Team:UI Indonesia/Human Practices


The iGEM UI_Indonesia team is fully aware of synthetic biology projects in the laboratory and pays attention outside the laboratory, such as ethical issues. Like the values conveyed by iGEM,

"Thinking deeply and creatively about whether a synthetic biology project is responsible and good for the world ".

We strive to realize feedback loops between synthetic biology projects in the laboratory and those outside the laboratory by holding the following values.

Our team members come from various interests or fields of study. Each of us has inspiration and values, which made us choose H.pylori eradication as the main object and complete our projects throughout 2021 while maintaining the values and our original goal. Some interesting stories of how our members got inspired and used that inspiration as the first step to develop HELICOSTRIKE.

Kevin Tjoa

Kevin is one of the initiators of the iGEM UI 2021 team. Long before the COVID-19 pandemic, he and other colleagues from the Faculty of Medicine Universitas Indonesia had the opportunity to discuss health issues with Prof.Dr.dr. Nila Djuwita Farid Anfasa Moeloek, Sp.M(K) (Minister of Health of the Republic of Indonesia; 2014-2019). Through these discussions, Kevin and his colleagues gained many insights about health problems in Indonesia, one of which is nutrition, which is closely related to the digestive tract. Therefore, digestive health becomes very important. Maintaining it requires intervention in the health sector, environment, food, agriculture, and the role of the community itself. Many health problems have not been explored much and require the volition and capability of the younger generation to study further and provide solutions based on existing problems. The discussion inspires Kevin to provide solutions to health problems, one of which is the H.pylori infection he seeks to realize through the participation of HELICOSTRIKE in the iGEM UI 2021 competition.

Firda Izzain Baliyati

Firda is the head of the policy and practice division of the iGEM UI_2021 team. In 2019, she attended the Biotech Open Camp held by the Universitas Teknologi Sumbawa, which brought Indonesian synthetic biologists and the iGEM Ambassador for Asia. On that occasion, she was inspired to become iGEMers and focused on developing policy and practice.

Through meetings with experts and people who have previously worked in health and synthetic biology, we get inspiration and feedback, which will become the basis for realizing the HELICOSTRIKE project in 2021.

Our team members also exchange opinions on how to make our project successful by collaborating with various parties and fulfilling human practice's values and goals.

We strive to make HELICOSTRIKE a responsible synthetic biology project that reflects the values of iGEMs. We tried to get much information about our project, the benefits, the risks, which communities we targeted, and what things are needed to improve our project. To obtain this vital information, we then conducted interviews with many experts related to our project. Our goal is to improve quality and reduce the possibility of effects arising from our project. The interview results containing various inputs and our plan of action can be seen in the Integrated Human Practice section.

We also deepened our knowledge of human practice by participating in a risks and values workshop organized by iGEM, which was guided by iGEM ambassadors for Asia, Jannah and Elisa.

We show our responsiveness to various inputs given by PI, mentors and the community by making adjustments and even improvements based on the inputs given to make our project better and more acceptable. We take opportunities to obtain necessary information and constructive input for our project and use media to communicate about projects we are working on to various communities, especially the communities that are the target of our projects; these people are susceptible to H. pylori infection. Our responsiveness in carrying out this project can be seen in the overall laboratory and non-laboratory activities. That can be seen in the entire section in this wiki.

HELICOSTRIKE and Human Practice

Dr. dr. Budiman Bela, Sp.MK (K) – Principal Investigator of iGEM UI 2021

Dr Budi is our principal investigator (PI) in implementing the HELICOSTRIKE project. He guides us in developing and implementing activities related to integrated human practice and public engagement and tells us to explore as much important information as possible and follow the projects. Thus, the knowledge gained can help us carry out integrated human practice and public engagement activities effectively, efficiently, and on target. In addition, he also provided constructive input on the design of the activities we carried out and helped us develop them for the better. Through his advice, we read and review many kinds of literature, held team discussions and interview with experts in microbiology, gastrointestinal, pharmacology, general practitioners and also parties from The Ministry of Health, National Food and Drug Agency and The Assessment Institute for Foods, Drugs, and Cosmetics Majelis Ulama Indonesia (MUI) to get necessary and sufficient knowledge for developing our project. In the end, through the various suggestions and inputs he gave, the implementation of the activities that we had previously planned became more focused and organized.

