Does sex modify the effect of pre-pandemic body mass index on the risk of Long COVID? Evidence from the longitudinal analysis of the Survey of Health, Ageing and Retirement in Europe.

BACKGROUND: Research on Long COVID risk factors is ongoing. High body mass index (BMI) may increase Long COVID risk, yet no evidence has been established regarding sex differences in the relationship between BMI and the risk of Long COVID. Investigating the nature of this relationship was the main objective of this study. METHODS: A population-based prospective study involving a sample of respondents aged 50 years and older (n = 4004) from 27 European countries that participated in the 2020 and 2021 Survey of Health, Ageing and Retirement in Europe's (SHARE) Corona Surveys and in Waves 7 and 8 of the main SHARE survey. Logistic regression models were estimated to produce unadjusted and adjusted estimates of the sex differences in the relationship between BMI and Long COVID. RESULTS: Linear relationship for females, with probability of Long COVID increasing with BMI (68% at BMI = 18, 93% at BMI = 45). Non-linear relationship for males, with probability of Long COVID of 27% at BMI = 18, 68% at BMI = 33, and 40% at BMI = 45. Relationships remained significant after adjusting for known Long COVID risk factors (age and COVID-19 hospitalization), presence of chronic diseases, and respondents' place of residence. CONCLUSION: Sex differences appear to play an important role in the relationship between BMI and risk of Long COVID. Overall, females were more likely to have Long COVID, regardless of their BMI. Males at the higher end of the BMI spectrum had a lower risk of Long COVID as opposed to their female counterparts. Sex-specific research is recommended for better understanding of Long COVID risk factors.

The state of health in the European Union (EU-27) in 2019: a systematic analysis for the Global Burden of Disease study 2019.

BACKGROUND: The European Union (EU) faces many health-related challenges. Burden of diseases information and the resulting trends over time are essential for health planning. This paper reports estimates of disease burden in the EU and individual 27 EU countries in 2019, and compares them with those in 2010. METHODS: We used the Global Burden of Disease 2019 study estimates and 95% uncertainty intervals for the whole EU and each country to evaluate age-standardised death, years of life lost (YLLs), years lived with disability (YLDs) and disability-adjusted life years (DALYs) rates for Level 2 causes, as well as life expectancy and healthy life expectancy (HALE). RESULTS: In 2019, the age-standardised death and DALY rates in the EU were 465.8 deaths and 20,251.0 DALYs per 100,000 inhabitants, respectively. Between 2010 and 2019, there were significant decreases in age-standardised death and YLL rates across EU countries. However, YLD rates remained mainly unchanged. The largest decreases in age-standardised DALY rates were observed for "HIV/AIDS and sexually transmitted diseases" and "transport injuries" (each -19%). "Diabetes and kidney diseases" showed a significant increase for age-standardised DALY rates across the EU (3.5%). In addition, "mental disorders" showed an increasing age-standardised YLL rate (14.5%). CONCLUSIONS: There was a clear trend towards improvement in the overall health status of the EU but with differences between countries. EU health policymakers need to address the burden of diseases, paying specific attention to causes such as mental disorders. There are many opportunities for mutual learning among otherwise similar countries with different patterns of disease.

Burden of infectious disease studies in Europe and the United Kingdom: a review of methodological design choices.

This systematic literature review aimed to provide an overview of the characteristics and methods used in studies applying the disability-adjusted life years (DALY) concept for infectious diseases within European Union (EU)/European Economic Area (EEA)/European Free Trade Association (EFTA) countries and the United Kingdom. Electronic databases and grey literature were searched for articles reporting the assessment of DALY and its components. We considered studies in which researchers performed DALY calculations using primary epidemiological data input sources. We screened 3053 studies of which 2948 were excluded and 105 studies met our inclusion criteria. Of these studies, 22 were multi-country and 83 were single-country studies, of which 46 were from the Netherlands. Food- and water-borne diseases were the most frequently studied infectious diseases. Between 2015 and 2022, the number of burden of infectious disease studies was 1.6 times higher compared to that published between 2000 and 2014. Almost all studies (97%) estimated DALYs based on the incidence- and pathogen-based approach and without social weighting functions; however, there was less methodological consensus with regards to the disability weights and life tables that were applied. The number of burden of infectious disease studies undertaken across Europe has increased over time. Development and use of guidelines will promote performing burden of infectious disease studies and facilitate comparability of the results.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study.

