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What it takes to successfully translate research into policy and action
Source: TropIKA.net editorial team
What it takes to successfully translate research into policy and action
Director of the Centre for Microbiology Research and Chief Research Officer at the Kenya Medical Research Institute (KEMRI), Dr Njeri Wamae is a forthright parasitologist and academic who speaks passionately about translating research into action. We met her in Algiers, at the African Ministerial Conference on Research for Health, held in June 2008, in preparation for the Global Ministerial Forum in Bamako.
The Algiers Conference has galvanized health ministers in the region to collectively commit to support the translation of research results into policy and action. At the same time, they have urged health researchers to become actively engaged with stakeholders in setting research priorities, and to link research activities to health challenges and priorities to bridge the knowledge gap.
We asked Dr Njeri Wamae about the successes and pitfalls of engaging with policy makers.
TropIKA: As a researcher with 25 years of experience, how would you describe your encounters with policy makers and ministry officials?
NW: I have been successful in engaging with policy makers. The highlight of my career was when we were able to translate evidence-based knowledge into policy. It involved providing policy makers with the findings of a multi-site study that we did with the support of TDR (the UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases) to find the best way to introduce interventions, particularly drugs, for the treatment of lymphatic filariasis (LF). LF occurs in 39 of 46 member states of the African region, with estimates of nearly 500 million people at risk of the disease. (See side bar). In Kenya, the disease is restricted to the Coast Province where over three million people are at risk of infection.
In most endemic countries in Africa, sustained drug delivery to all affected communities is difficult to achieve by the health services alone, either because they are overburdened with other responsibilities and are short of resources, or because the communities don't actively participate in the official programmes.
The Programme on Onchocerciasis Control (OCP) pioneered an approach whereby communities themselves distribute the necessary drugs. In 1994, TDR in collaboration with OCP decided to undertake a multi-drug study on community-based treatment with ivermectin (CDTI). Research found that this approach had unrivalled ability to carry services to the largest number of beneficiaries in the widest area. Following the success of CDTI for onchocerciasis, TDR commissioned research to determine whether it would work for LF.
TropIKA: What did the study involve and what were the findings?
NW: The African LF study sites were in Ghana and Kenya and the research took place between 1997 and 1999. We compared the treatment coverage through the regular health system with the community-directed treatment (ComDT) of filariasis. We found that if you let communities choose their own community drug distributors and use their own methods to deliver the drugs, they are able to cover and treat higher numbers of persons than otherwise reached by the health system. By the end of the 1990s, the multi-country study to test this approach for LF control found that it worked well in Africa, but failed in India where communities preferred to receive their drugs from health personnel.
TropIKA: Can you give us more details of the Kenyan results?
NW: We found that the community approach was significantly better, reaching treatment coverage of 88% of the population above 5 years of age. By comparison, treatment coverage through the health system was only 46% which is not sufficient for eliminating filariasis. We found that coverage through the health system was particularly poor in villages located more than 5km from a health facility, but distance did not affect the community-directed delivery, possibly because communities participating in this delivery mechanism are more motivated to ensure the tablets are collected and distributed. They also select the time of delivery which is suitable to the community, and so achieve higher coverage.
TropIKA: How did this community-directed approach work practically?
NW: We leave it to the community to decide their mode of delivery - it is not a uniform approach. It can be from door-to-door or some may decide they want to meet at a central place like a market or school, or combination of these - as opposed to going to the health facility to collect their drugs. The treatment is only once a year so it is achievable. The beauty of that strategy is the combination of two drugs, Diethylcarbamazine citrate (DEC) which is a filaricide against Wuchereria bancrofti, the only known human LF infection in Kenya, and Albendazole, which not only works as a synergy for effectiveness of DEC, but has the collateral benefits of clearing soil-transmitted helminths. The communities realise that these drugs are real public health "goodies"; they demand them and are very willing to take them. If you miss anyone, they'll come looking for you!
TropIKA: How did this translate into policy, possibly for other interventions?
NW: The move to eliminate LF started at the World Health Assembly in 1997 where WHO passed a resolution (WHA 50.29), calling for the elimination of lymphatic filariasis as a global public health problem by 2020, which all LF-endemic countries ratified. By ratifying the resolution, Kenya was committed to adopt it, and the LF programme was implemented in 2002. In terms of other interventions, TDR has recently published the results of a multi-country study on integrated community-directed interventions for multiple diseases (see Read On for website details).
