The fight against COVID-19 in the small island of Mauritius

Mauritius is a subtropical island located in the southwestern Indian Ocean, with a multiethnic population of about 1·3 million people. Mauritius also has one of the highest prevalences of diabetes worldwide, 1 a condition linked to the severity of COVID-19. 2 Despite the challenges in curbing the COVID-19 pandemic, Mauritius scored a very high mark on the Oxford COVID-19 Government Response Stringency Index 3 in the middle of April, 2020. In part, this success was due to a prompt and consistent governmental strategy. On Jan 21, all passengers arriving from China were quarantined for 14 days under strict sanitary conditions. 1 day later, the Prime Minister of Mauritius chaired a high-level committee meeting with all his ministers, as well as a representative from WHO to discuss approaches to control the pandemic. Because Mauritius is a very popular tourist destination, it was vital to control the arrival of overseas travellers with COVID infection. Temperature checks for passengers arriving at the international airport were introduced, and all visitors from high risk countries (eg, Singapore, Malaysia, and Thailand) were also quarantined from Feb 11. On March 18, the first three cases of COVID-19 were registered in travellers and consequently on March 19, the borders were closed. With the escalation of cases, a curfew was imposed on March 20, and eventually a complete lockdown was implemented on March 24. Mauritius and its citizens also stood firm against the pandemic. Work access permits were essential to avoid heavy fines and legal action. Health services were fully functional including a hotline telephone service to answer public queries. Between March 21, and July 20, 99 678 calls were received and attended to. A home visit team was set up which provided domiciliary visits consultations, and basic treatment. A mobile application, beSafeMoris was launched on March 26, allowing the Mauritian population to obtain real-time information about health and safety measures. In parallel, regional public health superintendents and several rapid response teams were responsible for the transfer of patients with suspected COVID-19 to quarantine and treatment centres and a contact tracing team aimed to identify related cases. WHO infection control standard precautions were strictly followed during the pandemic. 4 Because the pandemic originated during winter in the southern hemisphere, the annual anti-influenza vaccination campaign was carried out for the elderly population. This campaign was done using mobile caravans circulating house to house, maintaining social distancing and the wearing of masks. 68% of senior citizens were vaccinated in 2020, compared with 25% in 2019 and 20% in 2018. Testing for Covid-19 has also been a priority from the start of the pandemic. Not only all front-line health workers were tested for COVID-19 regularly, but testing was also carried out in asymptomatic persons who were susceptible to infection. People having symptoms compatible with COVID-19 were tested, which included those having a history of cardiovascular disease, hypertension, diabetes, and lung disease. The rapid response by the Mauritian Government, and appropriate and strong support and compliance from the public, were key factors towards the control of the pandemic in this island nation. The Mauritian authorities prioritised the health and well-being of their citizens over tourism and the national economy. At the time of writing, 340 of 368 people with registered infection in Mauritius have recovered, ten have died, and 18 remain active cases. As of Sept 24, borders are still closed to prevent a second wave. However, in the context of repatriation of Mauritian citizens and those who are holders of resident permits, all passengers will undergo a PCR test before they are permitted to board a flight back to Mauritius. While on the flight, a health surveillance card is provided to record any symptoms before landing. Upon arrival, a temperature check is undertaken. Under the guidance from the Ministry of Health and Wellness, the passengers are directed to quarantine centres where a PCR test is performed on the first day. Retesting is done on the seventh day and 14th day before leaving the quarantine centres. COVID-19 has only been present in Mauritius for 6 months and it may present a long-term health and economic challenge to the nation. We are now only starting to learn about the long-term health complications resulting from the infection, and Mauritius plans ongoing surveillance of all COVID-19 infected people to document possible long-term complications.

