Policy & Practices Journal

Week 5: June 2nd - June 6th

Human practices sub-team was formed to focus on the purpose of the project and the positive impact it could have globally. This week was focussed mainly on brainstorming potential ideas for application of a rapid diagnostic test for infectious tropical diseases. One of the most prominent ideas was that of misdiagnosis and overdiagnosis for malaria and the lack of resources to provide an accurate and rapid diagnosis of these other dangerous diseases. Throughout this brainstorming we indicated that we wanted to further look into Dengue Fever, Meningococcal Meningitis and pneumonia that are often misdiagnosed as malaria. In regards to these diseases, we looked into their symptoms and misdiagnosis statistics and existing technologies of diagnosis. We began to look into potential contacts and experts that would be able to assist us with their expertise on the subject of misdiagnosis.

Week 6: June 9th - June 13th

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Week 7: June 16th - 20th

On the 16th the human practices team met with Dr. Lisa Allen who has a biomedical background and a PhD in Public and Global Health. She has had direct international experience with misdiagnosis of malaria, working in a rural hospital in Tanzania since 2008. After discussing potential priorities of their impact with the hospital and the community, it was determined that malaria was perceived as the biggest issue. The medical officer in charge thought malaria diagnosis was ineffective, so the main task of their presence was to improve the situation. 95% of patients were diagnosed with malaria based on microscopy; however pregnant women and children under 5 malaria had a default diagnosis of malaria for a fever. In the region in which Dr. Allen worked, actual malaria cases were declining due to high altitude and the temperature drop to 4∘ Celsius during the night. Despite this decline the diagnosed cases of malaria were showing no decrease, despite the low potential for infection. Citizens of this area would automatically assume that that fever is malaria, culturally using this inclusive term to describe any similar illness, similar to how our society using the term “flu” to describe what is potentially different health issues. Dr. Allen emphasized that awareness and education of other neglected infectious diseases was imperative, as this mindset of clinicians was part of the problem. Missing a case of malaria is considered “unforgivable” therefore overdiagnosis is present. Clinicians are aware of the algorithms for diagnosis of other diseases, but usually do not have lab capacity for bacterial infections. Having “safer than sorry” mindset, patients often receive both antimalarial drugs and antibiotics in the hopes it will treat malaria, and whatever other diseases exist if it happens not be malaria. Overdiagnosis and treatment with both antimalarial drugs and antibiotics result in a great economic impact on institutions and patients, shortage of antimalarial drugs, and increasing drug resistance. Patients pay for their prescription drugs, and if the diagnosis is not accurate and treatment is unsuccessful, patients waste their personal resources. Dr. Allen also looked into rapid diagnostic tests (RDT) what clinicians think of them. Many seems to criticize them because RDT can’t quantify infections which might be important in determining the most effective type of treatment. The cultural mind set also plays a role. Microscopy slides come back positive, so malaria is diagnosed. A lot of RDTs come back negative and clinicians do not trust it. However, RDTs were only created to target malaria, so a multidiagnostic test might solve the problem in terms of mistrust because the big question asked when malaria tests come back negative is “If it is not malaria, then what is it?” Dr. Allen felt that an important aspect of success of the project would be to analyze the limitations that are presented in the developing world setting. We need to consider mind for our design include storage space (no freezers), shelf life, price (ideally the device needs to be under $1; microscopy only costs about 34), diagnosis time. Overnight tests were classified as an option that is not ideal as many patients have to work several hours to arrive at the hospital, and to commute again the next day would be discouraging for use of such testing. Dr. Allen recommended that we check the Foundation for Innovative New Diagnostics (FIND) and other organizations that are working on similar ideas for hopes of potential collaboration. We also discussed the potential for quantification of infection, and will look into this option however the PCR of DNA might affect this aspect. We have also introduced weekly policy and practice meetings to further discuss this subject with the Policy and Practices team. This week we are also planning on contacting Kirsten Jacobsen of Public Health Canada that was interested in this years iGEM team doing a video conference with a committee dedicated to looking at emerging technologies through Public Health Agency of Canada. This relationship could be a valuable resource to learning and impacting policy through our project and our policy and practices team. Additionally we are looking into contacting additional perspectives from experts in the field of malaria misdiagnosis to gather a broad view of perspectives from various individuals, occupations and respective regions of work. The team also broke up the weekly tasks into contacting additional experts and research on diseases in different regions as well as policy in Canada and developing countries.

