A descriptive study of COVID-19 cases in primary and secondary schools in the Maltese islands: a nationwide experience.

BACKGROUND: As part of the measures to contain the initial cases of Coronavirus Disease (COVID-19) in 2020, all educational facilities were closed in March 2020 and remained so for the remainder of that scholastic year. When they reopened in October 2020, most educational facilities on the Maltese islands did so with various mitigation measures in place. METHODS: A Schools Contact Tracing Team (SCTT) dedicated to the management of COVID-19 cases within schools was set up and networks established between the Ministries responsible for Health and Education to facilitate timely communication and, consequently, effective contact tracing. All cases pertaining to educational facilities, be they students, teaching or non-teaching staff were assessed and managed by this Team. RESULTS: Between October 2020 and June 2021, the SCTT assessed 2603 COVID-19 cases within educational facilities in Malta. The highest rate of cases overall was observed in teaching staff (56.53/1000). In 72.45% of cases, no contacts were identified as high risk and thus nobody was placed in quarantine. In 3.07% of school cases >21 high-risk contacts were placed in mandatory quarantine together with their household members. Only 11% of the cases were epi-linked to another positive case within school. CONCLUSIONS: The strong collaboration between the health and education authorities combined with strict measures observed in schools ensured that schools remained open throughout most of this pandemic. This study describes the processes by which contact tracing for COVID-19 cases in Maltese schools was carried out and analyses the data collected throughout the scholastic year 2020-21.

Age-specific associations between underlying health conditions and hospitalisation, death and in-hospital death among confirmed COVID-19 cases: a multi-country study based on surveillance data, June to December 2020.

BackgroundUnderlying conditions are risk factors for severe COVID-19 outcomes but evidence is limited about how risks differ with age.AimWe sought to estimate age-specific associations between underlying conditions and hospitalisation, death and in-hospital death among COVID-19 cases.MethodsWe analysed case-based COVID-19 data submitted to The European Surveillance System between 2 June and 13 December 2020 by nine European countries. Eleven underlying conditions among cases with only one condition and the number of underlying conditions among multimorbid cases were used as exposures. Adjusted odds ratios (aOR) were estimated using 39 different age-adjusted and age-interaction multivariable logistic regression models, with marginal means from the latter used to estimate probabilities of severe outcome for each condition-age group combination.ResultsCancer, cardiac disorder, diabetes, immunodeficiency, kidney, liver and lung disease, neurological disorders and obesity were associated with elevated risk (aOR: 1.5-5.6) of hospitalisation and death, after controlling for age, sex, reporting period and country. As age increased, age-specific aOR were lower and predicted probabilities higher. However, for some conditions, predicted probabilities were at least as high in younger individuals with the condition as in older cases without it. In multimorbid patients, the aOR for severe disease increased with number of conditions for all outcomes and in all age groups.ConclusionWhile supporting age-based vaccine roll-out, our findings could inform a more nuanced, age- and condition-specific approach to vaccine prioritisation. This is relevant as countries consider vaccination of younger people, boosters and dosing intervals in response to vaccine escape variants.

Mass Events Trigger Malta's Second Peak After Initial Successful Pandemic Suppression.

The second COVID-19 wave is sweeping the globe as restrictions are lifted. Malta, the 'poster child of Europe's COVID-19 first wave success' also fell victim shortly after it welcomed the first tourists on 1st of July 2020. Only four positive cases were reported over the successive 15 days. Stability was disrupted when two major mass events were organized despite various health professional warnings. In a matter of few just days, daily cases rose to two-digit figures, with high community transmission, a drastic rise in active cases, and a rate per hundred thousand in Europe second only to Spain. Frontliners were swamped with swabbing requests while trying to sustain robust case management, contact tracing and follow-up. Indeed, the number of hospitalizations and the need for intensive ventilation increased. Despite the initial cases were among young adults, within weeks a small spill off on the more elderly population was observed. Restrictions were re-introduced including mandatory mask wearing in specific locations and capping of the total number of people in a single gathering. Malta is an island and the potential for containment would have been relatively simple and effective and permitting mass gatherings was unwise. Protecting the health of the population should take centre stage while carrying out extensive testing, contact tracing and surveillance. Containment and mitigation along with public cooperation is the key to curbing resurgences especially with the influenza season around the corner.

Initial assessment of the COVID-19 vaccination's impact on case numbers, hospitalisations and deaths in people aged 80 years and older, 15 EU/EEA countries, December 2020 to May 2021.