Summary box The COVID-19 response in Mauritius, which is viewed as a success story, benefited from strong leadership, highest political engagement, and strong involvement of the WHO, the private sector and other key stakeholders. Another key success factor lies in clear, transparent and consistent communication, including feedback mechanisms to understand public perception, the result of which is good adherence by the population. Public health measures (quarantine, contact tracing, case investigation and isolation of contacts, mass testing) have also contributed to the success of the country in the fight against COVID-19. The Mauritian success story can be inspiring for other countries, especially regarding the importance of adapting measures to evolving knowledge and developing a clear and consistent communication policy so as to buy the adherence of the population. However, contextual factors (an island has a limited number of entry points) have also facilitated the implementation and success of these measures. Not all countries can expect similar results by copy-pasting the Mauritian response strategy and should probably adopt a comprehensive policy acting on various factors to fight the pandemic. Introduction Mauritius is an island state in the Indian Ocean located within the continent of Africa, categorised as an upper-middle-income economy. It has an estimated population of 1.27 million inhabitants, a gross domestic product (GDP) of US$12.2 billion and a per capita GDP of US$ 9630 in 2021.1 Following the declaration of the COVID-19 outbreak as a public health emergency of international concern on 30 January 2020, the WHO requested member states to develop a National Strategic Plan for Preparedness and Response to the Outbreak with nine strategic pillars.2 Mauritius was identified as the country with the highest risk of exposure in the African Region, and South Africa, Cameroon and Algeria were the only large countries among the top 10 highest risk of exposure.3 Using a mathematical model, stratified by age, to predict the evolution of COVID-19 epidemics, some authors predicted a median symptomatic attack rate of as much as 42% in Mauritius over the first 12 months, if the epidemics was unmitigated.4 The first three COVID-19 cases (all imported) were detected in Mauritius on 18 March 2020. On 19 March, the borders were closed. With the escalation of cases, a curfew was imposed on 20 March, and eventually a complete lockdown was implemented on 24 March.5 According to the national surveillance system, the outbreak quickly evolved from sporadic cases to clusters and then to local transmission and was contained on 26 April 2020, after 39 days, with no locally transmitted cases until November 2020. Then, two new community cases were reported, and since 26 November, only imported cases have been reported in the island. The measures adopted by Mauritius have highly been praised by international organisations.6 Countries around the world have experienced very different epidemic profiles, with contextual factors, including social and environmental factors, playing an important role in shaping the outcomes7—hence the importance of shaping response policies to local contexts8 and of adapting policies and interventions in light of emerging knowledge (evidence-based policy-making), engaging in transparent dialogues with stakeholders and developing appropriate communication strategies that build public trust and support.9 The purpose of this article is to analyse the success factors of Mauritius that could inspire other countries—if properly adapted to their context—in future outbreaks. This article adopts a reflexive analytical approach to comprehend the key success factors of Mauritius in fighting the COVID-19 pandemic. Reflexivity can indeed be defined ‘as an intentional intellectual activity in which individuals explore or examine a situation, an issue or a particular object on the basis of their past experiences to develop new understandings that will ultimately influence their actions’.10 Data were collected through participative observation of key stakeholders involved in the fight against the COVID-19 pandemic in Mauritius (WHO, Ministry of Health and Wellness) complemented by a targeted documentary and literature review. After presenting an overview of the evolution of the pandemic in Mauritius, we present a number of key factors that have emerged from our reflexive analysis as major contributors to explaining the success of Mauritius in the fight against COVID-19. Overview of the evolution of the pandemic in Mauritius As shown in figure 1, as of 17 January 2021, the cumulative number of confirmed COVID-19 cases was 556, of which 518 cases had successfully recovered, representing a recovery rate of 93.2%. Among the 556 confirmed cases, 341 (61.3%) were imported cases and 215 (38.7%) emanated from local transmission. There were 10 deaths in total; the incidence was 4.4 per 10 000 inhabitants and the case fatality rate was 1.8%.11 Figure 1 Cumulative cases and cumulated deaths, Mauritius, 18 March 2020 to 20 January 2021 (WHO COVID-19 Weekly Situation Report11). Table 1 compares the situation of Mauritius with selected countries of the Indian Ocean Island in terms of COVID-19 confirmed cases and deaths reported in the last 7 days by countries, territories and