpaniagua@yahoo.es Med Carlos Rojas crojas@guajiros.udea.edu.co Popay Oriana Rivera orivera@unicauca.edu.co Med Gustavo Montero gmontero99@hotmail.com pasto Claudia Figueroa claudialilifg@hotmail.com pasto Rodrigo Ordoñez rumeor@hotmail.com Arg Elsa Zerbini emilioconi@infovia.com.ar Maria Delfina Sequeira labconi@infovia.com.ar Boli Jose Antonio Mercado jose.antonio.mercado@gmail.com Horacio Gabriel Espinoza horaciodelvillar@hotmail.com Bras Ethel Leonor Noia Maciel emaciel@ndi.ufes.br Dr David Jamil Hadad davhadad@ndi.ufes.br costar Julia Freer Vargas colmillo@cooso.cocr 16

17 Ana María Jimenez Ecua Rocío Verduga Guat Dra Nancy Ayala sal Mario Rafael Soto sal René Guevara Hond Hilda carolina Membreño Jacobo Arguello Nicar Luis Alberto Chacón Perú Jaime Bayona William Ernesto Garay Cesar Bonilla Gloria Yale Cajahuanca repdom Belkis marcelino Leonarda reyes Wash Claudia Valencia Montero María Consuelo Garzón Cali Juan Francisco Miranda Cali Jose Fernando García Cali César Moreira Cali Carlos Eduardo Durán Cali Hildegard Piñeros Cali Margarita Chamorro Cali Lyda Osorio Cali Juan Carlos Higuita Cali Beatriz Porras Cali Olga Barón Cali Alisson Sombredero Cali Adriana Cruz Cali Ernesto Martínez Cali Ana Lucía Rodríguez Cali Mauricio Pérez William Burman Elsa Villarino Carole Mitnick Marcos Burgos William Cárdenas Beatriz Ferro Amina Jindani José Becerra Mercedes Becerra Stefan Goldberg, MD Ernesto Montoro Nancy Saravia María Consuelo Miranda