People could buy our product in pharmacies or it could be distributed by the government in an early screening program with a form of single capsule in blister packaging. The first step is to consume the capsule by drinking it with water. The enteric coating of the capsule will make sure the modified EcN inside the capsule will be safe until it reaches the intestine. In the intestine, the capsule will break down and the modified EcN will colonize the surrounding tissue, preferably the CRC tissue if present [1]. While colonizing, the modified EcN will also express the LIRA biodevice system into its secondary RNA structure. If there’s miR-21 or miR-92a present in the surrounding tissue, the LIRA will be able to bind with it, exposing the Ribosome Binding Site (RBS) and expressing the aeBlue chromoprotein gene. This chromoprotein will accumulate inside the modified EcN and since E. coli is observed to be increasing in the CRC patient feces, the modified EcN will also be accumulated and the blue color in from the aeBlue will be observed in the feces of the person. The whole process might need at least 12 hours to be able to be seen in the feces, depending on the diet of the person. Then the person will need to check the color by using the strip from the back of the packaging that serves as the positive control. If it has a matching color then the test result is positive. Since this product is only for an early screening, the person with a positive result will still need to be clarified by using a more accurate diagnosis method.

In order to obtain the license, we need to register our product with the national authorization. We attempted to contact the Ministry of Health once again to inquire about the requirements for registration, but as of October 10th, we have not received a response from them. This has impeded our progress in planning for the registration of our product. Furthermore, it highlights the absence of concrete regulations for diagnostic products like ours.

Based on our discussion with Ms. Endang who has been developing her research team probiotics, we plan to use the similar approach as what she used. We plan to manufacture the modified EcN in conventional methods first to acquire the data needed for scale up to industrial scale (Figure 1) [6]. First and foremost, the modified EcN is inoculated into the mother flask for some time before inoculated again in the fermenter at the optimal condition. Since we plan to use the same method as Ms. Endang, we will use a fermenter with a working capacity of 168L with the media composed of meat and pineapple extract according to Ms. Endang. The fermentation will be left for a day and then the resulting fermentation will be centrifuged to acquire the cell biomass. The biomass will then be added with skim milk and sucrose as the cryoprotectant agent Ms. Endang advised us to use it. In addition, the concentration of the bacteria needs to be adjusted to contain 1x10^10 CFU/3 gram of mixture. The mixture was then put into the freeze drying chamber. The resulting powder will then be divided into the capsule and then packaged with the primary packaging which is blister. This method will also be used for the preclinical studies needed for the registration of our product.

Since the end game of our project is to develop a partnership with the national screening program, we need to evaluate the proposed pharmacoeconomic model of our product. Cost-effectiveness analysis of a proposed CRC method is important to make a decision at the national level. A method is considered as “dominant” (cost-saving) when it gives a higher outcome with lower cost compared to the other method. While it is considered as “dominated” when it gives a lower outcome with higher cost [7]. When a method gives a higher outcome with higher cost, or vice versa, the cost-effectivity must be measured with incremental cost-effectiveness ratio (ICER). A method is considered as cost-effective if the ICER is below the threshold. According to WHO (2012) [8], for middle income countries, the recommended threshold is 1 to 3 times of gross domestic product (GDP) per capita. Indonesia GDP per capita is IDR 59.3 millions [9], it means that a screening method with ICER below 59.3 millions IDR will be considered as cost-effective.

To measure the outcome of colorectal cancer screening methods, Dr. apt. Dwi Endarti, M.Sc. suggested us to use sensitivity and specificity as the parameters of effectivity. Sensitivity and specificity of ColDBlu was estimated by averaging the sensitivity and the specificity from previous research [10,11,12]. Meanwhile, FOBT, FIT, sigmoidoscopy, and colonoscopy sensitivity and specificity were obtained from Knudsen et al. [13,14].

We also tried to estimate the cost of the ColDBlue test kit based on our discussion with Prof. Dr. Ir. Endang Sutriswati Rahayu, M.S., a probiotic expert with experience in developing probiotic products into industrial scale. She showed us the formula she used to calculate her probiotic product and since our product is manufactured the same way as probiotic, we used the same formula as her. However, since her product now has been adapted to the industry, we can’t publish the detailed formula we used. In summary, the cost of manufacturing a product can be divided into 4 different categories. Direct material cost represents all the material cost, Direct labor represents the labor price needed, manufacturing overheads represent all indirect cost needed for the manufacturing including the rent, taxes, and machinery, lastly is profit to make sure the project will be sustainable to the manufacturer. We propose a total of 1000 capsules per batch based on Ms. Endang’s experience (Table 1).

Cost-effectiveness of ColDBlu was analyzed by comparing the cost and outcome (sensitivity or specificity) of ColDBlu with other screening methods that were currently used in Indonesia. Cost of the screening methods were calculated in patient perspective (IDR), considering direct medical costs (kit price and medical provider cost), direct non medical cost (transportation cost), and indirect cost (productivity loss). From the calculation, ColDBlu is considered as cost-saving compared to the other screening methods (FOBT, FIT, sigmoidoscopy, and colonoscopy) because it gives higher sensitivity with lower cost. However, the cost-effectiveness of ColDBlu to obtain additional specificity compared to other methods needs to be calculated by ICER because it costs lower but also gives lower specificity.

ICER was measured by dividing the incremental cost by incremental outcome (specificity) of ColDBlu and other methods separately. The measured ICER (cost per additional specificity gained) of ColDBlu compare to FOBT, FIT, sigmoidoscopy, and colonoscopy were IDR 364,424; 80,858; 3,558,361; and 5,623,464 respectively. Since the ICERs were below IDR 59.3 millions (GDP of Indonesia), ColDBlu is considered as cost-effective. Hence, ColDBlu can be implemented in the national setting as an affordable colorectal cancer screening method in Indonesia, especially the rural areas.

For the future of our project we need to develop a plan for these consideration: