Part II: The Global Strategy
2. Control: Overcoming Malaria
B. Sustained Control: Maintaining Coverage and Utilization
When scale-up is achieved globally, the lives of approximately 75% of children under 5 who would have died from malaria will be saved annually, and the global malaria case load will be reduced drastically. On the African continent, hospital beds will be freed-up and billions of dollars of gross domestic product (GDP) will be recovered annually in endemic countries. Success in malaria control is likely to contribute substantially to the achievement of the other Millennium Development Goals and to play a strong role in reducing the burden of poverty world-wide.
Even if parasite prevalence falls to low levels, malaria control will not eliminate the mosquito vector, the parasite, or the favorable environmental conditions for transmission in many locations. To keep malaria at bay, countries need to maintain high levels of coverage even in the absence of a large number of cases.Global Malaria control and elimination: report of a technical review. Geneva, World Health Organization, Geneva, 2008.
Click for source Relaxation of control—whether because of the decline in political will, decrease in funding, or some other reason—could lead to resurgence in transmission and to epidemics.
Only by sustaining control will countries maintain the benefits they gained through universal coverage. This will require that countries continue the use of the preventive interventions, keep monitoring in place for early signs of clinical disease, increasing parasite prevalence or resistance to drugs or insecticides, and diagnose and treat the remaining cases with appropriate case management tools. This assumes that vector or parasite behavior does not change, which would make current tools less effective. One result of scale-up may be the loss of acquired immunity among people no longer continually infected with malaria parasites. Pregnant women in particular are more likely to have increased susceptibility to malaria infection during this stage and to suffer from severe disease with the risk of death. For infants and children protected from exposure entirely, protective partial immunity will never develop. Thus, if malaria makes a comeback, the whole population will be at risk of clinical symptoms and more severe cases.
In Sri Lanka in the late 1960s, relaxation of control measures after control led to a resurgence of malaria cases and more serious outcomes, which provides a powerful illustration of the importance of sustained control. (See Box II.4)
Box II.4: Malaria Resurgence in Sri Lanka
From 1945 until 1963, the number of reported malaria cases in Sri Lanka declined from 1.3M to a mere 17. Credit goes to widespread DDT campaigns in endemic areas and increased access to government health services. Following this success, the government stopped the DDT spraying program in 1964, relaxing their main vector control tool.
The DDT program was restarted, but by then resistance to DDT was widespread in the mosquito population and a switch to Malathion was made. In the 1980s and 1990s, river development projects created new breeding grounds for vector mosquitoes and at the same time, spurred population movements. Outbreaks in previously non-malarious areas and another significant resurgence occurred. IRS was used in the early 2000s to bring malaria under control once again. Both P. falciparum and P. vivax cases have declined to low numbers but the risk of resurgence remains if its control measures are relaxed. See Figure II.9: Resurgence of malaria in Sri Lanka.In 1935, the number of cases reported is extremely high, equivalent to 97% of the population. Explanations include: one individual
treated more than once or # of visits, not cases, reported. Sources: Wijesundera M. Malaria Outbreaks in New Foci in Sri Lanka.
Parasitology Today, vol. 4, no. 5, 1988; Mendis K et al. The neglected burden of Plasmodium Vivax malaria. Am. J. Trop. Med. Hyg., 64
(1, 2)S, 2001, pp. 97–106; Briet O et al. Malaria in Sri Lanka: one year post-tsunami. Malaria Journal, 5:42, 2006.
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Figure II.9: Resurgence of malariain Sri Lanka
Source: Wijesundera (1988); Mendis et al (2001); Briet et al (2006)
The goal of the sustained control stage is to maintain universal coverage and ensure high utilization with appropriate malaria interventions for all populations at risk, until it is made irrelevant by elimination or until field research suggests coverage by some tools can be reduced without risk of resurgence of malaria.
At the global level, the 2015 RBM targets state that global and national mortality is near zero for all preventable deaths,Preventable death is defined as deaths from malaria that can be prevented with rapid treatment with effective medication. Non-preventable deaths represent an extremely low mortality rate for the most severe malaria cases and occur even with the best available and most rapid treatment. that global incidence is reduced by 75% from 2005 levels which will contribute substantially to the achievement of the malaria-related Millennium Development Goal (halting and beginning to reverse the incidence of malaria).
