Team:Tec-Monterrey/Human Practices

INTEGRATED HUMAN PRACTICES

General Overview

In iGEM Tec Monterrey, we managed to integrate the legal and educational aspects related to our research and thus move from the laboratory to the classrooms and congress to reduce deficiencies in public health and education systems. From the beginning we went to experts in public health and Cystic Fibrosis, to know the areas that need the most help. Once defined the needs in which we would seek to create a change, we work with experts in law and educational development to realize our ideas. This year's work can be summarized in the following interviews and achievements:

• Proposed amendment of the law for the labeling standard of medicines and herbal remedies.
• Presentation and approval before the Congress of Nuevo León of an exhortation to the Secretary of Public Health of the State of Nuevo León to promote improvements in the labeling of medication.
• Interviews with doctors of the National Institute of Public Health
• Approach and collaboration with the Regiomontana Association of Cystic Fibrosis.

On Public and Educational Engagement we managed to consult with experts in the area and design several activities to approach scientists as well as the general population, children, adults and people with Cystic Fibrosis in order to establish a two-way conversation about Synthetic Biology and talk more about the technological advances in recent years while documenting as much information as possible for future teams that wish to build upon what we have achieved.

National Institute of Public Health of Mexico

In order to learn more about antibiotic resistance in our country, we contacted the National Institute of Public Health of our country. Thanks to them, we were able to talk with the members of the research line in public health about the access and usage of antibiotics and antimicrobial resistance.

Meeting with Anahí Dreser

On May 16, a call was made with Anahi Dreser, a researcher specialized in antibiotic usage, health policies and quality of care of the National Institute of Public Health. With this call we were able to know a little more about the current situation of antibiotic resistance in Mexico and analyze alternatives to generate an impact on society. She told us that the magnitude of the problem itself is unknown because of the lack of collection of information by governmental entities and because there is a record that Mexican doctors tend to misuse antibiotics and patients do not follow their prescribed treatment. We could also discuss the impact that a device like the one we propose and the human practices we plan will have. Dr. Dreser said:

In addition, there is a record that Mexican doctors tend to misuse antibiotics and that patients do not follow their prescribed treatment. We could also discuss the impact that a device like the one we propose and the human practices we plan will have. Dr. Dreser talked to us about the importance of creating a culture of antibiotics, and its importance in modern day.

"Just as the new generations are growing with a culture of recycling, it would be great that they could grow with a culture of the correct use of antibiotics".

Thanks to the information provided, we began to investigate the legislative situation of this issue, analyze the most resistant bacteria in our country and implement E-bug dynamics with patients more vulnerable to infections and with children of various ages.

Meeting with Jesús Silva Sánchez

We had the opportunity to interview Dr. Jesús Silva Sánchez, leader of the line of research in medicines used in public health to discuss the public policy in the area of ​​health and the existing methods for obtaining new antibiotics.

Asociación Regiomontana de Fibrosis Quística (ARFQ)

This association is dedicated to improve the life quality of patients with cystic fibrosis, in the state of Nuevo León, Mexico. They primarily give treatments and medications to patients with low incomes, and to achieve this, they organize fundraising events.

Through this contact we were able to meet members of the association, including children affected by this disease, which helped us to see the reality that patients live.

Meeting with Dr. Albino Rivas

After deciding that we would like to look for a solution to the problem of antibiotic resistance, we found ourselves looking for areas where we could apply it. Thanks to one of our team members, we realized that antibiotic resistance was an important part of the way Cystic Fibrosis is treated.

In published research on the consequences of patients infected with antibiotic-resistant P. aeruginosa, it is mentioned that these people are more susceptible to the symptoms of the disease; it progresses faster than normal and this has important implications for infection control, antibiotic use and lung transplantation. [1] We sought to do something about it but did not know how to approach the issue. Something did call our attention though:

¿Why was the life expectancy in Mexico 18 years old while the global average was almost 40?

We looked for information in articles and on the internet, however, we felt that talking to an expert in the field would give us a broader picture of what it means to have CF in Mexico. We found an association that helps people with CF in our city, the Regiomontana Association of Cystic Fibrosis (ARFQ). Our first contact with them took place during a visit we made to their offices where we met one of the doctors in charge of treating many of the patients they support, Dr. Albino Rivas.