areas, as of 17 January 2021. It shows that Mauritius is the country/territory that fares best in the Indian Ocean in terms of almost all indicators. Table 1 Comparison of Mauritius with neighbouring countries, selected COVID-19 indicators Reporting country/territory/area Cumulative cases New cases in last 7 days Cumulative cases per 100 000 population New deaths in last 7 days Cumulative deaths Cumulative deaths per 100 000 population Transmission classification Madagascar 18 001 234 65 5 267 1.0 Community transmission Maldives 14 462 397 2675 – 49 9.1 Clusters of cases Reunion 9443 196 1055 3 45 5.0 Clusters of cases Mayotte 6611 379 2423 2 58 21.3 Clusters of cases Comoros 1577 427 181 23 41 4.7 Community transmission Seychelles 689 187 701 – 1 1.0 Community transmission Mauritius 547 8 43 – 10 0.8 Clusters of cases COVID-19 Weekly Epidemiological Update.11 The key success factors identified are presented below. Strong governance and leadership First, the COVID-19 response in Mauritius benefitted from strong leadership and highest political engagement. A High-Level COVID-19 Committee, chaired by the Prime Minister, was instituted on 31 January 2020 to monitor the local and international epidemiological situations and to rapidly share key information among the different ministries. The committee was composed of ministers in charge of Health and Wellness; Foreign Affairs, Regional Integration and International Trade; Finance, Economics, Planning and Development; Tourism; as well as the WHO Representative, the Secretary to Cabinet and Head of Civil Service, medical technical advisors and other key stakeholders. This whole-of-government approach enabled a timely and informed decision-making for a coordinated and scaled-up national response. In addition to this, an intersectoral committee was established at the level of Ministry of Health and Wellness (MoHW), which monitored the evolution of the epidemiological situation as well as the daily activities related to the operational plan. It also elaborated guidelines and standard operating procedures when needed. Numerous protocols were devised for the different processes of case management, including transfer to intensive care unit, oxygenation, ventilation, discharge of recovered patients and taking charge of patients’ family members. Some of the protocols were the WHO protocols, whereas others were adapted to the local context, taking into consideration the capacities of the Mauritian healthcare system. Many of them were modified several times to adapt to the changes in resources and epidemiological context and integrate the lessons learnt. The COVID-19 response also benefited from a strong involvement of the private sector. Business Mauritius, which represents over 1200 local businesses, and the Mauritius Chamber of Commerce coordinated actions with the Government. For instance, the Mauritius Chamber of Commerce facilitated the making of food packs distributed by the Ministry of Social Security to families on the Social Registrar of Mauritius, ensured food supply chain continuity and contributed to devising the Work Access Permit and the alphabetical order strategy for shopping during the lockdown. It is also important to mention the pivotal support provided by the WHO Country Office since the discovery of the virus. This comprised the sharing and regular updating of key information and guidelines, and technical assistance to assess preparedness and strengthen the capacities of country’s response to a health emergency, including the elaboration of the National Action Plan for Preparedness and Response. The WHO Country Office sustained its support, as the country prepared to start its vaccination campaign in January 2021. The purpose of ‘national vaccine table top exercises’ was to support country to plan, develop and update the national deployment and vaccination plan for COVID-19 vaccines, including testing and enhancing its planning assumptions.12 Moreover, the WHO Country Office provided technical advice as member of the High-Level Committee on COVID-19. Clear, transparent and consistent communication Another key success factor in the fight against the pandemic of COVID-19 lies in clear, transparent and consistent communication. Mauritius started with an early intense sensitisation campaign on COVID-19. As of 23 January 2020, the MoHW started a national sensitisation campaign through different media (radio, television and written press) and visuals (posters, pamphlets, banners and billboards), explaining the occurrence of the novel coronavirus, its mode of transmission, signs and symptoms, and preventive measures to be taken to avoid the infection. During total lockdown, the National Communication Committee held press briefings in camera to avoid contact and answered questions from independent journalists sent on a live platform put in place by the National Broadcaster. These early messages placed emphasis on physical distancing, use of face masks, hand hygiene and cough etiquette, and encouraged the public to call the hotline for further information or to signal suspected cases. Pamphlets were distributed at the port and airport; in educational institutions, community halls and centres at the level of town municipalities; in village and district councils; and in all health facilities. Clear and consistent