Team:CPU CHINA/HP/Integrated
summary
We conducted our human practice with the purpose of evaluating whether our novel “immune like cells” would be practically plausible and of importance in the field of tuberculosis treatment. First we got in touch with Center for Disease Control (CDC) and researched on literature about this disease so that the idea of using innate immune system arose. Then we interviewed several professors and doctors to add all the parts to our original frame. We also communicated with loads of entrepreneurs and policy related experts, providing us with insights of what to do if we want to make our project a real product, during which we thoroughly considered the current market, our competition and our strength. We further communicated with experts from CDC and doctors again to make sure our design meets the needs of society. Last, we took a survey among patients which helps us understand the importance of disease management and eventually leads to our new APP. Our human practice is well integrated throughout with our project, and significantly broadened our horizon on this specific topic, and more importantly, improved our iGEM project by considering the views of different stakeholders.
The events of tuberculosis in schools
We learned that a school was temporarily closed because of the outbreak of tuberculosis. At the same time, an incident that many young children were infected with tuberculosis caused by a teacher carrying tuberculosis is, also indicated that tuberculosis is not far away from our life.
Inspiration
CDC
We learned from the epdimologists from Nanjing CDC that the main problems clinical practice are faced with are the multi-drug resistance issue and the absence of a long-term therapy with the anti-relapse characteristic.
Conclusion :
These are the directions in which we are seeking for improvements and even direct solutions. If we can design a method to activate the body's innate immunity against tuberculosis, it might be harder to render drug resistance and liver damage than traditional therapy.
The fight between human beings and Mtb has been on for hundreds of years, yet the weapons we hold have only gone through slight optimization, while our enemy is upgrading their systems all the time. The battle is still intense.
Hospital
From the interview, we found that poor compliance is one of major problems in the process of long-term medication. We also learned that patients must take more than three kinds of drugs a day, which is very inconvenience and may lead to the patients' unauthorized suspension of medication once the symptoms become not obvious.
Conclusion :
If long-term cell therapy is employed, the presence of Mycobacterium tuberculosis in the patient can be detected and constantly damaged, avoiding the discontinuation of treatment or a recurrence of tuberculosis. What’s more,long-term cell therapy can also be used as a preventive for high-risk populations.
Through this interview, we got aware of current status of tuberculosis diagnosis and treatment, which gave us a lot of insights of project design.
One of the problems is the difficulties of tuberculosis detection. As we all know, tuberculosis patients are infected with Mycobacterium tuberculosis (Mtb). However, there is no obvious symptoms for the early period patients which makes this disease sometimes hard to diagnose. When tuberculosis develop, the symptoms may become more obvious, like fever, fatigue, upset, poor appetite, long-term weight loss which make the patients very suffering. Currently, the main detection method is molecular examination carried out by hospitals. This method is efficient but cannot cover all infected people due to limited resources. Normally, it can only be applied on a part of high exposure populations who are generally considered to have higher risk to get this disease, for example, close contacts of tuberculosis patients. Obliviously, this scope of usage of this method is not sufficient compared to the population infected with Mtb, so we are wondering if we could endow our immune-like cells with other functions to simplify the detection methods, reduce the cost of diagnosis and realize precise early diagnosis (For more details please visit here).
Another problem is the compliance of patients (or we can say the acceptance of patients). The treatment period of tuberculosis is relatively long, which could last for 6 to 9 months. Therefore we tend to make a long cycle therapeutic strategy, to be more precisely, a strategy can be efficient for a long time after single administration to improve the compliance. What’s more, we learned that the patients tend to stop taking medicine when their symptoms relieve which, however, usually leads to the relapse of tuberculosis. Because although the symptoms seem to be less severe, the bacteria is not eliminated. So we came up with the idea to set up a system like this (For more details please visit here), capable of treatment and surveillance during a relatively long period after just a single injection, thus to improve the compliance of patients.
From the interview and the publication[1]，we learned that all drugs used on tuberculosis patients are chemical drugs, like rifampicin and isoniazid. There are two problems of chemical drugs, side effects and drug resistance. First, most existing drugs can result in liver and kidney damage, and the damage can be even more severe with long-term drug administration which is commonly required for patients. So we decided to develop a project which utilizes the body's own immune system to fight against pathogens. Furthermore, Some drugs have fought the Mtb for more than 50 years, and this bacteria have evolved to resist them. Some patients may even come up with multidrug-resistant tuberculosis (MDR-TB) with resistance to at least 2 powerful first-line anti-TB drugs, which means they may have no drugs to use! However, if we can take advantage of immune systems to fight against Mtb, it is not that likely to render resistance due to the quite different functional mechanism. So, we are aiming to develop a new strategy by activating the immune system to fight against Mtb that is quite difficult to render resistance, totally different from the existing anti-Mtb methods.