BACKGROUND: Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest. METHODS: DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries. RESULTS: Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low. CONCLUSIONS: The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Evaluating the knowledge acquisition of lower limb anatomy among medical students during the post-acute COVID-19 era.

Anatomy is the foundation of many medical and surgical specialties yet knowledge acquisition and retention among medical students is questionable. Over the years the anatomy teaching environment and teaching modalities have changed, even more so with the onset of the COVID-19 pandemic and the shift to a virtual environment. The aim of this study was to evaluate the knowledge acquisition of applied musculoskeletal lower limb clinical anatomy among first year medical students in Malta following the transition back to face-to-face lectures. The Kahoot online game-based quiz platform was used through a best out of four multiple-choice setting across four sessions. Scores generated by the platform along with frequencies of correctly answered questions were utilized to measure knowledge acquisition. The average scores for each question across sessions were statistically analyzed using ANOVA and student's t-test accordingly. Across the four sessions, the positive percentage response for clinical based questions remained higher than for pure anatomy questions. Anatomy knowledge acquisition appears to be subjective to clinical based knowledge rather than pure anatomy. There may be a plethora of reasons as to this outcome including the misconception that anatomy is not essential for clinical practice as well as the potential aftermath of the COVID-induced virtual learning environment. Further research is merit to ensure that students are provided with the best tools to enhance their knowledge acquisition, both as students and as future doctors.

The impact of the COVID-19 pandemic on Mediterranean diet adherence: A narrative systematic review.

BACKGROUND: The COVID-19 pandemic upended many aspects of daily life. For some individuals, this was an opportunity to re-evaluate their life and make better choices, while others were overwhelmed with stressors, leading to a deterioration in mental and physical health. AIM: The aim of this narrative systematic review is to explore the effects of the COVID-19 pandemic on Mediterranean diet adherence. METHODS: A systematic literature search was carried out on PubMed, Scopus and Web of Science electronic databases utilising the search terms 'Mediterranean diet' AND 'COVID-19'. This yielded 73 articles that fulfilled the inclusion criteria. RESULTS: The data suggests that a substantial proportion of individuals adhered less to the Mediterranean diet during the COVID-19 lockdown period. However, individuals receiving some form of lifestyle intervention had better adherence to the Mediterranean diet than their unassisted counterparts. CONCLUSION: This emphasises the importance of professional support during times of crisis to avoid deterioration of a population's health.

COVID-19 vaccinations: The unknowns, challenges, and hopes.

The entire world has been suffering from the coronavirus disease 2019 (COVID-19) pandemic since March 11, 2020. More than a year later, the COVID-19 vaccination brought hope to control this viral pandemic. Here, we review the unknowns of the COVID-19 vaccination, such as its longevity, asymptomatic spread, long-term side effects, and its efficacy on immunocompromised patients. In addition, we discuss challenges associated with the COVID-19 vaccination, such as the global access and distribution of vaccine doses, adherence to hygiene guidelines after vaccination, the emergence of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, and vaccine resistance. Despite all these challenges and the fact that the end of the COVID-19 pandemic is still unclear, vaccines have brought great hope for the world, with several reports indicating a significant decline in the risk of COVID19-related infection and hospitalizations.

An observational study of the Covid-19 situation following the first pan-European mass sports event.

