Mortality comparisons of COVID-19 with all-cause and non-communicable diseases in Cyprus, Iceland and Malta: lessons learned and forward planning.

OBJECTIVES: The COVID-19 pandemic has spread throughout the world, including Cyprus, Iceland and Malta. Considering the small population sizes of these three island countries, it was anticipated that COVID-19 would be adequately contained and mortality would be low. This study aims to compare and contrast COVID-19 mortality with mortality from all causes and common non-communicable diseases (NCDs) over 8 months between these three islands. METHODS: Data were obtained from the Ministry of Health websites and COVID dashboards from Cyprus, Iceland and Malta. The case-to-fatality ratio (CFR) and years of life lost (YLLs) were calculated. Comparisons were made between the reported cases, deaths, CFR, YLLs, swabbing rates, restrictions and mitigation measures. RESULTS: Low COVID-19 case numbers and mortality rates were observed during the first wave and transition period in Cyprus, Iceland and Malta. The second wave saw a drastic increase in the number of confirmed cases and mortality rates, especially for Malta, with high CFR and YLLs. Similar restrictions and measures were evident across the three island countries. Results show that COVID-19 mortality was generally lower than mortality from NCDs. CONCLUSIONS: The study highlights that small geographical and population size, along with similar restrictive measures, did not appear to have an advantage against the spread and mortality rate of COVID-19, especially during the second wave. Population density, an ageing population and social behaviours may play a role in the burden of COVID-19. It is recommended that a country-specific syndemic approach is used to deal with the local COVID-19 spread based on the population's characteristics, behaviours and the presence of other pre-existing epidemics.

At-risk population for COVID-19: multimorbidity characteristics of a European small Island state.

OBJECTIVES: Multimorbidity, defined as the co-occurrence of at least two chronic diseases, is a common occurrence with ageing and a recognised public health concern, especially during the COVID-19 pandemic. The multimorbidity population is more susceptible to the virus, its complications, and death. The study aimed to explore the multimorbidity characteristics and their associations at a population level for the first time in Malta. Such data enables adequate priority and policy planning due to COVID-19's predilection for this population. STUDY AND METHODS: Baseline data was collected from 3,947 adults recruited between 2014-2016 through a cross-sectional study. A single-stage sampling strategy was implemented and stratified by age (18 -70 years), sex and locality. Participants were invited to attend a health examination survey consisting of a questionnaire, anthropometric and biological measurements. Descriptive (chi-square) and analytic (regression modelling) statistics were used to determine the characteristics and associations of the multimorbidity population. The chronic diseases considered for multimorbidity were type 2 diabetes, obesity, hypertension, myocardial infraction, coronary heart disease and dyslipidaemia. RESULTS: Multimorbidity was present in 33% (95% confidence interval 31.54-34.47) of the study population, with a male predominance. Hypertension and myocardial infarction were the commonest multimorbidity combination from a young age group (20-30 years). Low socio-economic status and residing on the island of Gozo were positively associated with multimorbidity. CONCLUSION: Multimorbidity in Malta was evident from a young age, with the highest occurrence among the low socio-economic status and residents of Gozo, bringing forward the need for preventive action. An adaptive healthcare system and policies are recommended to prevent, support, and manage multimorbidity non-communicable diseases while bracing for the current COVID-19 pandemic.

A population-based paediatric Covid-19 vaccination progress and outcomes: The Malta case.

Background: Covid-19 is still pandemic with population vaccination, including among children, remaining the mainstay for hastening the exit from the pandemic. The article provides an insight in Malta's national paediatric vaccination modus operandi, vaccination uptake, and epidemiological trends while exploring geographical social inequalities among the ≤ 15 years cohort up till end of August 2022. Methods: The Vaccination Coordination Unit in Malta's only regional hospital provided an account of the strategic roll-out along with anonymised cumulative vaccination doses by age band and district. Descriptive and multivariant logistic regression analyses were performed. Results: By mid-August 2022, 44.18% of the under 15's population had received at least 1 vaccine dose. A bi-directional relationship was observed between increased cumulative vaccination and reported Covid-19 cases until early 2022. Central vaccination hubs were set up with invitation letters and SMSs sent to parents. Children residing in the Southern Harbour district (OR: 0.42, P < 0.01) had the highest full vaccination uptake (46.66%) as opposed to the Gozo district (lowest at 27.23%; OR: 0.3, P = 0.01). Conclusion: Successful paediatric vaccination is not only dependent on easily accessible vaccination but also on vaccine effectiveness against variants, as well as population characteristics, with potential geographical social inequalities hindering uptake.

The characteristics of an obesogenic small European country: results from a Malta cross-sectional study.