communication was facilitated by the creation of the National Communication Committee on COVID-19 as a unique, central communication mechanism. It is entitled to transmit decisions taken by the High-Level Committee on COVID-19 to the Mauritian population and to address the key issues during daily press briefings. In addition, members of the National Communication Committee on COVID-19 also participated in special live television programmes on COVID-19 on the national television and radio channels. These enable to provide more details on the different response measures and to answer questions raised by the general public. It has proven to be a very effective strategy to ensure an accurate, transparent and trustworthy stream of communication directly from the decision-makers to the general public and to reassure the population. To expand the dissemination of information on COVID-19 and to achieve a maximum reach, several media platforms were created: a website, http://www.COVID-19.mu; a Facebook page ‘Coronavirus Moris’ dedicated to COVID-19 in Mauritius; and a mobile application, ‘beSafeMoris’. Communication goes both ways, and henceforth, several feedback mechanisms to understand public perception on COVID-19 were established—namely, a hotline dedicated to COVID-19, the monitoring of social media platforms and live radio shows, and regular feedback from the Mauritius Police Force and MoHW. These mechanisms helped to monitor the populations’ behaviours with respect to the different measures implemented as well as their beliefs, fears and concerns which were consequently addressed during the regular press conference. As the outbreak progressed in Mauritius, the National Communication Committee on COVID-19 indeed observed that the population was more adherent to precautionary measures such as physical distancing and wearing masks while shopping and more respectful of the sanitary curfew in general.13 The National Communication Committee on COVID-19 also addressed rumours, misinformation and fake news with clear and correct clarifications with a view of halting their propagation. The committee condemned the spreading of fake news on social media—notably about the prevalence of COVID-19 cases in Mauritius, the number of deaths, the reliability of tests and treatments, and the reclosure of supermarkets—characterised such behaviour as antipatriotic and highlighted their negative impact such as installing a climate of fear or panic. Last but not least, the government was also engaged to reassure the population that the country is COVID-safe since 26 April 2020. The people were encouraged to remain alert and maintain recommended sanitary measures as the prevalence of COVID-19 is on the rise in foreign countries. This regular and transparent communication has proven to be highly effective. A considerable decrease in rumours and fake news was observed among the population and on social media. The population also reacted in a responsible and disciplined way when a cluster of two locally transmitted cases of COVID-19 were identified in November 2020. According to the reports from the COVID-19 testing centres, the Mauritius Police Force, media and social media, the population showed no behaviours expressing panic on the announcement of local cases. ‘The population is now better prepared and when there is a local transmission they understand that the authorities took the needful measures did the contact tracing … there was no panic, the population reacted responsibly and in discipline’—said Dr Joomaye Zouber, Senior Adviser to the Prime Minister in Mauritius, during his interview at the WHO Inter-Action Review exercise on 18 December 2020. There was also no indication of other behaviours such as panic buying and people not wanting to go to their workplace or sending their children to school. Population adherence to physical distancing measures During the COVID-19 community transmission phase in March to May 2020, high-level governmental commitment and good communication resulted in strong adherence of the population to physical distancing measures in place. These include, for example, the fact that while supermarkets opened 6 days a week, Mauritians were only allowed to shop twice a week in alphabetical order using family names: A to F on Mondays and Thursdays, G to N on Tuesdays and Fridays, and O to Z on Wednesdays and Saturdays. One person per household was allowed to shop for 30 min, and the wearing of protective masks was compulsory. Customers had to bring an identification document that was verified at the entrance of the supermarkets. The elderly, being more vulnerable, were dissuaded from shopping, whereas younger adults of the family were encouraged to do so. However, a special morning slot from 9:00 to 10:00 was created for elderly persons who had to shop for themselves. These measures were very well respected. Strong public health measures Capitalising on decades of experience in successfully fighting communicable diseases, Mauritius’ public health measures have also contributed to the success of the country in the fight against COVID-19. Contact tracing, case investigation and isolation of contacts were established under the supervision of the Communicable Diseases Control Unit. Once a positive COVID-19 case was notified by the Central Health Laboratory, the Communicable