World Health Organization

As part of their effort in emergency preparedness and response, the WHO keeps a record of the outbreaks that occur yearly. The latest outbreaks include Yellow fever, influenza A virus, Ebola virus, Plague, MERS-CoV, Measles, Dengue, as well as SARS-CoV-2. Certain diseases, such as Ebola, are recurrent in tropical and Subsaharan regions¹. Yellow Fever² is endemic in Africa and Central and South America, whereas the endemic regions affected by Dengue³ are even larger. These outbreaks of diseases need to be addressed with funds but also medical developments. This is all the more important in regions with fewer resources.

McNerney, R. (2015). Diagnostics for developing countries. Diagnostics, 5(2), 200-209⁴.

Lower-income countries have a higher incidence and prevalence of communicable diseases, because of a lack of correct diagnosis and follow-up treatment for the patients, due to geographical or financial reasons. As a consequence, they often face difficulties preventing the further transmission of these diseases.

Dr Assica Permata, M.D. currently working on TB in a research environment

Dr Permata told us about the situation in Indonesia, where patients in large cities usually could get tested. However, in smaller cities, where the laboratory facilities are not optimal, the samples have to be sent to larger facilities and patients may have to wait days to weeks for the results.

Peeling & Mabey, 2010⁵.

In the developing world, there is a need for point of care tests, as they can help speed up the diagnosis of bacterial, parasitic, and viral diseases. Additionally, the quality of the tests has to be improved. Systems for quality control and improving training in the use of the kit can help improve the quality of the tests.

Robin van Houdt, microbiologist at the Dutch Association for Medical Microbiology and the UMC Amsterdam

Robin van Houdt told us that RDTs are also very useful in developed, high-income countries where hospitals dispose of sophisticated laboratories. RDTs could be used to tests patients upon entry in the hospital, for instance, identifying the patients that should be treated in isolation. This could help save a lot of time and money, and is better for the patient’s wellbeing. RDTs could also be used to quickly test an entire ward if an infection does occur. This could then prevent spread to other parts of the hospital.

Huram Konjen, Chief executive officer of Dianox

Mr. Konjen told us that the need to improve diagnostics lies in the need to address and reduce the elevated costs associated with testing. These costs are mainly lab costs such as equipment and the staff.

Niek Savelkoul, iGEM 2017 Wageningen Mantis & Founder of Scope Biosciences

Niek shared his experience in the iGEM 2017 Mantis project, in which they attempted to develop a multiplex rapid test for infectious diseases. However, they did not manage to get a functional kit. He said that using a cell receptor sensor presented too many limitations, such as a delay due to the transcription and the fact that it contained living material. He suggested that a cell-free system would be preferred.

Prof. dr. Janneke van de Wijgert, professor in epidemiology UMC Utrecht & Liverpool

According to professor Janneke van de Wijgert, in general, a molecular-based diagnostic kit has an advantage over antigen/antibody-based or chemical biomarker-based kits when considering reliability. However, reliability depends on the type and complexity of the disease.

Dr Peter Bredenbeek, assistant professor in Virology LUMC

With Dr. Bredenbeek we discussed which scientific considerations were important. He stated that to be successful, our kit should be at least as sensitive as PCR, which is able to detect up to 4-5 copies/mL of sampled blood. He also encouraged us to include a positive and negative control in each of the kits.

Thomas Caltagirone, CEO of Alpagen LLP

We discussed with Dr. Caltagirone his publication of 2018, on a technique that is able to cause a color change in the reaction with the help of a DNAzyme, called the GQ-EXPAR system⁷. He told us that the amplification of the target in the tube would help to reduce false positives and increase the intensity of the colorimetric output.

Dr Armand Paauw, Scientist at TNO Defence, Security and Safety, & Dr Hans van Leeuwen, Senior Scientist at TNO

LAMP is a factor 5 to 10 less sensitive than qPCR. This is problematic for LAMP because qPCR will always be picked over LAMP in a lab environment. This means that if your kit is to be used in a lab, then it has to compete with qPCR and be at least as good. If your kit is meant for a setting outside of the lab (point-of-care), it is acceptable to lose some sensitivity. The point-of-care nature makes up for the loss in sensitivity.

iGEM EPFL 2019 ViTest

Thereafter, we reached out to the iGEM 2019 team from EPFL, that worked on developing a sensor for wine diseases as they used the RPA technique for amplification. They told us that RPA is highly specific and sensitive, but that as a result contaminations can interfere with the results. They suggested using the TwistDX kit for RPA.