BACKGROUND: All events in Europe, including EURO2020 football championship, were postponed due to Covid-19 in 2020. Instead, Euro2020 took place in 2021, as mitigation measures were relaxed, cross-country mobility increased and the Delta variant was spreading across Europe. This study explored the possibility of an increased Covid-19 spread across Europe following EURO2020 matches. METHODS: Covid-19 data on cases, vaccination and delta variant for participating countries, host cities/regions and neighbouring countries, for May till July 2021, were obtained from European Centre for Disease Prevention and Control, Our World in Data, Johns Hopkins COVID-19 Dashboard and the UK Government website. EURO2020 data were obtained from the Union of European Football Associations official website. RESULTS: A general increase in Covid-19 positivity trend in Europe was observed following a week of EURO2020 matches across most countries and host cities. A similar trend was observed for the Delta variant sample positivity rate. The increased incidence was mostly among the young generation (<49 years). A decline in positive cases was observed on a national level for most countries following the Finals match. CONCLUSION: The EURO2020 was an anticipated mass sports event, and it was the first-time spectators were allowed to enter stadiums in Europe. Stadiums instituted several mitigations to safeguard the spectators although reports of transmission were still present. The major challenges were the gatherings outside the stadiums that might have contributed to these observations. Targeted restrictions might be required during mass sport events especially in the presence of highly transmissible variant(s) and low vaccination rates among the young generation.

Methodological considerations in injury burden of disease studies across Europe: a systematic literature review.

BACKGROUND: Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies. METHODS: We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021. RESULTS: We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables. CONCLUSIONS: Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability of injury BoD estimates across Europe and beyond.

A year of Covid-19: experiences and lessons learnt by small European island states-Cyprus, Iceland and Malta.

BACKGROUND: COVID-19 became a global pandemic within weeks, as every country including small states and islands experienced a surge in cases. Small islands are known to face several challenges in the quest to curb the viral spread, but with the absence of land boarders and small population size, these factors should have played to their advantage to minimize the spread. The aim of this article was to compare and contrast the COVID-19 situation, restrictions, preparedness, management and the healthcare systems between the small population island states of Cyprus, Iceland and Malta. METHODS: Data were obtained from Ministry of Health websites and COVID dashboards of the three respective Island states in Europe. Comparisons were made between the reported cases, deaths, excess deaths, years of life lost, swabbing rates, restrictive measures, vaccination roll-out and healthcare system structures. RESULTS: Cyprus and Malta contained the COVID-19 spread better than Iceland during the first wave. However, a significantly higher viral spread and mortality rates were observed in Malta during the second waves. Similar healthcare preparedness and services, restrictions and relaxation measures were implemented across the three islands with some exceptions. Covid-19 vaccination has initiated across all Islands with Malta leading the vaccination roll-out. CONCLUSION: The small population size and island status proved to be an asset during the first wave of COVID-19, but different governance approaches led to a different COVID-19 outcomes, including high mortality rates during the transition phases and the subsequent waves.

Conducting national burden of disease studies and knowledge translation in eight small European states: challenges and opportunities.

BACKGROUND: Several countries across Europe are engaging in burden of disease (BoD) studies. This article aims to understand the experiences of eight small European states in relation to their research opportunities and challenges in conducting national BoD studies and in knowledge translation of research outputs to policy-making. METHODS: Countries participating in the study were those outlined by the WHO/Europe Small Countries Initiative and members of the Cooperation in Science and Technology (COST) Action CA18218 European Burden of Disease Network. A set of key questions targeting the research landscape were distributed to these members. WHO's framework approach for research development capacities was applied to gain a comprehensive understanding of shortages in relation to national BoD studies in order to help strengthen health research capacities in the small states of Europe. RESULTS: Most small states lack the resources and expertise to conduct BoD studies, but nationally representative data are relatively accessible. Public health officials and researchers tend to have a close-knit relationship with the governing body and policy-makers. The major challenge faced by small states is in knowledge generation and transfer rather than knowledge translation. Nevertheless, some policy-makers fail to make adequate use of knowledge translation. CONCLUSIONS: Small states, if equipped with adequate resources, may have the capacity to conduct national BoD studies. This work can serve as a model for identifying current gaps and opportunities in each of the eight small European countries, as well as a guide for translating country BoD study results into health policy.