A meeting was scheduled and held at our university. Dr. Rivas talked to us about the disease and many of the problems faced by CF patients. He pointed out that in our country the treatment for CF patients is inaccessible for most of the population due to its high costs, which is one of the main reasons the life expectancy of people with CF specifically in Mexico is so low compared to the rest of the world. These treatments usually consist of antibiotics to treat infections, enzymes to help digest food, medicines to expectorate sputum and mucolytics that are able to thin out the sputum. At first we were only focusing on antibiotics, he liked our stand on antibiotic resistance and mentioned a really important fact: Doctors can never give CF patients the same antibiotic on four occasions in a row, because after that, patients become resistant to them, even if they take the whole treatment correctly. The mucus that patients have in the lungs is so thick that antibiotics only kill some bacteria but not others, so they become resistant. After a while, patients’ infections are practically impossible to treat and options cease to exist. He did mention though, that for our treatment to be useful for people with CF, other treatment options would be needed in order for new antibiotics to be effective, because then they would only become resistant to the new ones discovered.

After the meeting with Dr. Rivas and a long thought process and brainstorming session, we came up with a method to allow antibiotics to more easily reach the bacteria that colonize the lungs of CF patients, by creating a mucolytic based on sialidases. By developing both processes at the same time, they would be able to complement each other and offer a complete treatment. The mucolytic would thin the mucus while the new antibiotics would penetrate deeper and eliminate more bacteria.

On the other hand, during the meeting Dr. Rivas also mentioned that here in Mexico there are other problems surrounding the disease. Statistics that seek to report data are often not accurate because there is no reliable body that reports all the information, there are many problems in diagnosing the disease because many of the pediatric pulmonologists do not know about it so it is confused with other respiratory and digestive illnesses. There are also social problems around it: lack of psychological support for patients, especially those with scarce resources, problems with parents of children with CF because one of the symptoms of the disease is that they cannot digest food well so it is sometimes believed that children suffer from malnutrition because of their parents, when in reality they have CF, among many other things particular to the disease in the Mexican context. It was after this meeting with the Doctor that we sought to relate a little more with the association and help them in whatever we could. The idea of holding a rally and giving workshops for children, particularly for the association's patients, was also born from here.

iGem Rally 2019

We organized multiple activities with the children of the ARFQ, including a rally and experiments, based on e-Bug, an international platform that aims to reduce antibiotic resistance by creating activities that helps them to comprehend the magnitude of this problematic while also talking about Synthetic Biology and its applications nowadays and in the future. We decided to teach these topics to CF patients because we wanted to transmit them the relevance of taking the appropriate antibiotics when indicated and in the recommended dose.

More about the workshops can be found in the Education and Public Engagement section.

This rally was really meaningful for the whole team, as we all had the opportunity to meet some of the children supported by the association as well as their parents. We did not talk much about CF, paying close attention to avoid topics that may be sensitive for them. The sole purpose of the rally was to get more in touch with the people that could be benefitted from our project and have a fun time while playing games and talking about antibiotic resistance and SynBio. We believe the bonds we made with the families helped us get closer to our project and pay more attention to detail.

Run for Water (6k)

To support the ARFQ association, the team participated in a fundraising race they organized in June, in the city of San Pedro Garza García. Here, we had the opportunity to meet some other patients from the association as well as some parents and collaborators at the association.

IMSS

On July 17, 2019, we had the opportunity to interview Dr. Paula Isabel Ramírez Ortega, she is in charge of the Epidemiology Area of ​​the Apatzingán Michoacán Mexican Institute of Social Insurance, IMSS hospital. She told us about the conflict of interest in private offices in the country and why doctors in the public sector tend to over-prescribe antibiotics. She said that doctors in the private sector earn more from the sale of medicines and that public sector doctors prefer to provide the patient with medications in order to avoid complaints. In the same way, she explained a little about the idea that society has of antibiotics and why there is widespread use of them; She concludes that people arrive looking for a quick cure for their discomforts and therefore end up consuming medications without knowing for sure if they will serve them. Finally, we talked about the shortcomings of the public hospitals of the IMSS and told us about some deficiencies with which she lives, which are the following:

• Hospitals do not have enough supplies to identify and attack infections properly.
• Nosocomial infections in large hospitals are very persistent and resistant, to the extent that they require hospitalization of a person more than 90 days in a row.

Law modification proposal

The approaches with the experts made us see that innovations in the area of ​​health in our country may become obsolete due to the deficiencies of the same health system. In a nutshell, it is no use for finding new antibiotics or creating new medications if people or institutions are going to misuse them.

For that reason, in iGEM Tec Monterrey we decided to leave the laboratory and begin to legislate to create a change that favors the proper use of medicines and that in the long term fosters the development of a national pharmaceutical policy that reduces the deficiencies of the current Mexican health system.