Dr Peter Bredenbeek, assistant professor in Virology LUMC

The first pathogen we naturally thought of was the pathogen responsible for the current pandemic, the coronavirus, as no molecular test had yet been approved. However, Dr. Bredenbeek strongly discouraged us from choosing SARS-CoV-2 as an application. We would be competing with very large companies that possess extensive resources and large networks. These companies are racing for financial gain and scientific novelty in a highly pressured environment. Aligned with iGEM's advice and expectations, we decided not to linger on this topic and instead, look into other applications.

René Paulussen, managing director Mondial Diagnostics

Our team set out to further research other pathogens, of which Vibrio cholerae. However, Mr. Paulussen discouraged us from developing a test kit for this disease. When an outbreak occurs in a community, only the first patients are diagnosed. Other patients with the same symptoms are treated for cholera without further testing. This is due to the epidemic nature of cholera. The cholera market is, therefore, an extremely low margin market for high development costs, which would not be viable for a project like Rapidemic.

Dr Hein Sprong, Research coordinator & scientist at Centre for Infectious Disease Control (CIb), RIVM, Netherlands

Dr. Sprong is a researcher in the zoonosis of infectious diseases, with a strong interest in tick-borne diseases. Dr. Sprong was very enthusiastic about the idea of a self-test for Lyme disease. He even qualified it as a "Nobel Prize idea" if we manage to detect the B. burgdorferi (the bacteria responsible for Lyme disease) nucleic acid in the area around the tick bite. However, he warned us that the concentration can be very low and that for diagnosis, a high rate of false positives/negatives can occur. Additionally, out of the many, many people bitten by ticks, only a minute fraction develops Lyme disease. Therefore, performing tests would be meaningless as the test results would not very informative.

Dr Lieselotte Hardy, Doctor at Institute of Tropical Medicine Antwerp, Belgium

Dr. Hardy focuses on infectious diseases and their diagnosis and has worked on projects in Sub Saharan Africa and Asia. She mentioned that the diagnosis of bacterial bloodstream infections is still insufficient and that a rapid diagnostic test (RDT) for these infections would be fruitful. However, she also mentioned that in the case of bacterial sepsis, the concentration of the bacterial agent can be very low. This input was confirmed by one of Hardy's colleagues, who is a medical doctor. While there is a need for better diagnosis of this affection, even in hospital settings, diagnosis of sepsis would require multiplex testing of various pathogens, which might not be accommodated by our kit.

Dr Heleen Koudijs, Tropical doctor

Dr. Koudijs also discussed TB as a potential disease our technology could be applied to. However, she mentioned that Genexpert has good control over the market. A drawback Genexpert has is that the kit is quite expensive.

Dr Heleen Koudijs, Tropical doctor

Dr. Koudijs proposed several mosquito-borne diseases, one of these is Malaria. According to Dr. Koudijs, the market for RDT for malaria is quite saturated. There are a lot of cheap RDT's available for malaria. The reason why they are so cheap is because the companies are funded by organizations such as the WHO, Gates Foundation, and other NGO's. As a consequence, malaria might not be the best disease to focus on.

Dengue and Malaria patients

We questioned patients diagnosed with Dengue (3) and Malaria (3) in Honduras, Argentina, Zambia, Congo, Costa Rica, and Indonesia about their diagnostic procedures. Some of the patients stated that they experienced difficulties in reaching a doctor to get tested, demonstrating that access to healthcare is not always easy. The patients experienced a very slow and inaccurate diagnosic procedure of the dengue virus and stated that it needs to be improved. Malaria patients also had to undergo repeated testing, even when tested in centers with experienced doctors. The patients expressed that they would prefer a quicker diagnostic procedure that would require less blood sampling.