TropIKA: Some time elapsed between the WHO resolution and Kenya's implementation of the LF elimination programme. Was lobbying necessary, or did it just take time to get policies approved?
NW: The resolution was passed way ahead of implementation and before confirmation of the best drug delivery method. The multi-site study was commissioned after the resolution was passed. Our research showed that the coverage accomplished by community drug distributors was close to computer simulations of 80% and above that which is expected to interrupt transmission. This is the goal - to mop up parasites, removing them from the blood circulation, thus denying the mosquitoes access to those parasites and thereby interrupting the life cycle. These results were published in 2000 and confirmed that ComDT was the best drug delivery method.
TropIKA: So this is a good example of how a resolution passed by a global intergovernmental body can move an agenda forward…
NW: Well, yes, the WHO resolution certainly highlighted the issue of LF, but adoption of a resolution is different from implementation or willingness to act. Implementation gets hounded by multiple problems that are mainly due to scarcity of resources.
What helped to move the agenda forward was our research, and technical arms within the Health Ministry which enable information exchange fora where, for example, KEMRI scientists will convey new findings to inform policy. Through designated offices at both KEMRI and the Health Ministry, there are open channels of communication, not to mention reporting systems, and we are in constant dialogue to inform government policy-makers on matters of national health.
TropIKA: Did adoption of the LF elimination programme involve much advocacy and lobbying?
NW: I never really had to spend much time convincing the policy makers; I had WHO behind me! And the evidence was there. Following the results of our research in Africa, WHO recommended that community-directed treatment be the method of distributing drugs for control of lymphatic filariasis in the African region, and it was then adopted by all the countries where this disease is endemic.
Seeing our findings being translated into public health policy for the good of so many people who either suffer or are at risk of suffering this debilitating disease, is to me a way of giving back, contributing a small piece to the jigsaw puzzle!
TropIKA: During your career, did you find any significant barriers in translating research into policy?
NW: Yes. The global programme for the elimination of LF advocates two pillars: interrupting transmission using the two drugs DEC and Albendazole, and alleviating morbidity. LF is a chronic disease causing elephantiasis and hydroceles, which is swollen male genitalia. Once the disease reaches this chronic phase, it is too late to intervene. But we can still do hydrocelectomy for men with hydroceles which is relatively expensive because of surgery, and what frustrates me is finding funding for this.
Another frustration is lymphoedema management. To manage lymphoedema (or swollen legs), it is imperative to form support groups to educate patients on how to manage and prevent secondary infections. The major problem with swollen legs is the sores which develop in the skin folds and create entry points for secondary infections. This condition is not easily reversible, but the suffering due to secondary infections can easily be reduced through proper hygiene, which is where support groups come in. A grossly swollen leg can be very difficult to handle alone, which is why one needs a partner to help. Support groups would also help the affected persons realise they are not the only ones with lymphoedema.
TropIKA: And your future plans?
NW: Going back to interrupting transmission, what I am excited about is that research in China has found that DEC can be added into cooking salt. This is similar to iodising salt, and by consuming it in small quantities in food intake, this approach has been shown to interrupt transmission and even achieve LF elimination. We would then not need the community drug distributors to distribute the drugs from door to door. I would like to see this not just in Kenya but in other African countries where we could advocate for fortifying cooking salt with DEC.
(Note: LF transmission in China was interrupted from 1994 using the strategies of mass drug distribution and fortification of salt with DEC. There were 330 million people at risk of LF infection before the control programme was implemented.)
There needs to be some political will and understanding between us as researchers and the pharmaceutical groups who would hopefully acknowledge that although DEC is a drug, its addition to cooking salt could go through the same regulatory process as a food supplement like iodine. Of course, fortifying cooking salt with DEC would not become the panacea of LF elimination overnight as there would still be other hurdles to clear such as salt distribution logistics and the need to address vector control. But this would kill two birds with one stone - interrupt transmission of LF and reduce its morbidity - and ultimately eliminate this debilitating disease.
Combination therapy to control neglected tropical diseases could "make poverty history"
The former Director of the Lymphatic Filariasis Support Centre based at the Liverpool School of Tropical Medicine, Prof. David Molyneux, believes that a "rapid impact package" - distribution of four anti-parasitic drugs across Africa to treat or eliminate seven neglected diseases - would bring tangible benefits to millions of the world's poorest communities and could permanently reduce their incidence. The neglected and disabling tropical diseases include LF, schistosomiasis, onchocerciasis, hookworm, ascariasis and whipworm as well as the bacterial infection which causes blinding trachoma.