It is estimated that countries with natural high transmission settings will need to sustain high levels of control for at least 15-20 years or more, until new tools enabling elimination are available. Countries with lower transmission settings may move from sustained control to elimination more rapidly, provided that they have addressed other factors (e.g. strong health infrastructure, good management of malarious borders and epidemiological milestones).Epidemiological milestone is slide positivity rate (SPR) <5% in fever cases, see Part II – Chapter 3: Elimination and Eradication:
Achieving Zero Transmission.
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To be successful, the sustained control stage requires a continued focus on the health systems activities started during scale-up and a sustained commitment from both endemic countries and the international community during years in which, if control is sustained successfully, few cases and deaths will occur. In addition, distribution channels for malaria products will need to be adapted and expanded to ensure that universal coverage can be continued. Below we discuss approaches to ensure this sustained and enhanced focus is achieved.
Sustained Commitment Needed from Key Stakeholders of the Health System
Maintain political support and sustained international funding. The continued support of external donors and national political leaders is critical to maintaining financial support. In the face of a greatly decreased malaria burden, attention will naturally shift to other priorities. However, universal coverage with interventions needs to be maintained until the beginning of the elimination stage, requiring long-term political commitment and high and predictable funding. Communication programs between the NMCP and other sectors within the country as well as at the local level are essential.
Support required. When the burden of disease is substantially decreased, strong advocacy efforts will need to be directed towards international donors, partners and endemic country leaders to emphasize the importance of continued malaria support. See Part IV - Chapter 2: Advocacy.
Expand human capacity in countries. Countries need more on-the-ground service providers, program managers, technical staff (logisticians, statisticians, accountants, etc.), scientists (e.g. entomologists, epidemiologists), researchers and skilled workers for monitoring and evaluation programs. An analysis of the objectives and needs of the NMCP should be carried out to build an adequate NMCP structure to coordinate partners. This structure will vary based on partner roles, degree of decentralization, public / private compositions, management styles, etc. As case management activities and some delivery circuits for preventive tools become more decentralized and malaria interventions become more integrated with other programs (such as reproductive health or child health programs), there is a crucial need for capacity building in management and technical skills down to the district and local level and also outside the traditional malaria system.
Support required. Countries need to be strongly supported in their efforts to plan for medium term human resource needs and in the expansion of capacity building programs especially through elaboration of adapted trainings and the creation of training networks.
Components of Health Systems that Sustain Universal Coverage
Improve policy and regulatory processes. Regulatory processes at the country level need to be continuously improved and accelerated. Regional regulatory processes could be considered for some countries where the limited size of the market could discourage manufacturers to enter into the national process. Strong governance structures need to be in place to strengthen policy-making processes and ensure that decisions are unbiased and based on scientific review.
Support required. International recommendations for regulatory and policy issues need to be updated taking into account changes in the malaria environment that might occur after scale-up. Countries need to be supported in capacity development of governance structures to strengthen national policy-making processes. See Part IV - Chapter 4: Policy and Regulatory Priorities for more detail.
Adapt planning for more effective decentralization. As the objective of the sustained control stage is to keep-up universal coverage of appropriate interventions, it will require a new round of planning to organize partners around the best-suited distribution systems for maintenance. This includes redefining the priorities of the control program around the strengthening of health systems in relation to malaria, including human resource capability and capacity building, equipment, infrastructure, logistics and supplies, supervision, monitoring and evaluation and improved communication / behavior change efforts as well as increased advocacy to ensure there is continued support for the malaria control efforts. The move from nationwide scale-up (thanks to national plans and implementation of mass distribution campaigns) to maintenance of control programs and strengthening of routine health systems and community health services is accompanied by a decentralization of authority. To ensure that strategies are adapted to local needs, it is even more important to develop local plans and to increase local political empowerment, leadership and budgeting power. In addition, regional malaria control initiatives should be encouraged in sustained control, which would require cross-country planning efforts. Strong inter-program and inter-sector collaboration are critical at this stage.
Support required. Countries need technical assistance in developing plans and funding proposals for the sustained control stage. These plans will also need to include the scale-up of new interventions. Support for collaboration on regional projects and the development and dissemination of best practices on approaches should be provided. See Part IV - Chapter 4: In-country Planning.