Hélène van Oorschot, Student in medicine

With Mrs. van Oorschot we discussed malaria and dengue as potential applications. She discouraged mosquito-borne diseases in general because if there is an epidemic, quarantine would not help. Apart from this, with malaria as an application, our kit would also compete with the medicine itself. This is because malaria medicine is cheap and readily available. For example, if the patient has the symptoms of malaria, but microscopy does not diagnose malaria, the patient is still given malaria medicine. In addition, testing for dengue is questionable as there is no cure available. Patients can therefore only be treated for their symptoms, rather than the source of disease, such as preventing dehydration.

Professor Pim Martens, Maastricht Sustainability Institute, director of the International Centre for Integrated assessment and Sustainable development (ICIS), School of Business and Economics, founder of AnimalWise and member of House of Animals, member of Dutch Health Council

Professor Martens worked on predicting the spread of Malaria and the associated risks. He told us that Malaria is still a very important disease to focus on in diagnostics as it is multifactorial and complex. Deforestation, increasing travel behavior, climate change, intensive farming and the increase in population density are increasing the emergence and the spread of novel pathogens, likely from zoonotic origin. Therefore, when we asked him which pathogen he would like to detect he responded:

"I would go for the one we don't know yet"

Dr Armand Paauw, Scientist at TNO Defence, Security and Safety, & Dr Hans van Leeuwen, Senior Scientist at TNO

The two scientists at TNO told us that influenza would be a good application, since this is a rapidly mutating virus and has potential to cause an epidemic/pandemic. Besides this, the high mutation rate is something that can be addressed well by the modular nature of the kit. However, one should then be able to prove that the test can be quickly used for various diseases and, by extension, adapted to novel diseases.

Willem Mees van der Bijl, Director IDE Netherlands at IDE Group

Mr. Van der Bijl mentored us on the kit development. Rather than trying to implement one product that can detect any pathogen, he advised focusing the development effort on a specific diagnostic application at first and extending the application later to the diagnosis of other diseases.

Dr Sophie van Baalen, Researcher team medical technology for Rathenau institute

Even though we aimed our kit to be used by patients, we did not only discuss patients as possible end-user with Dr van Baalen. According to her, the benefit of having the patient perform the test themselves is that there is no need for professionals to perform them. However, the benefit of having professionals handling the kit is that you have better quality control and immediate follow-up care. Moreover, it enables the collection of epidemiologic data from the tests. In the setting of outbreaks of infectious diseases, this crucial information would enable real-time monitoring of the spread.

Patients: Malaria, TB, Dengue and SARS-CoV-2

We first questioned patients (13) from around the world diagnosed with Malaria, Dengue and Tuberculosis to compare the diagnostic need and settings as well as to understand their preferences.

When asked whether they would feel comfortable performing a finger prick test or a nasal swab themselves, the vast majority responded that they would not feel comfortable doing so, and prefer to be assisted. We also asked whether they would trust a test performed by a doctor more or less than a self-RDT. Out of the nine people that answered this question, six said that they would trust a self-RDT less than a test conducted by a doctor.

We then also asked COVID-19 patients about their diagnostic experience. We found that if a patient does not experience symptoms that are unique or characteristic of a disease, or if the probability of getting the disease is not (very) high, patients do not think of purchasing a test for this specific disease unless they had been advised by their doctor.

Additionally, we questioned the risk of self-RDTs for the patients' health. Indeed, if a patient performs a self-RDT and tests positive, the patient would not be in a setting where it can immediately be provided with treatment if necessary. If the patient tests negative, the patient cannot test further for other diseases, nor have access to additional medical care, such as IV fluids or analgesia.

Finally, a patient reminded us that in certain countries, social security is a well-structured system that enables reimbursement to the patients. If a patient in these regions self-tests, but then also wishes to visit a doctor for a second opinion, self RDTs might be an additional procedure, thus an additional cost. A solution would be to sell RDTs solely under prescription.

René Paulussen, managing director Mondial Diagnostics

As it is challenging to bring a testkit to the market, Mr Paulussen discouraged us from making a home self-test right away. Indeed, companies first have to build up and a reputation and credibility. He, therefore, suggested starting by developing the kit for laboratories with limited infrastructure, where the tests can be conducted by minimally trained staff. This way, the quality can be safeguarded and, in turn, improves the credibility and reputation. Later on, the kit can be made more accessible to less/non trained individuals.