AIM: Obesity is a chronic disease and a global epidemic. The pathophysiology is well-documented; however, different countries are faced with different obesity characteristics. The aim was to establish the adult obesity characteristics of the obesogenic European country of Malta and explore for obesity links. METHOD: A national representative health examination survey was conducted. A single-stage random stratified sample population (n = 4000) was obtained from a national register. Data on sociodemographic, comorbidities and lifestyle were collected. Body weight and height were measured, and blood collected for fasting glucose and lipid profile. Multiple binary logistic regression analyses through generalized linear models were performed to assess for associations between obesity, sociodemographic characteristics and dysglycaemic status. RESULTS: Out of the study population (n = 3947), 69.75% (confidence interval (CI) 95%: 68.32-71.18) were obese, with a male predominance (55%). The obese category sub-population resided mostly (25.80%, CI 95%: 23.53-28.21) within the highly densely populated district (Northern Harbour) of Malta and had a 'routine and manual' social position (55.76%, CI 95%: 53.10-58.40). On multiple logistic regression modelling, an obese status was linked with males (odds ratio (OR): 1.8, CI 95%: 1.53-2.12, p < .01), age (OR: 1.01, CI 95%: 1.01-1.02, p < .01), Northern Harbour district (OR: 1.11, CI 95%: 0.91-1.36, p < .02), type 2 diabetes (OR: 2.46, CI 95%: 1.79-3.38, p < .01) and impaired fasting blood glucose (IFG: 1.31, CI 95%: 1.17-1.90, p < .01) after adjusting for confounders. CONCLUSION: Obesity is a major health concern in Malta. Social determinants of health and metabolic changes appear to have a role in the obesity phenotype. Target actions that are gender-sensitive, social groups-focused and geographically oriented may be essential. The link between obesity and dysglycaemia brings forward the suggestion for incorporation of routine dysglycaemia screening during family doctors' consultations for patients with higher than normal body weight.

Diabetes, pre-diabetes and their risk factors in Malta: a study profile of national cross-sectional prevalence study.

BACKGROUND: Type 2 diabetes mellitus constitutes a global epidemic and a major burden on health care systems across the world. Prevention of this disease is essential, and the development of effective prevention strategies requires validated information on the disease burden and the risk factors. Embarking on a nationally representative cross-sectional study is challenging and costly. Few countries undertake this process regularly, if at all. METHOD: This paper sets out the evidence-based protocol of a recent cross-sectional study that was conducted in Malta. Data collection took place from November 2014 to January 2016. RESULTS: This study presents up-to-date national data on diabetes and its risk factors (such as obesity, smoking, physical activity and alcohol intake) that will soon be publicly available. CONCLUSION: This protocol was compiled so that the study can be replicated in other countries. The protocol contains step-by-step descriptions of the study design, including details on the population sampling, the permissions required and the validated measurement tools used.

Prevalence of obesity in Malta.

BACKGROUND: Obesity is a global epidemic with the Mediterranean island of Malta being no exception. The World Health Organization (WHO) has identified Malta as one of the European countries with the highest obesity prevalence. METHOD: A cross-sectional study was conducted (2014-2016) under the auspices of the University of Malta. The prevalence of overweight-obesity in Malta was calculated and then age stratified for comparisons with previous studies. RESULTS: The study identified 69.75% (95% CI: 68.32-71.18) of the Maltese population to be either overweight or obese. The men overweight/obese prevalence (76.28% 95% CI: 74.41-78.14) was statistically higher than that for women (63.06% 95% CI: 60.92-65.20) (p = 0.0001). Age stratification revealed that both genders had the highest overweight prevalence rates between 55 and 64 years (Men = 23.25% 95% CI: 20.43-26.33; Women = 24.68% 95% CI: 21.44-28.22). Men obesity prevalence rates were highest in the 35 to 44 years group (22.52% 95% CI: 19.65-25.68) while for women it was highest in the 55 to 64 years group (28.90%, 95% CI: 25.44-30.63). CONCLUSION: Over a 35-year period, an overall decrease in the normal and overweight BMI categories occurred with an increase in the prevalence of obesity. An exception was observed in the women, where the prevalence of normal BMI increased over this time period. Also, it appears that while the total population obesity prevalence increased (for 2016), a percentage of the women have shifted from an obese to an overweight status.

Laparoscopic pancreatic resections.

Current experience with laparoscopic pancreatic resections based on the reported literature and our own experience is reviewed and indications and preoperative work-up. The technical aspects of laparoscopic pancreatic resections are described with particular reference to 70% to 80% distal pancreatectomy with en block splenectomy. The experience with distal laparoscopic pancreatic resections has been entirely favorable, with benefit to the patient in terms of postoperative recovery, minimal morbidity, and short hospital stay. Case selection is important. These operations should only be attempted by surgeons who have experience in open pancreatic surgery and who have acquired the necessary advanced laparoscopic skills. A team of two experienced surgeons who are used to working together best conducts laparoscopic pancreatic resections. The use of strategic rest breaks with desufflation of the pneumoperitoneum halfway through the surgery is recommended to prevent fatigue and to protect the patient from prolonged periods of positive-pressure pneumoperitoneum. Laparoscopic segmental pancreatic resections with or without splenic preservation should be differentiated from laparoscopic enucleation of islet cell tumors. Both benefit from the use of laparoscopic contact ultrasonography. The most common postoperative complication after laparoscopic pancreatic resection and enucleation is pancreatic fistula. The incidence of this complication may be reduced by suture closure of the transected pancreatic duct and application of fibrin glue. By contrast, our limited experience with laparoscopic pancreatico-duodenectomy has been unfavorable. With the current technology, the laparoscopic approach for this procedure is too prolonged and does not seem to offer any benefit to the patient. Its use cannot be recommended.

Laparoscopic infracolic approach for complications of acute pancreatitis.

The laparoscopic infracolic approach has been used to treat eight patients with large pseudocysts. Early uncomplicated resolution was observed in seven and delayed resolution (at 3 months) in one. The median hospital stay was 6 days (range 5 to 15). The same approach was used to perform necrosectomy and postoperative lavage of the infected lesser sac in three patients with infected pancreatic necrosis. Two of these patients recovered without further treatment; however, the third patient required further open necrosectomy but survived after a prolonged illness complicated by pancreatic ascitis. The infracolic laparoscopic approach seems to be a useful technique for internal drainage of pancreatic pseudocysts. Its use for necrosectomy, drainage, and irrigation of the lesser sac merits further evaluation.