Prioritisation of elderly people in COVID-19 vaccination campaigns aimed at reducing severe outcomes in this group. Using EU/EEA surveillance and vaccination uptake, we estimated the risk ratio of case, hospitalisation and death notifications in people 80 years and older compared with 25-59-year-olds. Highest impact was observed for full vaccination uptake 80% or higher with reductions in notification rates of cases up to 65% (IRR: 0.35; 95% CI: 0.13-0.99), hospitalisations up to 78% (IRR: 0.22; 95% CI: 0.13-0.37) and deaths up to 84% (IRR: 0.16; 95% CI: 0.13-0.20).

The epidemiology of invasive meningococcal disease and the utility of vaccination in Malta.

Invasive meningococcal disease (IMD) is a vaccine-preventable devastating infection that mainly affects infants, children and adolescents. We describe the population epidemiology of IMD in Malta in order to assess the potential utility of a meningococcal vaccination programme. All cases of microbiologically confirmed IMD in the Maltese population from 2000 to 2017 were analysed to quantify the overall and capsular-specific disease burden. Mean overall crude and age-specific meningococcal incidence rates were calculated to identify the target age groups that would benefit from vaccination. Over the 18-year study period, 111 out of the 245 eligible notified cases were confirmed microbiologically of which 70.3% had septicaemia, 21.6% had meningitis, and 6.3% had both. The mean overall crude incidence rate was 1.49/100,000 population with an overall case fatality rate of 12.6%. Meningococcal capsular groups (Men) B followed by C were the most prevalent with W and Y appearing over the last 6 years. Infants had the highest meningococcal incidence rate of 18.9/100,000 followed by 6.1/100,000 in 1-5 year olds and 3.6/100,000 in 11-15 year old adolescents. The introduction of MenACWY and MenB vaccines on the national immunization schedule in Malta would be expected to reduce the disease burden of meningococcal disease in children and adolescents in Malta.

Cost-effectiveness of public health interventions against human influenza pandemics in France: a methodological contribution from the FLURESP European Commission project.

BACKGROUND: The FLURESP project is a public health project funded by the European Commission with the objective to design a methodological approach in order to compare the cost-effectiveness of existing public health measures against human influenza pandemics in four target countries: France, Italy, Poland and Romania. This article presents the results relevant to the French health system using a data set specifically collected for this purpose. METHODS: Eighteen public health interventions against human influenza pandemics were selected. Additionally, two public-health criteria were considered: 'achieving mortality reduction ≥40%' and 'achieving morbidity reduction ≥30%'. Costs and effectiveness data sources include existing reports, publications and expert opinions. Cost distributions were taken into account using a uniform distribution, according to the French health system. RESULTS: Using reduction of mortality as an effectiveness criterion, the most cost-effective options was 'implementation of new equipment of Extracorporeal membrane oxygenation (ECMO) equipment'. Targeting vaccination to health professionals appeared more cost-effective than vaccination programs targeting at risk populations. Concerning antiviral distribution programs, curative programs appeared more cost-effective than preventive programs. Using reduction of morbidity as effectiveness criterion, the most cost-effective option was 'implementation of new equipment ECMO'. Vaccination programs targeting the general population appeared more cost-effective than both vaccination programs of health professionals or at-risk populations. Curative antiviral programs appeared more cost-effective than preventive distribution programs, whatever the pandemic scenario. CONCLUSION: Intervention strategies against human influenza pandemics impose a substantial economic burden, suggesting a need to develop public-health cost-effectiveness assessments across countries.

Television food advertising to children in Malta.

To undertake a cross-sectional survey of the extent and nature of food and beverage advertising to children on Maltese national television stations. Seven national free-to-air channels were recorded for seven consecutive days in March 2014 between 07:00 and 22:00 h. Advertisements were coded according to predefined categories, with a focus on advertisements aired during 'peak' children's viewing times, defined as periods during which more than 25% of children were likely to be watching television on any channel. Food and beverage advertisements were classified as core (healthy), non-core (unhealthy) or miscellaneous foods. Malta. Whole population, with a focus on children. Food and drinks were the most heavily advertised product category (26.9% of all advertisements) across all channels. The proportion of non-core food/drink advertisements was significantly greater during peak compared with non-peak children's viewing times (52 vs 44.6%; p ≤ 0.001). A majority of advertisements aimed at children are for non-core foods, and are typically shown during family-oriented programmes in the late evening rather than being restricted to children's programmes. 'Taste', 'enjoyment' and 'peer status' were the primary persuasive appeals used in adolescent and child-focused advertisements. This first content analysis of television advertising in Malta suggests that there is scope for the implementation of statutory regulation regarding advertising of foods high in fat, sugar and salt (HFSS) during times when children are likely to watch television, rather than during children's programmes only. Ongoing, systematic monitoring is essential for evaluation of the effectiveness of regulations designed to reduce children's exposure to HFSS food advertising on television.