Gilbert Lazarus, S.Ked - iGEMers 2019 and Mentor of iGEM UI_Indonesia 2021

Gilbert is the manager of iGEM_UI Indonesia 2019; he provided a lot of help and instruction to run our team and projects, principally and technically. We had many discussions and got much feedback from him in the implementation of our project. He gives us tips and tricks and tells us things that can be anticipated and developed in the team. Through the discussion with him, we immediately arrange and divide the tasks in each existing division in the team. We also regularly hold division and team meetings to follow up the work within the team as suggested by him. His experience as IGEM UI_Indonesia team manager in 2019 also helped us plan and realize the HELICOSTRIKE project this year.

Aulia Reski Widyaningrum, S.Si - iGEMers 2016 and Mentor of iGEM UI_Indonesia 2021

Aulia Reski is our senior and mentor. We met her to present and discuss the main idea and framework of our project. After presenting our idea and project, she gives us insights and feedback that has a significant impact on our project.

The insight:
The idea of ​​making a booklet on H.pylori infection and its prevention can be an advantage and an excellent educational medium. To maximize the distribution and utilization of the booklets, she suggested that the booklets be translated into foreign languages, especially translated into languages ​​from countries that have a high prevalence of H.pylori so that the targeted community will be more targeted and can be a place for collaboration with the iGEM team from countries with high H.pylori infections

Our response:
We made our booklet in Bahasa Indonesia and translated it into various local languages, including Papua, Bugis, and Batak, the ethnic group in Indonesia with a high prevalence of H.pylori infection. We also translated our booklet into other languages from the country with a high prevalence of H.pylori infection and collaborated with the iGEM team from that country to distribute the booklet.

The insight:
In addition to creating a business model canvas and value proposition canvas, we must also be able to create clear product prototypes and clearly describe the business opportunities of the products produced in the future.

Our response:
We made the iGEM UI probiotic survey to get the public opinion about probiotics and their preference in choosing probiotic products. According to the survey result, we made the SWOT, business model canvas, value proposition canvas, and prototype from our products. You can see our business idea and prototype in the business section

The insight:
We must empower front liners in primary health care in education efforts. One way to do this is to distribute the booklets that we have compiled to primary health services, especially in areas with a high prevalence of H. pylori

Our response:
We send our booklets to our senior and general practitioner who works in primary health care so that they can use it to educate the public in their region.

The insight:
We must maximize the media and educational content delivered to vulnerable groups. One way is to hold a webinar with a specific and linear theme with our project, in this case, food processing hygiene and sanitation, as an effort to prevent H.pylori infection

Our response:
We held a live Instagram session with the title "Safe Food Processing for the Gastrointestinal Tract" in collaboration with dr. Erfi Prafiantini, M.Kes as a doctor and expert in nutrition and Ekida Rehan Firmansyah, S.Ked, a health influencer and educator, received 130+ viewers. We also conducted webinars about the opportunities and challenges of synthetic biology in collaboration with apt.Trilokita Tunjung Sari, S.Si.,M.Biomed from Biofarma Indonesia and Muhammad Farhan from Synbio Indonesia and was attended by 100+ participants.

Through her advice, we were able to identify problems that might occur in implementing our planned ideas and find solutions to overcome them. In addition, we can also refine our ideas in carrying out activities related to integrated human practice and public engagement.

Prof. Dr. dr. Ari Fahrial Syam, SpPD-KGEH, MMB, FINASIM, FACP- Gastroenterologists

Our team had a chance to discuss our project with Prof. Dr. dr. Ari Fahrial Syam, SpPD-KGEH, MMB, FINASIM, FACP. He is one of the best gastroenterologists in Indonesia who dedicated his time to do research about Helicobacter pylori in Indonesia. In this session we discussed a lot about H. pylori, especially its risk of infection and management in Indonesia.

H. pylori is a bacteria that can live in an acidic environment such as the human stomach. H. pylori infection is a chronic process ranging from gastritis to gastric cancer. In 2015, he conducted his research about risk factors and prevalence of H. pylori infection in five largest islands in Indonesia. Prof. Ari told us about his journey in detecting H. pylori cases in rural areas without adequate equipment and so he needed to bring his own endoscopy. Diagnosing H. pylori infection can be done with two major methods: invasive by using endoscopy and non-invasive by urea breath test. In the era of pandemic, urea breath tests are no longer used because of safety concerns.