Maintain predictable and long-term access to resources. The magnitude of costs to sustain control are similar to the cost of SUFI, with two main differences: 1) the mix of costs will change with lower treatment costs and higher program costs due to stronger surveillance systems and higher preventive costs due to population growth and 2) funding flows need to be prolonged for a long period of time. Therefore, long-term and predictable funding will be needed to maintain the appropriate level of control required. To improve predictability, tools or frameworks for medium term planning for financing such as the Medium Term Expenditure Frameworks could be used. See Part IV - Chapter 6: Financing.
Increasing in-country funding. Countries should be encouraged to increase the level of internal resources spent on malaria to a point where they can sustain their own programs. Increasing national health budgets and the share allocated to malaria will make funds and funding gaps more predictable. As economic growth in high-burden countries will likely rebound after incidence goes down,Malaria control is only one enabler to economic growth among numerous other factors. it is important that this is translated into increased national health spending for malaria and used to advocate for in-country inter-sector (education, agriculture etc.) funding. Private sector financing should be promoted.
Continued need for external funds. However, it is unlikely for many countries, especially the lower income countries, that internal financing alone can cover their needs. Countries will need to continue to seek external financing from international donors. As long-term commitments will be essential in this stage, a shift towards performance-based management will be important. In order to sustain interest from the donor community, increased financial reporting capabilities need to be in place by implementing, for instance, Malaria Sub-Accounts which will help better identify financial flows and therefore economic impact.
Support required. An international resource mobilization strategy with medium- and long-term goals is required to fund in-country implementation activities and international support needed, coming from external and increased domestic resources. Countries need to be supported in their efforts to improve medium-term planning for financing to clarify requirements for the future. This will help the donor community and national budget allocations for malaria to be more predictable during sustained control. International guidance is required on the use of tools to increase accountability of funding flows such as Malaria Sub-Accounts.
Adapt distribution systems to maintain coverage. Maintaining high coverage levels requires a combination of adapted distribution approaches to strengthen all routine delivery mechanisms and to improve integration with other disease programs where appropriate. Strong inter-program collaboration and robust procurement and supply chain management systems and accurate forecasting capabilities are prerequisites. Increased decentralization of decision-making and budgeting will also be accompanied by strengthened community participation in the delivery of interventions.
Sustain quality of interventions. Sustained control is the time when quality of interventions needs to be maintained and improved continuously. With the decreasing burden, care providers might reduce the attention required and quality of services they deliver. Capacity building especially through continuous training programs is critical to maintain the level of quality required for interventions as countries move towards elimination. If control is successful and incidence goes down, some of the diagnostic and treatment interventions will be less frequently used. To ensure their continued quality, adequate quality control testing programs need to be in place. The need for strengthened collaboration with other programs such as reproductive and child health programs to ensure prompt effective diagnosis and treatment for all cases would be critical at this stage.
Support required. Procurement and supply chain management capacities within countries need to be strengthened during the sustained control stage. Manufacturers of products in malaria- endemic countries need to be supported to meet the international standards. As new tools become available, adequate procurement and supply systems to roll them out need to be in place. International guidance and mechanisms should be established for quality control monitoring of all major interventions. Countries need to be supported in their efforts to strengthen forecasting capabilities. See Part IV - Chapter 7: Procurement and Supply Management.
Develop communication and behavior change methodologies. As the burden of malaria decreases, people may let down their guard: they may stop sleeping under nets or delay health seeking treatment. Health workers might decrease focus on malaria. Strong education and communication programs need to be in place to educate communities about the continuing risks of malaria. In addition, community-based communication programs aiming at increasing use of the various interventions also need to be maintained.
Support required. In-country communication programs are essential to maintain high levels of utilization of the interventions deployed. Countries need to determine what human resources are needed to conduct in-country communication programs in a sustainable way. Technical assistance will then be needed to train these workers. Standardized M&E indicators aimed at measuring progress in in-country communication programs will need to be in developed. See Part IV - Chapter 8: Communication and Behavior Change Methodologies.
Strengthen Monitoring and Evaluation (M&E). Monitoring and evaluation takes on even greater importance in sustaining control. M&E systems should be able to routinely track coverage and utilization levels of interventions, as well as the quality of interventions delivered. Staff needs to be increased and M&E capabilities strengthened at the local level (districts and communities), along with the implementation of new mapping and communication tools, to track and respond locally to intervention gaps and malaria infections in a prompt manner. For this purpose, national support systems will increasingly move to sub-regions. M&E activities need to be more integrated into routine health information systems. If routine and local monitoring mechanisms are strengthened sufficiently so that they provide robust and timely data on coverage and impact, the need for national, population-based surveys could decrease. To ensure continued support for malaria control, regular reporting to all stakeholders for global tracking of progress and advocacy is essential.