Dr Heleen Koudijs, Tropical doctor

While working in Ethiopia, Dr Koudijs found that a large share of the population is analphabetic. Therefore, she does not trust the patient to perform the test themselves. She thus recommended developing the kit with health centers or health professionals working in posts in rural villages as end-users. They are probably the best way to reach rural villages as they are greatly respected by the locals.

Eric de Coster, Medical coördinator in the General Infectious Disease Control and Travel Advice

Mr de Coster told us about what happens when a patient tests positive for a disease in health centers (GGD) in the Netherlands. The GGD tests the patients, but also gathers the data (results) and sends the anonymized files to the National Institute for Public Health and Environment (RIVM). Collecting data is crucial as it can help to manage the spread of diseases and subsequently determine decisionmaking on a governmental level.

Dr Heleen Koudijs, Tropical doctor

Dr. Koudijs has worked with RDT's during her time in Ethiopia. However, according to her, the corona test kit used by doctors in Ethiopia lacks a clear description and has a very confusing design. This resulted in unnecessary errors and false results. Therefore, Dr. Koudijs highly recommended ensuring that a clear instruction manual (pamphlet) is present as well as a simple, clear kit design.

John Tonkinson, Chief Business Development Officer DCN Dx

Mr. Tonkinson told us to make use of engineering to complete the biological limitations that the kit might present. He strongly emphasized anticipating the slightest errors that one could make. The results should also not leave any room for interpretation, as this is a source of errors. Clear color-coding to show the outcome is a good example to prevent interpretation.

René Paulussen, managing director Mondial Diagnostics

Mr Paulussen also had some remarks about the design of our kit. He proposed to use the KISS strategy (Keep It Simple, Stupid). Therefore, the explanations of the kit should be given in pictograms, such that they can be understood by everyone, regardless of their education level. The different reagents (such as the buffer and the sample) that should be added together should be color-coded as well.

Professor dr Aldrik Velders, Nanobiotechnology at Wageningen University & Dr Vittorio Saggiomo, Organic Chemistryl

The two chemists working on developing microfluidic devices told us that it is important to keep the handling of the device to a minimum and to limit the possibility of contaminations to ensure a reliable outcome. Thus, ideally, the kit should be as passive as possible and happen in a single reaction tube.

Niek Savelkoul, iGEM 2017 Wageningen Mantis & Founder of Scope Biosciences

Niek told us that behind projects to improve diagnostics lie a strong philanthropic desire. As many RDTs are developed for low resource areas, the tests cannot be too expensive as they would not be used in the regions in need.

Prof. dr. Janneke van de Wijgert, professor in epidemiology UMC Utrecht & Liverpool

Professor van de Wijgert said that most RDTs are not widely available. In resource-poor countries, almost all tests are considered too expensive.

John Tonkinson, Chief Business Development Officer DCN Dx

Mr. Tonkinson told us that typically during pandemics, tests are funded or subsidized by foundations working with local governments (such as the Gates foundation). He told us that they set the cost depending on the budget and that the test kits should then be produced for that price. Therefore, the tests have to be economical and the prices have to be set at the beginning of the development process. He also told us that producing in very large amounts, as is done for Malaria RDTs, enables us to drastically reduce the price per kit.

Erik van Vught, Goffin Molecular Technologies

Mr van Vught said that a kit should not cost more than 10€, as determined by the market, or perhaps 12€ if the test is very unique. This price should include the costs of distibution and logistics. However, doing distribution ourselves would jeopardize the value creation out of our sales. Therefore, it is recommended to outsource distribution.

Dr Dam, Medical doctor

Dr. Dam told us that in The Netherlands tests for this pandemic were paid by the government. For other infectious diseases, the tests are paid by health insurance companies.

Dr Heleen Koudijs, Tropical doctor

In order to get the cost of the kit low, Dr. Koudijs told us it is important to follow the guidelines of UNESCO, UNICEF, WHO and other NGO's. For many lower-income countries, these organizations fund the purchase of diagnostic tests. In other countries, like Ethiopia, the government pays for medical devices.