Key Points

Although he found that Indonesia had only 22,1% of people infected by H. pylori which is considered as low prevalence, that number was accumulative from many tribes in Indonesia. Javanese and Dayaknese are two examples with low incidence of H. pylori infection, while Bataknese, Buginese, and Papuan are among the tribes with the highest incidence of H. pylori infection in Indonesia. Because of this tribe-based features of H. pylori infection, our research now can be focused towards those high prevalence tribes in Indonesia such as Bataknese, Buginese, and Papuan. Geneticity may have the biggest role as a risk factor of H. pylori infection, because those tribes with high prevalence have different nutritional and behavioral features. Water sanitation may also have a role in H. pylori infection because people with poor water sanitation are at higher risk of infection.
H. pylori infection in Indonesia is treated by triple therapy: clarithromycin, levofloxacin, and PPI. Resistance of antibiotics may be found in daily practice and the patient must be treated by quadruple therapy using clarithromycin, levofloxacin, PPI, and bismuth. One of the problems in Indonesia is the availability of bismuth which can't be found in our country. Indonesia is experiencing the misuse of levofloxacin and so the resistance towards this antibiotic is imminent. Also, antibiotic treatment only acts as bacterial eradication not as a biofilm destructor while H. pylori is making biofilm in its host stomach environment as a protection.
Prof Ari said that our innovation may lead to the breakthrough of bacterial infection not only towards H. pylori but also to other GI tract bacterial infection using AMP. For H. pylori infection, Prof Ari hopes that our project can be useful in eradicating H. pylori particularly for several tribes which are at high risk. He also mentioned that our E. coli must be able to live in the acidic environment of the human stomach.

Reaching the Frontliners - dr.Joseph Mikhael Husin in Berau, East Kalimantan

Our team contacted dr. Joseph Mikhael Husin as a doctor stationed at Berau, East Kalimantan, to know more about the situation of H. pylori infection particularly in remote areas. Berau is one of the districts in East Kalimantan, with a hard-to-access public health centre and unstable internet connection. The journey to the public health centre is bumpy and only accessible by car. Berau people itself is not populated and the majority of the people work in the field. Other than discussing the H. pylori situation in Berau, we also talked about how to engage Berau people.

Key Points

Dyspepsia is one of the most common chief complaints that makes people come to seek help from the doctor. But sadly, there are not any sufficient diagnostic tools that can be used in order to screen for H. pylori infection, even in the district hospital. Most patients will be dismissed after being given an antacid and proton-pump inhibitor. Half of the patients will come back later with the same complaint and after that the patient will be referred to other hospitals for endoscopic testing.

Berau people most likely do not know about H. pylori that can destroy their stomach wall. They are only aware of dyspepsia. But on the other side, they are also aware about sanitation and cleanliness. They only drink from sterilized water, not from crude sources such as rivers, and every house has its own toilet.

Those kinds of situations only leave us one direct approach in order to introduce a new product. We need to approach them person-per-person. It is hard to assemble all the people in the public health centre because their home is located far away from the public health centre and the journey itself is not easy. The internet is also hardly accessible so we can not reach people through the internet network. Most of them will accept the new paradigm such as our new projects easily because they accept all the doctors tell them about maintaining their own health. As long as our products are not chemical products, then it will not be a problem for them consuming it.

Dr. dr. Mardiastuti H Wahid, M.Sc, SpMK and Dr. Andi Yasmon, S.Pi, M.Biomed - Microbiologist

Dr. dr. Anis Kurniawati, SpMK recommended us to discuss our project with Dr. dr. Mardiastuti H Wahid, M.Sc, SpMK and Dr. Andi Yasmon, S.Pi, M.Biomed. Both of them are also experienced bacteriologists who ran several projects about H. pylori. As a fastidious bacteria H. pylori culture is not available for public services and only used for research. Even they struggle to grow H. pylori in the Microbiology laboratory, Faculty of Medicine Universitas Indonesia . And so our biggest challenge in this project will be growing H. pylori in the culture medium because the chances are thin.