Support required. Countries need to be supported to follow international guidance on the shift and enhancement of M&E capabilities for sustained control. In particular, they need support in capacity building and technology development (mapping or communication tools) at the local level. See Part IV - Chapter 9: Monitoring and Evaluation.
Ensure cross-border collaboration. Cooperation between countries becomes even more important once countries have scaled up and are sustaining control. Adjacent countries often have similar epidemiological settings, including transmission intensities and levels of resistance. It is therefore advantageous for countries to work together to harmonize intervention strategies as well as approaches to insecticide and drug tracking and reporting. Frequent communication between different malaria control programs facilitates best practice sharing and gathering of information regarding epidemiological changes which may require changes in policy.
Support required. The international community can support countries within regions by providing funding and institutional support for regional coordination meetings and regional coordinators. See Part III: Regional Strategies.
Box II.5: Scaling Up and Sustaining Control in BrazilPresentation from Dr. Jose Ladislau, Ministério de Saúde: Secretaria de Vigilância em Saúde Programa Nacional de Controle da Malária. Geneva, 2nd Consultation Global Malaria Business Plan Meeting, July 2008.
Brazil's Amazon region—where 13% of the country's population lives—is where virtually all malaria transmission takes place in the country. After decades of on-and-off control, the Brazilian government is applying proven interventions to control the disease. Migration throughout the multi-country region makes elimination an unrealistic short-term goal, but sustained control can be achieved and can keep the malaria burden low and manageable for the 24 million people in Brazil's Amazon region.
Since the last disease peak in 2006, Brazil has:
- Instituted uncomplicated P. falciparum malaria treatment with ACTs in an expanded network of diagnostic laboratories,
- Stepped up distribution of free LLINs and
- Maintained high levels of IRS and other forms of site-specific environmental management.
The pool of malaria control personnel has been expanded continually since 1999, which has improved the dissemination of control interventions and increased the capacity for operational research and monitoring. A powerful information management system captures the information collected and provides a clearer picture of changes, closer to real time than ever before.
Brazil's stepped-up control program is still new, but the results are promising. After the first year (2006), total malaria cases were down 17% and falciparum cases down 37%. Hospital admissions for malaria were cut by one-third, and there were only 73 deaths.
Brazil has identified the next challenges, concentrating on continued scale-up and sustaining control. With these measures, Brazil is on a path to meet the RBM 2010 goals and, thereafter, continuing control and documenting further declines in its malaria burden.
Adapted Delivery Strategies Are Critical to Sustain Universal Coverage
To ensure ongoing universal coverage, the interventions must be provided on a regular basis during sustained control. The fabric and effectiveness of LLINs last for approximately 3 to 5 years.Time of efficacy of LLINs could be lower in certain field conditions.
IRS can be effective for 3-6 months depending on the insecticides used and the surfaces sprayed.Even if some insecticides such as DDT can be effective for up to 9-12 months in certain conditions. Policy Brief, Malaria Global Fund Proposal Development. Geneva, World Health Organization Global Malaria Program, March 2008.
Click for source Drugs and RDTs are used up and expire. To maintain the coverage, the delivery systems set up during the scale-up stage should be continued, including the mass distributions if indicated.
There are multiple ways to maintain universal coverage of malaria interventions. Some intervention-specific success factors are presented below, but two key enablers apply to across interventions: integration with other programs and the enhanced use of the private sector.
While standalone interventions sometimes put additional pressure on health systems, integrated delivery mechanisms benefit from synergies between various programs that often target the same populations or the same areas. Although integrated mechanisms may be more difficult for some interventions (e.g. indoor residual spraying), countries need to make the best use of those which proved to be effective. The use of routine delivery systems (such as antenatal or immunization visits) and integration with the routine distribution programs of other diseases (e.g. Expanded Program for Immunization) need to be strengthened as they prove to be a cost effective way to maintain coverage levels. Expanding and strengthening malaria interventions, such as quality-assured microscopy, can also have a positive impact on other diseases.