Dr Sophie van Baalen, Researcher team medical technology for Rathenau institute

Dr. Van Baalen also suggested thinking about strategies to ensure equal distribution during a pandemic. For example by adopting a model in which high-income countries would pay a higher price for test-kits than lower-income countries.

Qserve

Qserve is a consultant company that helps diagnostic companies to get a CE label from the notified bodies. There are two notified bodies in the Netherlands, Dekra inc. and BSI. A CE label is proof that a product conforms to the European regulation and is therefore essential when bringing a product to the European market. The EU regulation our kit needs to abide by, in order to obtain the CE marking, is the In Vitro Diagnostic Regulation 2017/746. The notified bodies test our kit independently to ensure that our kit abides by the regulation.

Erik van Vught, Goffin Molecular Technologies

When trying to receive approval to sell our kit overseas, Mr van Vught suggested to first market the product in our own country, the Netherlands, as it is one of the leading countries in (molecular) diagnostics, therefore also the most critical market. If it works in the Netherlands, we would be more comfortable selling it in other countries.

René Paulussen, managing director Mondial Diagnostics

Outsourcing or licensing a part of our business to large companies is the optimal for bringing our kit on a foreign market as they have a great sales and distribution network and often have contacts with regulatory bodies or government members. The latter is important as good relations with the local government facilitates the approval and implementation of the devices.

Ward Heij, Monitor Deloitte

Ward Heij told us that there is a difference between public and private markets. Procurement for public healthcare is often centralized either on a national or regional level. Sometimes, smaller consortia of hospitals procure together. It is rare that individual hospitals procure for themselves. Additionally, procurement is often done through tendering. It is also important to remember that due to price competition, better quality is not necessarily sought after. Often, the cheapest product that matches all certifications is sold.

Guus Eskens, Retired researcher and CEO of CARE Nederland

Guus shared with us some of his extensive experience with CARE Netherlands, Cordaid, IDA Foundation, and years of living in Africa. He provided us with insight into the state of the market for diagnostics and therapeutics in Africa. In certain countries, the major players in the medical field are international NGOs, often financed by large funds or wealthier countries. These NGOs work with funding programs (or missions), where they address a single crisis situation. The equipment and drugs are purchased depending on the goods that have been certified, tested, and approved by large bodies such as the FDA and the WHO. The equipment is then imported into the area in need. In a crisis situation, the complicated and delocalized logistics, may cause an inevitable administrative delay in bringing a novel product from the lab to the field. Therefore, to get into this market, the kits have to be approved by the larger bodies. The idea of modularity is interesting, but it will never be approved by these bodies if the tests are modular. As a consequence, the immediate, "rapid response" to epidemics is not fully achievable.

René Paulussen, managing director Mondial Diagnostics

According to Mr. Paulussen, distribution is always a challenge. However, the difficulty lies in getting our kit approved in the countries where we want to sell. Once we get our approval first, then the distributors will come.

Dr Otto Kroesen, researcher of cross-cultural entrepreneurship for development

Dr. Kroesen also proposed that (a part of) the production could be done in Africa. He gave South Africa as an example to do packaging in. However, it is definitely important to take into account what the benefits are of moving production to Africa.

René Paulussen, managing director Mondial Diagnostics

Distribution in Sub-Saharan Africa happens on trucks driving through the desert. The temperature inside these trucks can exceed 55°C. Therefore, it is essential that the kits are robust and can withstand these extreme temperatures.

Dr Heleen Koudijs, Tropical doctor

Dr Koudijs told us that in Ethiopia RDTs are distributed in distribution centers (mostly from UNICEF) on scooters on walking paths to the remote villages.

John Tonkinson, DCN Dx

Mr. Tonkinson suggested making a kit with the least plastic possible, small and compact, which would be easier for transport.

Guus Eskens, Retired researcher and CEO CARE Nederland

Mr. Eskens told us that the conditions for logistics and distribution in certain remote places, like on the African continent, can vary greatly. These variations can complicate the distribution in certain regions. The availability and reliability of electricity can compromise the cold transport chain and the very long distances between regions yield high distribution costs. The temperature in containers left in harbors without a cooling system can reach 60-70°C. Their unreliability can be a problem to safeguard the quality of the tests.