The cost of the package would be negligible, often less than 50 US cents per person per year totalling just US$250 million annually, to deliver a package of four drugs to about 500 million Africans. Three of the drugs in the package (ivermectin, azithromycin, and albendazole) are being donated by their manufacturers, and the fourth (praziquantel) now costs only a few cents per tablet.
"If resources are made available, a scaled-up approach to simple interventions could lead to sustainable decreases in poverty in some of the world's poorest countries," he and his co-authors wrote in the New England Journal of Medicine and PLos Med. He argues that the costs are modest in comparison to controlling the "big three" diseases of HIV/AIDS, malaria and TB, whose control would be far more effective if they also included control of the neglected tropical diseases.
"The evidence indicates that co-infection with one or more neglected tropical disease may profoundly affect the outcome of one or more of the big three," says Molyneux. For example, people with HIV infection or TB who are also infected with helminth infections, such as hookworm and schistosomiasis, have a worse prognosis. There is also emerging evidence that people infected with the neglected tropical diseases are more susceptible to becoming infected with the big three, and it is clear that there is extensive geographic overlap between the big three and the neglected tropical diseases.
"The neglected tropical diseases must now join the big three to create a 21st century 'gang of four,' he urges.
TropIKA: Would you recommend using CDTI for this rapid implementation package?
David Molyneux: "The issue of triple therapy for soil-transmitted helminthiasis, schistosomiasis and LF is in the early stages and needs careful monitoring as it goes to scale in areas of high endemicity, and when no treatments have been undertaken. The delivery strategy may well vary - it's a case of 'horses for courses', and we need more operational research on this," he said.
"It's too early to say how in the future triple therapy will combine with existing delivery mechanisms for individual diseases like LF. We need to do further safety studies and the timelines for these will depend on countries and settings. Studies in Zanzibar (see link below) pointed the way to what was possible, and it is now up to countries - with guidance from WHO - to go forward in stages, where and if appropriate," said Molyneux.
TropIKA: How important is it for disease control policies to be evidence-based? What happens when they are not?
DM: "Most interventions are based on evidence but often fail for unpredictable and unanticipated reasons. The malaria eradication programme of the 1950 and 60s did not anticipate either chloroquine or DDT resistance, nor could it predict the environmental resistance to the use of DDT," explained Molyneux. He added that in some settings, there may be problems not because of the technical approach applied, but because of social and behavioural factors which emerge.
"I think the evidence base is always critical, but often programmes can only learn by doing at large scale. Operational research in programmes is critical and a proportion of the budgets should be committed to this type of research."
Njeri Wamae comments: "Regrettably, for too long, the public health community has been using hitherto available tools and recommended options to tackle each of these diseases in isolation. With the new advances in treatment formulations, acquisitions and dosage schedules, there is willingness and enthusiasm to embrace new integrated interventions.
"The current optimism of combination therapy for multiple neglected tropical diseases will have to stand the test of unique realities in the field. However, with resources, not only for drug shipment to the peripheral health facilities but also for advocacy and community empowerment to embrace ownership, which are essential for successful delivery, it can work. The spin-off would be strengthened health systems, making health care delivery more efficient. Failing to embrace integrated interventions with the available new advances, amounts to public health negligence."
READ ON
Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI)
http://www.kemri.org/CMR.html
UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases
http://www.who.int/tdr/
New results of multi-country study on integrated community-directed interventions for multiple diseases
http://www.who.int/tdr/publications/publications/pdf/cdi_report_08.pdf.)
Global eradication of lyphatic filariasis: value of choinic disease control
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0002936
Triple administration of ivermectin, albendazole and praziquantel for co-treatment of onchocerciasis, schistosomiasis, and LF - a safety study in Zanzibar (Incorporating a Rapid-Impact Package for Neglected Tropical Diseases with Programs for HIV/AIDS, Tuberculosis, and Malaria: A comprehensive pro-poor health policy and strategy for the developing world)
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2217668
Control of neglected tropical diseases
http://content.nejm.org/cgi/content/full/357/23/2407
http://www.eurekalert.org/pub_releases/2006-01/plos-cnt012406.php
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Profile: Dr. Njeri Wamae
Dr. Njeri Wamae is a forthright parasitologist and academic who speaks passionately about translating research into action.
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