Reaching beyond the public sector to partner with the private sector for service delivery can be an effective way of sustaining coverage. Among other things, the private sector can assist with improving demand generation for malaria services, reaching isolated populations through expanded commercial networks, or even giving trainings to increase logistical, procurement and supply chain management skills within countries.
Maintenance of vector control. Vector control is important to sustain control and includes LLINs, IRS, and a variety of other interventions.
Maintenance of LLINs. The combination of approaches chosen during the scale-up will continue. If mass distribution campaigns were used to reach universal coverage, these campaigns need to be continued regularly to renew the installed base of nets. Routine services such as ANC and immunization visits should complement the distribution system by continuously distributing nets between the mass campaigns. Ethiopia, which has reached high coverage with LLINs, is developing a plan to maintain this coverage level through a combination of replacement campaigns (through the Health Extension Workers and other community-based agents) and routine delivery in health facilities and antenatal clinics.Ministry of Health of Ethiopia, personal communication, 2008; PMI Malaria Operational Plan – Ethiopia. 2008. Also see PMI webpage.
Click for source Private sector distribution coupled with voucher mechanisms could complement these efforts.
Maintenance of IRS. As for scale-up, rounds of spraying will be performed once or twice a year, depending on the seasonality of malaria transmission and the insecticide used. In areas of stable malaria transmission where IRS is used routinely, long-term and predictable commitment from donors and authorities is needed to avoid gaps in coverage. In areas of unstable transmission, IRS will be increasingly needed to reduce transmission in residual foci or new active foci and to control outbreaks.
Maintenance of other vector control interventions. Other vector control interventions (larviciding, environmental management etc.) are of greater importance in sustained control as the burden goes down and targeted approaches towards breeding sites can be very effective in reducing vector populations. Their sustainability relies on the ability to conduct continuously reliable surveillance and mapping activities to identify areas where these interventions are most appropriate.
Maintenance of diagnostics. As mentioned earlier, universal access to parasitological diagnosis (by microscopy or RDTs) to confirm clinical diagnosis needs to be maintained for all populations at risk. For the moment, WHO recommendation is based on parasitological diagnosis for all age groups, except for children under 5 in areas of high transmission who should be treated on the basis of clinical diagnosis.Guidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.
Click for source As the number of fevers due to malaria decreases, the use of parasitological confirmation will be extended to all age groups. During the sustained control stage, microscopy capabilities need to be extended substantially to prepare for elimination. For microscopy, quality assurance controls need to be in place. At a local level, when skilled workers are not available to conduct microscopy, RDTs as a community or home case management tool will be essential to ensure prompt and effective treatment.
Maintenance of anti-malarial treatment. As outlined in the scale-up chapter, the main pillars of universal coverage in treatment are improving the use of existing professional resources, expanding the reach of the health system especially through the development of community health workers networks, increasing financial access through subsidies or cost sharing mechanisms, and expanding geographical access with enhanced private sector distribution. These pillars continue to be critical to sustaining control.
Community-based access to treatment aims at giving community members the opportunity to participate in malaria control, for example through community health worker programs (see Box II.6). These programs are usually not malaria-specific and cover a broad range of health interventions such as management of diarrhea and promotion of breastfeeding. Maintaining high levels of training and expanding these community health worker programs could be an effective way to maintain treatment coverage over time, and are one of many potential successful solutions. Community-based access programs must consider human resource factors related to motivation and compensation to prevent burnout and encourage retention. Additionally, the number of tasks required per health worker must not be so high that the quality of care delivered suffers. As incidence diminishes and as treatment occurs more at the community level, forecasting capabilities need to be further strengthened to avoid stock-outs and expiration of drugs.
Box II.6: Health Services Extension Program and Health Extension Workers in EthiopiaMinistry of Health of Ethiopia, personal communication, 2008.
The health service extension program (HSEP) provides primary health care service to prevent major communicable diseases that account for 80% the health, hygiene and environmental sanitation, maternal and child health problems. The program is developed to deliver preventive, selective and curative health care services in all the 15,000 kebelesSmallest administrative unit of Ethiopia. of the country.
The program started in 2003 with training and deployment of 33,200 Health Extension Workers (HEW) to all kebeles and the establishment or upgrading of 3,153 health centers in order to strengthen referral exchanges and supportive supervision to HEW for the attainment of equitable essential health care service at all levels.