Sella turcica bridging: a systematic review.

PURPOSE: Sella turcica bridging (STB) has significant implications during neurosurgery, since it alters regional anatomy; however, no studies have investigated the global prevalence of STB. Our systematic review aimed to establish the global prevalence of STB, in specimens/individuals with and without comorbidities, in males and females, and of partial, complete, unilateral, and bilateral bridging. METHODS: A literature search was conducted in MEDLINE/PubMed, ScienceDirect, and Google Scholar with various key words relating to Sella turcica bridging. Quantitative data were extracted and statistically analysed. RESULTS: Eighty-two studies satisfied our inclusion criteria. The mean prevalence of STB was 26.54%, and most prevalent in Europe. STB was detected more frequently using radiological investigations. STB was less prevalent in healthy individuals (21.12%) when compared to individuals with comorbidities (33.31%). Partial STB was found to be the more prevalent in both individuals with (41.06%) and without (21.55%) comorbidities. The prevalence of unilateral and bilateral STB was only studied in healthy individuals, with unilateral bridging being the more prevalent (6.26% vs 3.84%). CONCLUSION: The global overall prevalence of Sella turcica bridging in the general population was found to be higher than previously thought. Anatomical and embryological textbooks should consider including information on STB in their texts, due to its considerable prevalence and effects to the regional anatomy.

COVID-19 and vaccination induced changes in hospital activity in Malta, Q1 2020 to Q1 2021: a population-based study.

BACKGROUND: COVID-19 has severely impacted global healthcare services. Malta has only one acute state hospital, Mater Dei Hospital (MDH), and at the time of writing is the most vaccinated country in Europe. Malta thus provides an ideal setting to assess the impact of COVID-19 on healthcare services at population level, including the impact of vaccination on hospital admissions. METHODS: Hospital data was obtained as anonymised totals from MDH's Clinical Performance Unit and the European Centre for Disease Prevention and Control. COVID-19-related data was obtained from the Ministry of Health dashboard. Comparative assessments were performed to explore associations between the COVID-19 situation, vaccination, and hospital activity. Poisson regression was used to model the counts of monthly accident and emergency (A&E), outpatient clinics attendances and hospital admissions. RESULTS: A&E, hospital admissions, and outpatient clinics attendances declined (31.88%; 23.89%; 29.57%; p < 0.01 respectively) with onset of COVID-19 till April 2021 when compared to pre-COVID years (2017-2019). Admissions due to COVID-19 initially increased in parallel to the population's COVID positivity. Vaccination rollout led to a decline in COVID-19 admissions. CONCLUSIONS: The drastic drop in admissions and outpatient attendees was expected but not for A&E attendees as acutely ill patients should still have attended. This is of public health concern since delayed or deferred medical management increases population morbidity, mortality and increases the eventual burden on the healthcare system. Mass vaccination saw the return to normality with an increase in A&E burden.

Adverse reactions to Pfizer-BioNTech vaccination of healthcare workers at Malta's state hospital.

