Preventing the Reintroduction of Malaria in Mauritius: A Programmatic and Financial Assessment

Abstract

Sustaining elimination of malaria in areas with high receptivity and vulnerability will require effective strategies to prevent reestablishment of local transmission, yet there is a dearth of evidence about this phase. Mauritius offers a uniquely informative history, with elimination of local transmission in 1969, re-emergence in 1975, and second elimination in 1998. Towards this end, Mauritius's elimination and prevention of reintroduction (POR) programs were analyzed via a comprehensive review of literature and government documents, supplemented by program observation and interviews with policy makers and program personnel. The impact of the country's most costly intervention, a passenger screening program, was assessed quantitatively using simulation modeling.On average, Mauritius spent $4.43 per capita per year (pcpy) during its second elimination campaign from 1982 to 1988. The country currently spends $2.06 pcpy on its POR program that includes robust surveillance, routine vector control, and prompt and effective treatment and response. Thirty-five percent of POR costs are for a passenger screening program. Modeling suggests that the estimated 14% of imported malaria infections identified by this program reduces the annual risk of indigenous transmission by approximately 2%. Of cases missed by the initial passenger screening program, 49% were estimated to be identified by passive or reactive case detection, leaving an estimated 3.1 unidentified imported infections per 100,000 inhabitants per year.The Mauritius experience indicates that ongoing intervention, strong leadership, and substantial predictable funding are critical to consistently prevent the reestablishment of malaria. Sustained vigilance is critical considering Mauritius's enabling conditions. Although the cost of POR is below that of elimination, annual per capita spending remains at levels that are likely infeasible for countries with lower overall health spending. Countries currently embarking on elimination should quantify and plan for potentially similar POR operations and costs.

The economics of malaria control and elimination: a systematic review

“…Barring a few exceptions, reported elimination costs per capita were generally lowest in the Asian countries (i.e., China [13, 50, 53, 54], India [10], Indonesia [10], Philippines [57], Taiwan [10], Thailand [10], Sri Lanka [50], and Vanuatu [58]) and Mexico [51, 52]. Costs were generally highest in African nations, such as Mauritius [49], São Tomé and Principe [50], Swaziland [13, 50], and Tanzania (Zanzibar) [13].

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“…Other countries report much higher cost per PAR. For example, the cost of Mauritius’s second elimination campaign in 1975–1990 was approximately $4.63 per PAR per year, even though several economic costs and contributions by external partners were not included [9, 49]. Costs per PAR in different provinces in the Philippines ranged from $2.77 to $4.33 (excluding outbreak years) [57].…”

Cross-Border Malaria: A Major Obstacle for Malaria Elimination

“…Both Oman and the UAE have provided free treatment to everyone who tests positive, whether they are nationals or foreigners. Testing for malaria at entry points in Mauritius was shown to provide benefits for investment, by maintaining elimination despite large cyclones in 1994 and 2002 that caused costly damage and an increase in the number of travellers arriving from malaria-endemic countries (Tatarsky et al, 2011;Aboobakar et al, 2012). Screening arriving passengers for malaria at the border points and obtaining a detailed travel history have been deployed to assess the impact of human population movement on malaria in Djibouti (Noor et al, 2011).…”

Human movement data for malaria control and elimination strategic planning

“…Testing at entry points for the case of Mauritius, however, was recently shown to provide marginal benefits for large investments [20]. Furthermore, targeted screening, for example to fever-presenting individuals, may miss asymptomatic parasite carriers.…”