Dr Armand Paauw, Scientist at TNO Defence, Security and Safety, & Dr Hans van Leeuwen, Senior Scientist at TNO

According to the two scientists, our kit should be considered as contaminated hospital waste and should be disposed of accordingly. They also said that in order to inactivate the pathogens, the samples should be lysed entirely, which would render the pathogens harmless. This can be achieved with a lysis buffer, for instance. However, they suggested testing whether the pathogens are effectively neutralized and that a lysisbuffer is sufficient to do so. Alternatively, they told us that the samples could be inactivated by steaming them for 10 minutes at 80°C before disposal.

Bram de Graaf, Project Manager hazardous waste NNRD

The NNRD is a waste transporting company responsible for the waste collection and transport for the areas Drachten and Groningen. All the waste transporting companies in the Netherlands follow the regulations from the ADR. The driver has to have an ADR diploma and the truck has to be ADR certified as well. After the waste is collected from the hospitals, the waste is dropped brought to the depot until there is enough waste to be transported to the waste disposal company Zavin in Dordrecht.

Ron Roffel, Operational director Zavin

According to Mr. Roffel, the hospital staff in the Netherlands is rather considerate of waste separation and disposal infrastructure. However, he said that Dutch general practitioners sometimes fail to separate their medical waste correctly, yet this is improving. According to Mr. Roffel, if the waste disposal of point-of-care kits is left to the general public (patients), proper separation of the medical waste is practically unachievable.

We also learned from this visit that the majority of medical waste worldwide is improperly disposed of, even in Europe. In a best-case scenario, all the medical waste is incinerated in the open air. In worse conditions, the kit may end up in an open landfill or in nature. In the latter case, the kit should be hermetically sealed off and non-hazardous, to ensure it does not present a health threat to the population.

To read more about our visit to Zavin: Click here!

Gerard Vincent, CEO Red Bag Solutions Europe

Red bag solutions is an alternative option for medical waste disposal in the Netherlands. Instead of incineration, they use water sterilization. The benefits of their technique are mainly environmental. They can reuse up to 95% of all their materials. This tech also saves up almost 100% of nitrogen and 75% of CO2 from medical waste.

Dr Heleen Koudijs, Tropical doctor

According to Dr. Koudijs, the waste in Ethiopia is thrown on top of a pile until the pile is big enough to be incinerated out in the open. However, the situation in hospitals is better. Hazardous waste in hospitals in Ethiopia is well separated. It is very unclear how the waste is separated and processed in countries like Zambia and Tanzania.

Dr Assica Permata, M.D. currently working on TB in a research environment

Dr. Permata shared with us how infectious waste is handled in Indonesia. One of the anecdotes that stuck with us is the fact that some doctors expose contaminated material to sunlight for sterilization. The remaining waste is disposed of in bags and likely burned.

Dr Heleen Koudijs, Tropical doctor

A significant portion of the Ethiopian population lives in extreme poverty. This means many people in Ethiopia earn less than one euro per day. Therefore, taking a day off to test has severe consequences for the families. Testing in Ethiopia is regulated and performed by the Ethiopian government. The patients are tested and then put into isolation (quarantine) until the results are in. If the result of the test is positive then they are isolated two more weeks, if not then they are free to go. This has severe financial consequences for the families involved. Another cultural consideration is that Ethiopians will probably not wait long to get the test result. According to Dr Koudijs, keeping people in hospitals was, therefore, quite the issue. To combat this, it is recommended to have a kit that has a test result within two hours. Lastly, having a disease (like HIV, for instance) in countries like Kenia is a big social taboo. Privacy is therefore crucial and should not be neglected.

Dr Otto Kroesen, researcher in cross-cultural entrepreneurship for development

According to Dr. Kroesen, there is very little trust in shop owners. Even physicians are not always trusted. If the kits are given to health workers for free then there is a good chance that kits will go missing. However, for any transaction, it is important to have the trust of the locals. It is also important to have kits handled by trustworthy people. Trust can be earned through schools and churches. However, it does take a lot of time to gain trust.