Addressing childhood obesity through policy: A cross-sectional study in Malta.

Introduction: Childhood overweight and obesity are major public health challenges, with Malta having one of the highest prevalences among European countries. The COVID-19 pandemic may further worsen this epidemic. The food and physical activity environments impact children's behaviours. This study looks at barriers to maintain a healthy weight, responsibility to address obesity, and assesses parental support for 22 policies aimed at addressing childhood obesity. Public support for policy is key because it influences which policies are adopted and their success. Methods: A cross-sectional, paper-based, quantitative survey was conducted amongst parents of primary school-aged children in Malta in 2018-2019. Ethical approval was obtained. Statistical analysis was performed using SPSS. Results: 1,169 parents participated. The food environment was more commonly identified as a barrier to maintain a healthy weight than the physical activity environment. Parents were least supportive of taxation policies, and most in favour of increasing spaces available for safe physical activity (94.0%), followed by providing free weight management services for children (90.8%). The level of support varied significantly by various socio-demographic/economic characteristics; parents with a higher educational level were significantly more supportive of most policies. Most findings were consistent with the international literature. Conclusions: Most policies supported are trans-sectoral; a health-in-all policies approach is needed to address the obesogenic environment. The strong public support identified for several policies should embolden policymakers to consider policy options that were not previously considered.

Hybrid immunity and protection against infection during the Omicron wave in Malta.

By December 2021, administration of the third dose of COVID-19 vaccinations coincided with the spread of the Omicron variant in Europe. Questions had been raised on protection against infection conferred by previous vaccination and/or infection. Our study population included 252,433 participants from the COVID-19 vaccination registry in Malta. Data were then matched with the national testing database. We collected vaccination status, vaccine brand, vaccination date, infection history, and age. Using logistic regression, we examined different combinations of vaccine dose, prior infection status and time, and the odds of infection during the period when the Omicron variant was the dominant variant in Malta. Participants infected with Sars-Cov-2 prior to the Omicron wave had a significantly lower odds of being infected with the Omicron variant. Additionally, the more recent the infection and the more recent the vaccination, the lower the odds of infection. Receiving a third dose within 20 weeks of the start of the Omicron wave in Malta offered similar odds of infection as receiving a second dose within the same period. Time since vaccination was a strong determinant against infection, as was previous infection status and the number of doses taken. This finding reinforces the importance of future booster dose provision especially to vulnerable populations.

Case-control studies of sporadic enteric infections: a review and discussion of studies conducted internationally from 1990 to 2009.

Epidemiologists have used case-control studies to investigate enteric disease outbreaks for many decades. Increasingly, case-control studies are also used to investigate risk factors for sporadic (not outbreak-associated) disease. While the same basic approach is used, there are important differences between outbreak and sporadic disease settings that need to be considered in the design and implementation of the case-control study for sporadic disease. Through the International Collaboration on Enteric Disease "Burden of Illness" Studies (the International Collaboration), we reviewed 79 case-control studies of sporadic enteric infections caused by nine pathogens that were conducted in 22 countries and published from 1990 through to 2009. We highlight important methodological and study design issues (including case definition, control selection, and exposure assessment) and discuss how approaches to the study of sporadic enteric disease have changed over the last 20 years (e.g., making use of more sensitive case definitions, databases of controls, and computer-assisted interviewing). As our understanding of sporadic enteric infections grows, methods and topics for case-control studies are expected to continue to evolve; for example, advances in understanding of the role of immunity can be used to improve control selection, the apparent protective effects of certain foods can be further explored, and case-control studies can be used to provide population-based measures of the burden of disease.

Digitalizing and Upgrading Severe Acute Respiratory Infections Surveillance in Malta: System Development.