[1] Mabhula, A., and Singh, V. (2019). Drug-resistance in Mycobacterium tuberculosis: where we stand. Medchemcomm 10, 1342-1360
Professor Yu liu, our PI
In our original design, we used granule enzyme B and perforin to kill Mtb , but our PI suggested us to use antimicrobial peptide, since Granular enzyme B and perforin may also damage the normal cells.
Conclusion:
We sorted 3 antimicrobial peptides from the literature and screened out granulysin as the most efficient one through mathematic modeling. (See detailed information here)
Yu liu, Professor. She is focusing on the development of monoclonal antibody drugs and the biochemical drug activity and mechanism of action.
Doctor Chen
We interviewed Doctor Chen from Jiangning Hospital to learn about doctor’s opinion about our project. He told us that if we want to fight tuberculosis through the body's innate immunity, we must consider theintracellular macrophages, since Mtb can survive inside macrophages.
Conclusion:
We decided to add another system to kill the bacteria inside the macrophages. We searched the publications and decided to choose exosomes, a vesicle that can carry miRNA or mRNA to do the job.
Jiangning Hospital is one of the designated hospitals for tuberculosis in Nanjing. It has established a tuberculosis clinic and is qualified to treat tuberculosis patients.
Dr. Haoqian Zhang
At The 3rd Nanjing iGEM Regional Meetup, when Dr. Zhang commenting on our design, he mentioned that NF-κB may not respond strongly enough.
Conclusion:
We searched the literature and found that there is a positive feedback mechanism between let-7f and NF-κB, but the specific situation requires further experimental exploration.
(For more details, please visit here!
Professor Yibei Xiao
We consulted Prof. Xiao for his advice to our current design and he said that we ought to distinguished the infected Microphages and uninfected microphages, because if exosomes combined with macrophages that are not infected with Mycobacterium tuberculosis, it is equivalent to a waste of resources.
Conclusion:
So we planed to find a way to specifically target the macrophages that infect the intracellular parasitic Mycobacterium tuberculosis to making our design more specific.
Professor Yijun Chen
We also talked with Prof. Chen who suggested us to target infected macrophages through immunology.
Conclusion:
We searched a great deal of publications, and found that macrophages infected with Mycobacterium tuberculosis expressed higher level of PD-L1 than normal macrophages. So we came up with an idea to add a peptide targeting PD-L1 on the exosomal membrane to target the macrophages infected with Mycobacterium tuberculosis, leaving the uninfected macrophages unaffected, thus improving the safety and selectivity of our immune-like cells.
Questionnaire to patients
Based on the information obtained by doctors and CDC specialists, we designed a questionnaire to investigate the impact of tuberculosis on patients' lives.
The survey showed that patients do not dare to communicate with others, because they are afraid to transmit the bacteria to others and are inferior about their disease. At the same time, the supervision and care of the patients by the community doctors were mostly 1-2 times a week, or even 1-2 times in half a month.
Conclusion:
So we designed an app: NCDS, which is convenient for online consultation of doctors and patients, daily automatic supervision and medication, etc. This app can also avoid tuberculosis patients entering the crowds to reduce the risk of tuberculosis transmission.
(The survey also shows that the drug price is very expensive in the case of multi-drug treatment, which leads us to think of including this fee in the medical relief policy and asking the CDC again for help.)
Recognition from commercial competitions
A, China artificial Intelligence summit 2019, Most potential award
B, The second college student innovation competition in Nanjing, Excellent award
C, United Kingdom and China Entrepreneur Association, global fourth prize
Conclusion:
In order to improve patient compliance and access to doctors, we designed daily program recommendations, including diet and online counseling. The doctors of Nanjing Drum Tower Hospital said that if there is such an app, they are willing to try as online doctors. And based on the feedbacks we came up with the idea of visiting the CDC again to understand the relevant policies, and put it into practice soon.
A: China artificial Intelligence summit 2019，Most potential award
The judges commented on our thoughts and told us that we should start with the management of infectious diseases, so that we can solve.
The first is that the compliance of patients with tuberculosis.
The second is that the tuberculosis patients may effectively isolate the source of infection in the case of reducing contact with the outside world.
B:The second college student innovation competition in Nanjing
The judges expressed their affirmation on the management status of patients who wish to improve chronic diseases, but they also pointed out that we should invest more energy in the online inquiry system, and doctors should be more inclined to retirees.