Key Points

The reason why H. pylori is hard to grow in a medium culture is the incapability of our laboratory in Indonesia. Whether the bacteria came from biopsy or from a vendor, it's still hard to culture H. pylori. One of the tricks to have a successful H. pylori culture is rapid inoculation in approximately 2 hours after the bacteria is taken. Because it's very difficult to grow H. pylori in the laboratory, they can only use molecular techniques in order to assess the resistance of H. pylori. Sometimes bacteria can be genetically resistant to antibiotics but phenotypically susceptible, or vice versa, so H. pylori culture is encouraged to be done.

As for biofilm formation, biofilm can not be identified by usual techniques under light microscope. It requires special treatment such as using special stains to detect biofilm formation in biopsy specimens. In order to destroy the biofilm in the stomach, protease is the best thing we can make from the E. coli. While culturing H. pylori is challenging, making biofilm itself is still unknown. Also information about antimicrobial peptides and proteases are limited.

From their research, H. pylori resistance may be due to unsafe antibiotics consumption. As the stomach is the first place of drug metabolism, H. pylori is the most intensively exposed bacteria to antibiotics. They encourage our project as an alternative to this resistance problem because this may replace the use of antibiotics in H. pylori eradication.

Dr.dr.Anis Kurniawati, SpMK-Microbiologist

Helicobacter pylori (H. pylori) is a bacteria that is usually found in the stomach and causes infection in 50% of the population in the world. Some diseases that are caused by H. pylori infection are gastritis and peptic ulcer, which sometimes can complicate into gastric lymphoma or gastric carcinoma. Its ability to produce urease helps it withstand the acidic environment of the human stomach. Besides that, H. pylori is also supported by its flagella-mediated motility, adhesins, and toxins so it is able to attach and cause infection. H. pylori can also form biofilm by quorum sensing to protect itself from the human immune system and antibiotics. Therefore, H. pylori is difficult to eradicate. In that case, we had the opportunity to discuss the nature of H. pylori with Dr. dr. Anis Kurniawati, SpMK., as one of the experts in bacteriology. She shared her concerns and advice to further understand our project.

Key Points

In diagnosing H. pylori, culture and polymerase chain reaction are the common tools used to identify the existence of H. pylori. For culture, gastric lavage through endoscopy is the most common tool to take the specimen. Feces and vomit can be used as specimens as well. H. pylori contaminated water has not been proved to be appropriate as a culture specimen for now. Nonetheless, there are some problems that hinder the culture process of H. pylori because of its characteristics, such as being difficult to grow and short-lived outside of its optimum habitat.

The transmission of H. pylori generally occurs from human to human, specifically oral-oral, fecal-oral, gastric-oral, or sexual routes. There has not been any evidence that H. pylori infection is a zoonosis disease. This may also be explained by H. pylori’s fragility outside of its usual habitat.

H. pylori antibiotic susceptibility test has not been done regularly because there has not been any standard reference as a result of the difficulties in growing H. pylori. Moreover, the European Committee on Antimicrobial Susceptibility Testing (EUCAST) has not recommended the testing because the treatment by current antibiotics is still effective. Regarding its resistance, dr. Anis said that the detection of antimicrobial resistance genes may be the answer to further develop the treatment of H. pylori infection.

Last, she shared her concern regarding our ideas in H. pylori eradication using probiotics because until now, H. pylori is the most commonly mentioned bacteria that can survive in the human stomach. Although there are still many floras that have not yet been identified in the human body. Nevertheless, she states her support toward the idea of eradicating H. pylori by anti-biofilm substance which can optimize the effect of current antibiotics.

From and to the public - drg. Arfianita Rachman (Head of Puskesmas Kelurahan Tanah Tinggi, Kecamatan Johar Baru)

Our team had a chance to discuss about Indonesia’s primary health care system and the strategy in promoting the awareness against H. pylori infection with drg. Arfianita Rachman. She is the head of the Tanah Tinggi Primary Health Care as we call it in Indonesia “puskesmas”. Primary health care is a public health service that plays an important role in keeping Indonesians healthy and coordinating with other higher level of health care services such as district hospitals or even national reference hospitals in order to improve people's health-being. Most of the people with common symptoms and signs of H. pylori come to seek help from Puskesmas. Puskesmas in Indonesia are mainly helped by cadres, group of people who volunteered in improving their neighborhood's health-being.