BACKGROUND: In late 2020, the European Centre for Disease Prevention and Control and Epiconcept started implementing a surveillance system for severe acute respiratory infections (SARI) across Europe. OBJECTIVE: We sought to describe the process of digitizing and upgrading SARI surveillance in Malta, an island country with a centralized health system, during the COVID-19 pandemic from February to November 2021. We described the characteristics of people included in the surveillance system and compared different SARI case definitions, including their advantages and disadvantages. This study also discusses the process, output, and future for SARI and other public health surveillance opportunities. METHODS: Malta has one main public hospital where, on admission, patient data are entered into electronic records as free text. Symptoms and comorbidities are manually extracted from these records, whereas other data are collected from registers. Collected data are formatted to produce weekly and monthly reports to inform public health actions. From October 2020 to February 2021, we established an analogue incidence-based system for SARI surveillance. From February 2021 onward, we mapped key stakeholders and digitized most surveillance processes. RESULTS: By November 30, 2021, 903 SARI cases were reported, with 380 (42.1%) positive for SARS-CoV-2. Of all SARI hospitalizations, 69 (7.6%) were admitted to the intensive care unit, 769 (85.2%) were discharged, 27 (3%) are still being treated, and 107 (11.8%) died. Among the 107 patients who died, 96 (89.7%) had more than one underlying condition, the most common of which were hypertension (n=57, 53.3%) and chronic heart disease (n=49, 45.8%). CONCLUSIONS: The implementation of enhanced SARI surveillance in Malta was completed by the end of May 2021, allowing the monitoring of SARI incidence and patient characteristics. A future shift to register-based surveillance should improve SARI detection through automated processes.

Emerging electronic cigarette policies in European member states, Canada, and the United States.

BACKGROUND: Increased electronic cigarette (ECIG) use has motivated new regulations to address the changing landscape of tobacco use and promote public health. METHOD: This policy scan compares ECIG prevalence and regulations in the European Union (EU), Canada, and the United States (US) at the federal- and local-level to foster a policy dialogue around modern tobacco prevention and control regulations. RESULTS: Among young adults, 40 % in the US, 29 % in Canada, and 28 % in the EU report ever using an ECIG. Results from the policy scan find significant variation in approach to regulating ECIGs. EU member states are subject to the most stringent requirements regarding nicotine concentration regulations, and several member states have also opted to ban flavors and/or require plain packaging or out of sight retail sales. Among EU and US states, taxation is a popular strategy, though taxing strategies vary widely. Regarding youth use, US states have led the way for increasing the legal age of sale to 21 at the federal level, and in Canada recent federal regulations are innovative in their approach to banning advertising that may appeal to youth. CONCLUSION: Strategies to achieve public health goals related to ECIGs vary widely, with federalism playing an important role in policy innovation, offering opportunities to evaluate their effectiveness and inform future regulations.

WITHDRAWN: Vaccine hesitancy in the University of Malta Faculties of Health Sciences, Dentistry and Medicine vis-à-vis influenza and novel COVID-19 vaccination.

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Withdrawn: Vaccine hesitancy among Maltese Healthcare workers toward influenza and novel COVID-19 vaccination.

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WITHDRAWN: COVID-19: The possible seasonal shape of things to come.

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WITHDRAWN: Malta tourism losses due to second wave of COVID-19.

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WITHDRAWN: One of COVID-19's many costs: Malta's expenditure in consumables and non-consumables, a population-based study.

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WITHDRAWN: Needed: less influenza vaccine hesitancy and less presenteeism among health care workers in the COVID-19 era.

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Are children attending child play areas at risk of infectious diseases? What can be done?

AIMS: Child play areas can pose a risk to children of infectious diseases. The prolonged presence of micro-organisms in the environment has already been established. In order to quantify this risk, specific studies are required when carrying out a risk assessment. METHODS: In order to assess the microbiological hazard in play areas in Malta, a study was performed during 2005, which consisted of an examination of the hygienic practices carried out in play areas by means of face-to-face interviews; inspections of the premises; environmental sampling and testing, and a study on the awareness and attitudes of parents to risk factors (face-to-face interviews). Follow up studies were performed after recommendations on risk management were provided. RESULTS: Overall, the hygienic practices in play areas were satisfactory. Of the premises 66% were licensed, 55% of the food handlers were registered, appropriate cooking and cooling facilities were available for most of the premises, temperature control records were available at 80% of premises, 60% were using disinfectant for cleaning play area surfaces and monitoring of refrigerated vehicles was carried out by 60%. There was an overall improvement after recommendations were given. At the first inspection, 67% of the premises were categorized as being fair and 33% as being good. On repeat inspection, after recommendations were made, the grading of the premises were: excellent 7%, satisfactory 33%, good 53% and fair 7%. The results of the environmental swabs taken had low counts of indicator organisms indicating a good overall hygienic condition. Parents stated that 58% of the areas were in good hygienic condition but lacked adequate hand-washing facilities for children. All parents agreed with the importance of hand hygiene and that infectious diseases can be transmitted via contaminated objects and from one person to another. CONCLUSION: An effective control strategy needs to be implemented involving all stakeholders to ensure that effective hygienic practices in play areas are available to protect children from infectious diseases.