BACKGROUND: The long-term control of COVID-19 depends on an effective global vaccination strategy. Protecting healthcare workers (HCWs) from serious infection is critical. Malta, a European country, initiated the vaccination roll-out using Pfizer-BioNTech COVID-19 vaccine targeting HCWs. This study determined vaccination adverse effects (AEs) in this cohort. METHOD: An online survey was disseminated to all HCWs via work email (29/3/21 to 9/4/21) to gather AEs regarding pain, redness and swelling at injection site, fever, chills, fatigue, muscle/joint pains, headache, vomiting and diarrhoea severity following each dose (Likert scale). Descriptive, comparative and multiple binary regression analyses were performed. RESULTS: A response of 30.30% (n = 1480) was achieved with the commonest AEs being pain at injection site (88.92% CI 95%: 87.21-90.42), mostly mild (51%) and moderate (43%). Fatigue was reported by 72.97% (CI 95%: 70.65-75.17), 42% were mild and 41% were moderate. Females reported significantly (P ≤ .05, respectively) more pain (OR: 1.90), redness (OR: 2.49), swelling at injection site (OR: 1.33), fever (OR: 1.74), chills (OR: 2.32), fatigue (OR: 2.43), muscle (OR: 1.54) and joint pains (OR: 2.01), headache (OR: 2.07) and vomiting (OR: 3.43) when adjusted for age and HCW role. Localised AEs were reported following both vaccine doses unlike systemic AEs that were mostly reported after second doses. CONCLUSION: Vaccination benefits outweigh the minor AEs experienced, with females exhibiting a higher susceptibility. The general low vaccination AEs observed within the HCW cohort is encouraging and should help in allaying vaccine hesitancy among the population.

Estimating the direct Covid-19 disability-adjusted life years impact on the Malta population for the first full year.

BACKGROUND: Disability-adjusted life years (DALYs) combine the impact of morbidity and mortality, allowing for comprehensive comparisons of the population. The aim was to estimate the DALYs due to Covid-19 in Malta (March 2020-21) and investigate its impact in relation to other causes of disease at a population level. METHODS: Mortality and weekly hospital admission data were used to calculate DALYs, based on the European Burden of Disease Network consensus Covid-19 model. Covid-19 infection duration of 14 days was considered. Sensitivity analyses for different morbidity scenarios, including post-acute consequences were presented. RESULTS: An estimated 70,421 people were infected (with and without symptoms) by Covid-19 in Malta (March 2020-1), out of which 1636 required hospitalisation and 331 deaths, contributing to 5478 DALYs. These DALYs positioned Covid-19 as the fourth leading cause of disease in Malta. Mortality contributed to 95% of DALYs, while post-acute consequences contributed to 60% of morbidity. CONCLUSIONS: Covid-19 over 1 year has impacted substantially the population health in Malta. Post-acute consequences are the leading morbidity factors that require urgent targeted action to ensure timely multidisciplinary care. It is recommended that DALY estimations in 2021 and beyond are calculated to assess the impact of vaccine roll-out and emergence of new variants.

Taking care of the ordinary in extraordinary times-delayed routine care means more morbidity and pre-mature mortality.

Individuals with chronic diseases are more susceptible to its grave complications and negative outcomes if infected by COVID-19. Furthermore, mandatory isolation and cancellations of routine healthcare services led to the disruption of the screening and management plans for chronic diseases. Fear of attending health services as well as disruptions to public transport are other factors increasing health risks among persons with chronic conditions during the pandemic. Ensuring access to universal healthcare services, increasing use of digital services, targeted interventions to risk groups are examples of measures that need to be taken when reviewing health systems preparedness for future pandemics and other disasters.

Malta's only acute public hospital service during COVID-19: a diary of events from the first wave to transition phase.

INTRODUCTION: COVID-19 has challenged healthcare systems worldwide. Some countries collapsed under surge conditions, while others (such as Malta) showed resilience. Public health measures in Malta quickly reined in COVID-19 spread. This review summarizes pandemic preparedness measures in Malta and the impact on routine services. METHODS: A literature search was conducted using Google, Google Scholar and PubMed and by reviewing Maltese online newspapers. A comprehensive summary of internal operations conducted at Mater Dei Hospital (MDH) was made available. RESULTS: A hospital 'Incident Command Group' was set up to plan an optimal COVID-19 response strategy. A 'rapid response team' was also created to cater for the logistics and management of supplies. A 'COVID-19 Emergency Operation Centre' simulated different COVID-19 scenarios. All elective services were suspended and all staff were mandatorily trained in wearing personal protective equipment. Staff were also retrained in the care of COVID-19 patients. In preparation for potential admission surges, MDH underwent rapid expansion of normal and intensive care beds. Swabbing was ramped up to one of the highest national rates worldwide. The cost for hospital COVID-19 preparedness exceeded €100 million for Malta's half a million population. CONCLUSION: Malta and its sole acute hospital coped well with the first wave with 680 cases and 9 deaths. The increased ability to deal with COVID-19 (a principally respiratory pathogen) will serve well for the anticipated combined annual influenza and the COVID-19 second wave this coming winter.