Diseases Control Unit contacted every person tested positive for case investigation following their transfer to the COVID-19 treatment centres. Key information about how long they had been sick, the people they stayed with, the people they had been in contact with and whether their contacts were sick, and the places they visited is collected. A list of all of the patient’s contacts is elaborated, and each of them is contacted, asked for symptoms and instructed to self-isolate while waiting to be visited by the contact tracing team. On 27 April 2020, a mass rapid testing campaign for COVID-19 targeting frontliners was initiated by the MoHW. By 7 July 2020, 160 315 rapid tests were carried out among health personnel from both public and private institutions, including members of the police force, prison detainees, expatriates living in dormitories, pharmacies’ personnel, scavenging and cleaning services, supermarkets personnel, personnel working for port and airport authorities, private sector staff, staff from various ministries, members of religious and sociocultural organisations, public transport workers and athletes, among others. This campaign was designed to ensure that there was no case of COVID-19 in Mauritius in preparation for the phased ease of lockdown. No positive case was subsequently found, and the testing campaign was stopped. Laboratory testing has also been a priority from the start of the pandemic. The total number of tests conducted as of 17 January 2021 was 319 242, comprising 158 927 PCR tests and 160 315 rapid antigen tests. A 14-day quarantine is mandatory for those entering Mauritius, with entrance conditioned on the presentation of a negative PCR test 7 days before travel to Mauritius and three tests during the quarantine on day 1, day 7 and day 14. All positive cases are treated in dedicated treatment centres until they get two consecutive negative tests at an interval of 24–48 hours. Mauritius is now elaborating the COVID-19 National Deployment and Vaccination Plan with a goal of re-opening borders. Conclusion On 19 January 2021, the High-Level Committee chaired by the Prime Minister met for the 101st time. It took note that while the number of cumulative cases compare with other African countries, the situation changed drastically because Mauritius, which was one of the most heavily hit African countries in April 2020, was the lowest affected country in the African region in January 2021.11 Like many other countries, Mauritius faced an unprecedented situation because it had never experienced a pandemic of that scale and responded promptly by actions initially taken on an ad hoc basis. However, the government learnt throughout the national response and improved its management of the pandemic accordingly. Overall, it is estimated that measures implemented to prevent widespread community transmission of COVID-19 may have saved the country 837 human lives worth international US$258 080 991. This evidence, conjointly with human rights arguments, calls for increased investments to bridge the existing gaps for achieving universal health coverage by 2030.14 We have identified governance and leadership, and communication, coupled with proactive contact tracing and test-and-treat measures as key factors contributing to the success of Mauritius. Other authors have also pinpointed the rapid response by the Mauritian Government, and appropriate and strong support and compliance from the public as key factors towards the control of the pandemic.5 A retrospective study using inferential statistical methods identified a number of factors that have contributed significantly in controlling the propagation of the novel coronavirus in Mauritius; in particular, the sanitary curfew/lockdown, sanitisation and sensitisation campaigns, and safe shopping guidelines have helped to curb down, by a large extent, the number of COVID-19 cases. Hence, such preventive and proactive measures, with the main focus on sanitisation measures at grocery stores and in busy public places, should be maintained even after lifting lockdown orders. Quarantine centres for all incoming passengers have also significantly helped in timely containment of the novel coronavirus, eliminating to a great extent the risk of spreading in the local community.6 The Mauritian success story can be inspiring for other countries. However, it should be noted that contextual factors have also facilitated the implementation and success of these measures. The fact that Mauritius is an island, with a limited number of entry points, has obviously facilitated the identification of arriving persons and the follow-up of their quarantine. The fact that Mauritius is a close-knit society has also perhaps facilitated social control and adherence to governmental measures. Therefore, not all countries can expect similar results by copy-pasting the Mauritian response strategy—and most countries should probably adopt a comprehensive policy acting on complementary social, economic, physical and environmental factors to improve the health stock of the population and to curb the COVID-19 mortality.7 Nevertheless, Mauritius illustrates well the importance of adapting measures to evolving knowledge and developing a clear, transparent and consistent communication policy so as to buy the adherence of the population.