Week 8: June 23rd - 27th

This week we began to work on the delegated tasks that each member of this subteam receive. We concentrated on looking at two regions: Tanzania and Ethiopia. One of the topics that was researched is the organization and management structure of the National Health System in Tanzania. The National Health System in Tanzania has central-district government structure. There are several layers in the Health Services Structure: village health service, dispensary services, Health Centre Services, District Hospitals, Regional Hospitals, and Referral/Consultant Hospitals. Village health service is the lowest level. Usually each village has two health workers who received short training before starting. Dispensary services supervise all the village health posts in its ward. Health Centre Services provide care for about 50,000 people. Each district then has a district hospital. Regional hospitals are similar to district hospitals, but they offer additional services and have specialists in certain fields. Referral/Consultant Hospitals represent the highest level in the country. There also are private health facilities that are often owned by government health care workers which creates a conflict of interest. In Ethiopia, on the other hand, the core of the health policy is accessibility of healthcare for all parts of the population, and encouraging private and non government organization participation in the health sector. Some of the priorities of the health policy include health information, education, communication, development of health service management systems, and provision of essential medicines, medical supplies, and equipment. We also found a paper on National Drug Policy of The Transitional Government of Ethiopia (Nov. 1993). The following is the summary of the relevant sections: 1. Selection of Drugs This section states that National Drug list will be formulated considering safety, efficiency, quality and cost and based on health problems in the country, infrastructure, and fundings. National Drugs Advisory Committee will be established to evaluate and decide upon drugs and to create lists of drugs used in the country. 2. Drug Supply The country plans to establish drug manufacturing facilities with the possible help from private investments. Pharmacists would be responsible for compounding drugs in hospitals, pharmacies and drugs while maintaining required standards. The government will also establish an enterprise to distribute the drugs on the national and regional levels. Both public and private sectors will be involved in the production of drugs. 3. Stock Management and Distribution Storage facilities will be created to ensure proper conditions for drug storage. 4. Drug Administration and Control The National Drug Advisory Committee will be responsible to evaluating drugs based on safety, quality, price, and other criterias. Drugs that satisfy the requirements will be issued certificated and existing drugs will go through regular evaluations. Information about harmful and beneficial effects of drugs will be collected. 5. Manpower Training and Utilization All professionals and biotechnologists will receive proper training. 6. Drug Information and Promotion Accurate information and reference materials will be distributed to the workers in the field. 7. Trading Agencies and Scientific Bureaus 8. Drug Use A list of prescription and nonprescription drugs will be created. Drug dispensing will be monitored by licensed professionals. 9. Traditional Drugs 10. Research and Development Research facilities will be established to carry out drug-related research. Research will strengthen the quality of pharmaceutical services. 11. Drug Pricing The government will make an effort to ensure that public gets affordable pricing for drugs. Additionally we continued to reach out to experts in the area of misdiagnosis and are waiting on the responses of two individuals to give us another perspective on this global issue.

Week 9: June 30th - July 4th

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Week 10: July 7th - July 11th

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Week 10: July 7th - July 11th

Week 11: July 14th - July 18th

Week 12: July 21st - July 25th

Week 13: July 28th - August 1st

Week 14: August 5th - August 8th

Week 15: August 11th - August 15th

Week 17: August 25th - August 29th

Week 18: September 1st - September 5th

Week 19: September 8th - September 12th

Week 20: September 15th - September 19th

Week 21: September 22nd - September 26th

Week 22: September 29th - October 3rd

Week 23: October 6th - October 10th

Week 24: October 13th - October 17th