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.

Mapping the burden of diabetes in five small countries in Europe and setting the agenda for health policy and strategic action.

BACKGROUND: Diabetes is a global epidemic affecting every country. Small countries, however, face distinctive challenges related to their health system governance and their ability to implement effective health systems' reforms. The aim of this research was to perform a comparative assessment of existing diabetes management practices at the population level and explore governmental-related policy for Cyprus, Iceland, Luxembourg, Malta and Montenegro. This is the first time that such an evidence-based review study has been performed in the field of diabetes. The overall purpose was to set the agenda for health policy and inform strategic actions for small countries that can benefit from dealing with the diabetes epidemic at a country level. METHODS: We collected data and synthesized the evidence on dealing with diabetes for each of the five small European countries according to the (1) epidemiology of diabetes and other related metabolic abnormalities, (2) burden of diabetes status and (3) diabetes registers and national plans. We collected data by contacting Ministry representatives and other bodies in each state, and by searching through publicly available information from the respective Ministry of Health website on strategies and policies. RESULTS: Diabetes rates were highest in Cyprus and Malta. National diabetes registers are present in Cyprus and Montenegro, while national diabetes plans and diabetes-specific strategies have been established in Cyprus, Malta and Montenegro. These three countries also offer a free holistic healthcare service to their diabetes population. CONCLUSIONS: Multistakeholder, national diabetes plans and public health strategies are important means to provide direction on diabetes management and health service provision at the population level. However, political support is not always present, as seen for Iceland. The absence of evidence-based strategies, lack of funding for conducting regular health examination surveys, omission of monitoring practices and capacity scarcity are among the greatest challenges faced by small countries to effectively measure health outcomes. Nevertheless, we identified means of how these can be overcome. For example, the creation of public interdisciplinary repositories enables easily accessible data that can be used for health policy and strategic planning. Health policy-makers, funders and practitioners can consider the use of regular health examination surveys and other tools to effectively manage diabetes at the population level.

Protecting our vulnerable in the midst of the COVID-19 pandemic: lessons learnt from Malta.

OBJECTIVES: COVID-19 is a health burden threatening the elderly and those with comorbidities. Malta is an ageing and cardiometabolic country. The study depicts how Malta protected the elderly and the effect of vaccination on this subpopulation. STUDY DESIGN: Observational study with quantitative analyses. METHOD: Data were obtained from Malta's COVID dashboard, Institute for Health Metrics and Evaluation and Maltese newspapers. The case-fatality ratio (CFR) and Years of Life Lost (YLLs) for COVID were calculated. Comparisons were made between COVID-19 mortality and YLL to the pre-COVID leading mortality causes. Comparative observations were made between positive and mortality cases stratified by age groups in relation to the cumulative vaccination doses. RESULTS: The elderly were cocooned during the first wave (CFR 0.98) through the Vulnerable Act, with only 10.80% of positive cases and seven out nine deaths above 65 years. The Vulnerable Act was not reinstated again, with 13.68% of positive cases and 91.34% (n = 369) of deaths above 65 years during the second wave (CRF 1.39). The elderly were given priority in COVID-19 vaccination rollout leading to an inverse relationship between positive cases/mortality and vaccination coverage. CONCLUSION: The elderly should be protected with timely restrictions to reduce morbidity, mortality and burden on healthcare systems. Vaccination is key to protecting the elderly, although mitigation measures, such as physical distancing, are still required to prevent the resurgence of infections and hospitalizations, especially in this group.