C: The United Kingdom and China Entrepreneur Association
Investors say that our app has taken shape and has great prospects, but in UK, it can be more convenient if we can combine medical insurance with an online store, the precondition is to pay attention to safety and policy issues.
Professor Jun Zhou
Prof. Zhou raised the problem of excessive cell overload and transfection stability. She believes that if our artificial cells need to identify and kill the bacteria at the same time, the cell burden is relatively heavy, and the success rate and stability of expression is uncertain, which can be further improved in the future.
She also gave us the following suggestions:
a. TLR1/2 have a membrane protein detection problem, because membrane protein has both intracellular and extracellular segments. These receptors participated in a series of reactions which may results in some difficulties in the detection. She hopes us can refer to other publications and clear our experimental methods.
b. She also mentioned that the stability of TLR1, TLR2 expression might be a problem since the experimental process is only instantaneous transfection. After a period, it might be hard to determine whether these receptors will still exist on the cell membrane.
Although our idea is valid, it is necessary to find more relevant documentary evidence.
Karen Wang
We interviewed Ms. Karen's views on drug ethics and safety. As a drug management manager, she explained to us that drug ethics and safety are actually the ethics of every detail in the process of production and use. Safe, legal compliance, so as to the experiment or preparation, you need to ensure that every detail is safe and effective, so that the safety of the drug are guaranteed.
Conclusion:
Safety
Frank Lim
Frank told us some people with tuberculosis in the Philippines are not going to see a doctor because they are worried about the cost of medical treatment. But in fact, such inspections in the Philippines are as free as China, so we are trying to raise local awareness of tuberculosis related policies.
Conclusion:
Analogous to China, we conducted research, through comics and other ways to enhance public understanding of policies, and we began to think about how to use modern network tools to help people better understand tuberculosis.
Yangtze River Pharmaceutical Group
In order to further understand how to industrialize the products, we got in touch with the Taizhou Municipal Government and went to visit the China Medical City. After learning about the local government's planning for the vaccine industry, we went to Yangzijiang Pharmaceutical.
After learning about the local government's planning for the vaccine industry, we went to Yangzijiang Pharmaceutical.
Conclusion:
In Yangzijiang Pharmaceuticals, we visiting factories and museums, which gives us a better understanding of how to refrigerate and manage biological cell vaccines. The release rate and hemorheology parameters of our vaccines containing microencapsulated cells after injection into the body remain to be considered. (For more details please visit here.)
He Wang
When marketing a product, we need to have a sound supervision mechanism. At the same time, we need to know more about the product. For each audience's acceptance and price, when we are doing “to business and to customers.” We must pay attention to the health of every patient. We believe that people-oriented vaccines will produce many social benefits.
Conclusion:
His philosophy coincides with us. When we try to use synthetic biology to benefit the majority of TB patients, we must consider the price of our products.
Doctor Chen
If our treatment plan is put into use, although it is cheaper than cell therapies like CAR-T, it will still be more expensive than most traditional drugs. Therefore, we seek help from clinicians to ask how we should reduce the cost of patients and improve the market competitiveness of our programs.
Conclusion:
The doctor said that our therapeutic can compare to the MDR-TB treatment drug bedaquiline, which is currently undergoing clinical research. He suggested that we can also cooperate with the government to try to include our treatment plan in the scope of medical insurance to reduce the patient's treatment burden.
Mr Min Luo, Marketing Manager, Bank of China Insurance Department
He explained to us that critical diseases insurance in China does not cover tuberculosis, but the Chinese government has made a great relief policy for the free use of first-line drugs for non-resistant tuberculosis infections.
However, with the emergence of multi drug resistant Mycobacterium tuberculosis, a increasing number of patients are required to use second-line drugs and they have to bear the cost on their own, so relevant commercial insurance can also become a promising solution.
Conclusion:
At the same time, the questionnaires distributed to patients also showed that in the case of multi-drug treatment, the patient's drug price is very expensive, which makes us consider including it in the medical assistance policy. In this case, we decided to seek help from the CDC once again.
CDC again
This time, we revisited the CDC with the ideas of other experts. This time we have a policy understanding of the reform of the medical insurance structure and try to incorporate our treatment plan into the national health insurance policy. The CDC said that the current development of TB drugs is not very fast, and the country will quite welcome us to provide new ideas for the treatment of tuberculosis.
Conclusion:
Under the guidance of the CDC, we have wrote a proposal to suggest including vaccines for the prevention of major infectious diseases into health insurance.