Key Points

Puskesmas is one of our strategies to improve people’s knowledge about H. pylori and its infection. By empowering puskesmas in Indonesia more people will be covered in our aims. Puskesmas is well-known by most people so informing a new thing may be easier through them. Strengthening primary health care will not only be a benefit for us but also for the government. Drg. Arfianita said Puskesmas is the main entry for us to educate people about H. pylori and from here the health information may be spreaded towards people by Puskesmas’ health programmes and also by cadres.

Programs that can be enforced in the puskesmas towards H. pylori infection are education about H. pylori itself and how to prevent it. Puskesmas may also have the role in early detecting H. pylori infection and referring to higher levels of health services once the case has been found. In advance, puskesmas may be the right place in placing our probiotic products for eradicating H. pylori infection.

We also told drg. Arfianita that one of our projects is making a booklet about H. pylori and so we agreed that our booklet can be used for informing healthcare personnels in Puskesmas and also cadres as their media of information in educating other people. Hopefully this issue may be addressed in all of Puskesmas in Indonesia. So people are aware about H. pylori infection and what damage it caused.

Dr. Ir. Mardiah, M.Si - LPPOM MUI

Although Indonesia is not a muslim country, it has 87,2% muslim from its own population in 2021. With this situation, our end products must be halal in order to be used. So our team had a chance to discuss our project with Dr. Ir. Mardiah, M.Si, one of LPPOM MUI officers. LPPOM MUI is an organisation who gives halal labels to drugs and foods in Indonesia. In this session we were happy to know about what we should do to obtain halal status for our product and what things we can and can not use for making our products. Our end product which is some kind of yogurt or dairy fermented product will need a culture medium for bacteria growth. Her concern is mostly about the source of this medium and how the process is done. In her opinion, our projects are very innovative and we are very cautious to discuss its own halal status. Halal certification is very important to boost the usage because people may feel more safe when consuming it.

Key Points

We can only use halal certified materials for our culture medium. Some basic materials that are usually contained in culture medium for yogurt or dairy products such as water, minerals, and agar are in the MUI positive list. MUI positive list itself is a list of products which are always considered halal and don't need to have a halal certificate. Other products such as vitamins, sugar, and enzymes need to have halal certificates from the supplier because those products may be derived from pork or lard and also human parts. The criteria for halal products are not containing any pork or human or genetically modified organism or touching pork in the process.

In order to obtain the halal status from LPPOM MUI, one must enter its course about halal production. In that course they will teach us anything that we need to obtain a halal certificate for our product. After implementing all steps needed for around one to two months, a halal officer will come to inspect our production and tell us everything that we still need to change. After that, a halal certificate can be issued and our products may use halal logo.

Prof. Dr. dr. Purwantyastuti, M.Sc., SpFK- BPPOM Indonesia

To polish our final work, we had the chance to consult and discuss it with Prof. Dr. dr. Purwantyastuti, M.Sc., SpFK. Prof.Purwantyastuti is a pharmacologist from Faculty of Medicine Universitas Indonesia, who specializes in food supplements. She is also currently working in the National Agency of Drug and Food Control (Badan Pengawas Obat dan Makanan or BPPOM) or also known as Indonesian FDA.

Prof.Purwantyastuti shared her opinion regarding our project. From her point of view, our project is feasible, but it will take years to go as far as becoming a treatment. Therefore, she suggested that we should focus first on proving the strain of E. coli that we use is a probiotic, which will also take some time. Then after we manage to prove the characterization of E. coli as probiotic, according to the official procedure from the National Agency of Drug and Food Control, we can move on to develop our product into a treatment.

There are three points regarding the finishing of our product, that she emphasized.
1. Ensure our product’s safety by conducting research in the wet lab
2. Ensure that the E. coli strain that we use in our product qualifies the probiotic criteria and register it to the official institution
3. Carry out the implementation of our probiotic product as a H. pylori treatment

As for the form of our probiotic products, she said that any form will do, considering the advancement of food technology nowadays. However, we cannot yet determine the optimum temperature storage and composition mixture for our product. Thus more extensive investigation and research about the characteristics of the specific bacteria strain that we use are still needed.