HSEP contains 5 main package programs: disease prevention and control (malaria, tuberculosis, and HIV/AIDS), family health (maternal and child health, family planning, Expanded Program on Immunization - EPI, adolescent reproductive health and nutrition), hygiene and environmental sanitation, and health education. These package programs are implemented at household and health post level in each kebele. On average a kebele consists of 5,000 people and gets the service by two trained female HEW.
Malaria prevention and control is one of the programs which benefited most from HSEP. It improved case management by making diagnosis and treatment services available at a walking distance. In Integrated Vector Management, HSEP contributes to the successful distribution and proper utilization of LLINs, prompt IRS operation and continued environmental intervention. Finally it started community dialog on the malaria burden, prevention and control strategies tailored to the community need.
Maintenance of Malaria in Pregnancy (MIP) interventions. Interventions for malaria in pregnancy are delivered through antenatal clinics. During sustained control, continued work is required to integrate maternal health and malaria services and to build the capacity of the maternal health workforce around malaria issues. Among other things, communication programs need to promote regular antenatal visits for all pregnant women.
Risks Must be Managed
Despite the many benefits, global control also brings risks. In particular, three risks need to be planned for during the sustained control step: the fatigue among key stakeholders, the wide-spread emergence of resistance to insecticides and drugs and the increased risk of epidemics and severe malaria.
Risk of malaria fatigue. As successful control efforts reduce the burden of malaria, there is a strong risk that interest in malaria could drop amongst key stakeholders (e.g. donors, politicians, health officials and the public). If not addressed, this fatigue could lead donors to lower funding for malaria control, governments and health ministers to place less emphasis on malaria control and the public to reduce utilization of preventive and treatment measures. Strategies to combat fatigue are discussed above when discussing key stakeholders of the health system above and in Part II – Chapter 3: Elimination and Eradication: Achieving Zero Transmission.
Risk of increased resistance. Sustained universal coverage means that parasites and vectors will be exposed to large amounts of anti-malarial drugs and insecticides over a long period of time. There is still some debate whether the spread of malaria resistance is faster in high versus low transmission areas. It seems that generally it is increased in areas of high transmission, but for some drugs it also spreads rapidly in low-transmission areas.Talisuna AO. Intensity of Malaria Transmission and the Spread of Plasmodium falciparum–Resistant Malaria: A Review of Epidemiologic
Field Evidence. American Journal of Tropical Medicine and Hygiene, 77 (Supplement 6), 2007.
Click for source However, there is little debate about the fact that resistance to chemicals widely used in prevention and treatment will likely emerge. It is essential that countries create robust programs aiming at monitoring resistance while putting in place the adequate policies to mitigate it, such as the use of combination therapies, emphasis on targeting treatment and maximizing adherence, insecticide rotation for vector control, and the universal use of diagnosis where transmission diminishes. The international community must have strong operational research programs to develop new approaches to mitigate resistance, as well as research and development to create new formulations of drugs and insecticides that will replace current ones. Good policies are essential, such as banning the use of artemisinin monotherapies. To improve international tracking of resistance, regional collaborative networks could be built, as is the case in South Asia with the South-Asia Surveillance Network for Malaria Drug Resistance. In addition, ensuring procurement of high-quality medicines and insecticides is necessary to manage resistance.
Risk of epidemics and severe malaria. In areas of natural high transmission, frequently exposed populations at risk develop acquired immunity over time, resulting in low levels of severe clinical illness for adults (adults can be infected without symptoms — thus creating asymptomatic reservoirs of parasites). A strong decrease in incidence due to successful control measures in scale-up will likely decrease immunity and therefore increase the severity of malaria in adult populations. Pregnant women in particular become at increased risk of severe clinical illness and death as pregnancy increases a woman's susceptibility to malaria infections, and protective acquired immunity is lost in low prevalence situations. Therefore, targeted communication will be required among adult populations to explain the increased risk of severe illness and deaths, as well as stronger epidemics management, with surveillance systems to promptly detect risks of epidemics and to rapidly deploy adequate response systems.
Countries in Sustained Control Must Prepare for Elimination
In sustained control, countries also prepare the move to elimination. Country efforts to strengthen health systems and maintain a low level of burden are important pre-conditions for pre-elimination and elimination. By building the capacity to plan at the national, regional and local level, to reach remote populations, and to conduct advanced M&E activities, a country will build the groundwork for the health systems required to conduct successful elimination programs.