5th Annual Meeting of the African Science Academy Development Initiative

November 10-11 2009Accra, Ghana

Dr James TibenderanaInterim HeadUganda Malaria Research CentreAndDirector Case ManagementMalaria ConsortiumEmail: j.tibenderana@malariaconsortium.org

Outline of presentationSet the stage to illustrate a case of

translating knowledge into actionDescribe the intervention/s used for

knowledge translationIllustrate the national and media interest in

DDTDescribe a framework of the knowledge

transfer process and contextualise to this case

Relevance of the consensus report

A case of knowledge into action

The national contextHigh burden of malaria

High under-five mortality (137 deaths per 1000 live births; Millennium Development Goal of 56 per 1000 live births by 2015).

Estimated 188,000 under-five deaths in 2006, the 5th highest in Africa (tied with Tanzania) – after Nigeria, DR Congo, Ethiopia and Angola.

More than three quarters (76%) of this mortality is due to preventable or easily treatable infection (malaria 23%, pneumonia 21%, and diarrhoea 17%)

Political pressure to reduce the burden of malaria Increasing funding for malaria control e.g. Global Fund (inception

2002), President’s Malaria Initiative (launched 2005) and from GoU

Multi-prong approach to malaria prevention and control

Source: Malaria Consortium

The national contextMinistry of Health - Uganda

Decision taken to use Dichlorodiphenytrichloroethane (DDT) as one of the insecticides for Indoor residual Spraying (IRS) but environmentalists against this

General publicProtagonists believe that DDT is the magic bullet

whereas antagonists against the idea because of the effects on the environment and organic food exports

National research communityLack of consensus as to whether to use DDT or not

The problemLack of

(accessible)

Evidence

Lack of Knowledg

e

No consensus

Taking on the challenge

“In September 2006, UNAS held a workshop on Malaria Control and Prevention: Strategies and Policy Issues. The findings of the workshop summary report served as the basis on which the UNAS executive council selected the topic for their first consensus study addressing malaria vector resistance to insecticides used for indoor residual spraying in Uganda.”

UNAS brochure

InterventionConsensus study (July 2007) comprising

Committee of nine multi-disciplinary experts (national, regional and international)

Committee of ten reviewers (mirror composition of above)Use clear statement of task to identify, review and assess the

current state of knowledge and policies pertinent to monitoring malaria vector resistance in the context of an effective national program for IRS with DDT for controlling malaria

Recommend best practices for the effective use of DDT and other malaria vector insecticides for use in Uganda that take into consideration insecticide susceptibility

Dissemination of report targeting key stakeholders

Output of interest

Malaria Mosquito Alert

Approaches to assessing and managing malaria vector resistance to insecticides used for IRS in Uganda – contributing to a National IRS strategy

© 2008 Uganda National Academy of Sciences

Malaria eradication – political capital

February 2009, 12 months after UNAS report completed

Knowledge transfer components(1) problem identification and communication;(2) knowledge/research development and selection;(3) analysis of context;(4) knowledge transfer activities or interventions;(5) knowledge/research utilization.

Source: Ward, V., A. House, et al. (2009). "Developing a framework for transferring knowledge into action: a thematic analysis of the literature." J Health Serv Res Policy 14(3): 156-64.

Source: Ward 2009

Attention on one insecticide

• Less attention to one specific insecticide• Understanding of IRS as an approach

Rational use of insecticides in IRS

Access to reliable evidence

Willingness to accept evidence

Evidence synthesis into guidelines

Guidelines implementation

Available financial and human resources

Malaria alert

Targeted dissemination

Insecticide resistance monitoring occurs

Knowledge

Actions

What happened to DDT?Since 2006, IRS used in 9 of 81 districtsDDT used in 2 of 9 districts in 2008No DDT use after high court case in June

2008; judgement in favour of MoH in May 2009 but now case is with the constitutional court

Susceptibility testing in 6 districts between Aug and Oct 2009 funded by PMI

Preliminary results in discussion with MoH

Relevance of the report

“The report was the first published document to highlight the possibility of DDT resistance in the country”

“It was a useful document to convince the decision makers of the need to monitor insecticide resistance”

Expert Malariologist, Uganda

Is it time for an evaluation of the impact of the report?

Report recommendations moving into action1a: Previously conducted susceptibility tests

carried out in 2005 and 2006 should be confirmed…….

2: The MoH should carry out a baseline assessment of key entomological variables such as mosquito species and biting behaviour …..

3: In selecting insecticides for IRS, the MoH should be guided by the ITS policy and the strategy for insecticide resistance management…..

Cause-effect association not verified

In summary – an example of KTSteps in knowledge transferStep 1 – the “what”Step 2 – “to whom”Step 3 – “by whom”Step 4 – “how”Step 5 – “with what effect”Sources: WHO (2004). World Report on Knowledge for Better Health -

Strengthening Health Systems. Geneva, World Health Organisation.Lavis, J. N., D. Robertson, et al. (2003). "How can research organizations

more effectively transfer research knowledge to decision makers?" Milbank Q 81(2): 221-48, 171-2.

AcknowledgementsMembers of the expert committee

Nelson MusobaMaureen CoetzeeBenson EstambaleCharlotte Muheki ZikusookaJessica Nsungwa-SabiitiJohn BahanaMary HamelAllan Schapira

UNAS council and staff