Situation in Mexico

The inadequate prescription of antibiotics in the Mexican public sector is a serious problem. It has been shown that respiratory and stomach infections are the worst treated. According to Gutierrez et al, "Research carried out mostly during the 1980s and 1990s, concluded that between 60 and 80% of patients with HAIs and EDAS received antibiotics in public and private primary health services in the country, when in fact their use was justified only in 10 to 15% of the cases. "[2]. Additionally, it is known that justified prescriptions are made in the most advanced hospitals. Nevertheless, many of the doses or treatments provided were excessive, which represents a serious threat to patients. In conclusion, most antibiotic prescriptions are unjustified or inadequate and this has negative consequences for society.

In monetary terms, the inappropriate use of antibiotics comes to represent 11% of the public spending in health. This expense is caused by incorrect prescriptions and the lack of follow-up of treatments by patients. In addition, the incorrect prescriptions of medications come to represent 1 or 2 percent more than the patient's daily minimum wage. The bad prescriptions come to represent a large economic spill that affects the Mexican economy.

In Mexico, a large part of the strategies implemented have been in the educational area and directives of the health sector. First, training in prescriptions in medical schools began to improve. This was intended to improve prescriptions for respiratory and stomach infections. In the same way, the use of clinical guidelines for better prescriptions in public health institutes was encouraged. [3] Nevertheless, there is no study that talks about the results of the implementation of these techniques. In a few words, it has sought to improve prescriptions in Mexico, but it is not known if it is working.

Our proposal

In order to begin a change in the subject of legislation in the area of ​​health, iGEM Tec Monterrey began to promote an amendment to the Official Mexican Standard NOM-072-SSA1-2012. This rule establishes the guidelines to follow in the labeling of medicines in Mexico, of which we proposed an improvement in the warnings about the damage of antibiotics and the modification of an article to force pharmaceutical companies to improve their labeling and the information provided about your medications.

Our strategy was to start with the modification of a rule that directly affects society. With this modification, clearer and more concise information on medicines would be offered to society. This type of modification would lead to the proper use of free medications and antibiotics, as well as to warn in a stronger way the risk involved in the inappropriate use of antibiotics.

In addition to the above, it will be a precedent to propose further modifications in the national health sector. Modifications that seek to establish a clearer authority for the health sector, strengthen health regulations and improve the education system of the health sciences area.

Approach with the government

In order to make our proposal a reality, we took on the task of seeking help in the local congress of the state of Nuevo León (Mexico), where we were able to collaborate with the deputy Rosa Isela Castro who is part of the health commission.

Initially, we were able to present our bill to the deputy and her team, with them we were able to discuss the pros and cons of this initiative, in addition to the legal mechanisms to make it happen. With this meeting we could review our proposed law at the federal level, which was as follows:

Law proposal (English) Law proposal (Spanish)

With this first approach we define that the main changes for the Official Mexican Standard NOM-072-SSA1-2012 would be the following:

• Modification of the article 5.12.7, defining the warning that antibiotics should contain about antibacterial resistance. However, its effectiveness and understanding are limited, so it was agreed to propose a more forceful and visible message.
• Modification of the article 7.3, the wording of this article makes the placement of informative inserts optional in the labeling of over-the-counter medications and antibiotics. To offer more information to the consumer and promote more appropriate use of medicines, we proposed to make the placement of informative inserts and the creation of methodologies that allow the creation of effective inserts mandatory.

Then, an exhort was prepared for the secretary of health of the state of Nuevo León, with which he was invited to begin the process to make this modification to the Mexican congress. This exhortation was analyzed and approved unanimously by the Congress of Nuevo León and set the first precedent for this proposed law.

Law exhortation (English) Law exhortation (Spanish)

Thanks to this collaboration with the local congress we were able to make our proposed law modification more efficient and to use the appropriate legal mechanisms to create the desired change in Mexico.

References

1. Lechtzin, N., John, M., Irizarry, R., Merlo, C., Diette, G. B., & Boyle, M. P. (2006). Outcomes of Adults with Cystic Fibrosis Infected with Antibiotic-Resistant Pseudomonas aeruginosa. Respiration, 73(1), 27–33. https://doi.org/10.1159/000087686
2. Dreser, Anahí; WIRTZ, Veronika J; CORBETT, Kitty K and ECHANIZ, Gabriela. Use of antibiotics in Mexico: review of problems and policies. Public Health Méx [online]. 2008, vol.50, suppl.4 [cited 2019-05-15], pp.S480-S487. Available at: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0036-36342008001000009&lng=es&nrm=iso>. ISSN 0036-3634.
3. Gutiérrez G, Guiscafre H, Bronfman M, Walsh J, Martinez H, MuñozO. Changing physician prescribing patterns: evaluation of an educational strategy for acute diarrhea in Mexico City. Med Care 1994;32:436-446.