Early COVID-19 response in two small island developing states: Maldives and Trinidad and Tobago.

Problem: Coronavirus disease 2019 (COVID-19) was declared a pandemic on 11 March 2020. Severe illness requires intensive care facilities, which are limited in smaller, resource-constrained settings. Context: Maldives and Trinidad and Tobago are small island developing states with comparable climates. Similar to island nations in the Western Pacific Region, they are prone to natural disasters and so engage in planning and preparedness activities on an ongoing basis. This paper describes the initial measures taken by both countries during the first wave of COVID-19, from March to May 2020. Action: In both countries, multisectoral high-level leadership allowed for timely and decisive actions. Early school closures, early border closures and early lockdowns were enforced. Mandatory mask wearing and physical distancing were instituted. Cases and contacts were isolated in facilities away from public sector hospitals, and isolation was implemented at the government's expense. Volunteers were trained to manage dedicated hotlines. Additionally, the governments held daily press briefings. Outcome: During the first wave, Maldives contained its epidemic to one geographical cluster; Trinidad and Tobago successfully avoided community spread, thus averting an overwhelmed health system. Discussion: Diligent contact tracing with quarantine implemented at the government's expense successfully minimized spread in both countries. Small countries need volunteers to help with activities such as contact tracing, and recruiting and training volunteers before a health emergency occurs is key. Lessons learned from the experience of Maldives and Trinidad and Tobago could serve as a model for other small island developing states, including those in the Western Pacific Region.

Emotional distress in COVID-19 patients in Maldives.

BACKGROUND AND OBJECTIVES: Researchers are exploring the epidemiology, clinical characteristics, treatment, vaccination and the challenges faced by healthcare authorities. However less focus is being paid towards the impact of COVID-19 on mental health of the patients. This study is a cross-sectional study, measuring the prevalence of emotional distress among patients with COVID-19 in the Maldivian population. METHODS: This study was conducted in Maldivian nations above 18 of age with COVID-19 who were admitted in isolation facilities. Patients who were on treatment for any other chronic medical conditions, severe and critical COVID-19 disease were excluded. This study was conducted over a period of 2 months by administering a local translated version of DASS21 questionnaire. RESULTS: The total of 195 patients were included in this study. The mean age of the patients was 40 (CI at 95% 38-42) years. The respondents were 48.7% men and 51.3% women. Overall, 9% of patients with COVID-19 had depression while 23% of patients had anxiety and 12% of the patients had stress. There was a statistically significant relationship between gender and depression, anxiety and stress (p < 0.01). Symptomatic cases had a significantly higher level of stress than asymptomatic patients (p < 0.05), but no significant association was observed with symptomatic status and anxiety or depression. CONCLUSION: The management of patients with COVID-19 should be multi-disciplinary with special focus on the mental wellbeing of our patients. We should aim to establish proper communication with the patients in order to identify emotional distress and provide appropriate mental health care.

The role of social value orientation in modulating vaccine uptake in the COVID-19 pandemic: A cross-sectional study.

COVID-19 vaccination is the only pharmaceutical measure available to control the pandemic and move past the current crisis. As such, the Maldives, a small island country, invested heavily on securing and vaccinating the eligible population through an intensive risk communication campaign to create awareness on vaccination benefits. This paper reports on the vaccine coverage after a year of COVID-19 vaccine being introduced into the country, based on data obtained from the Values in Crisis Survey - Wave Two among Maldivian adults (n = 497). The findings show a vaccine coverage of 94%, with only 2.2% of the respondents indicating they will not get vaccinated. No significant differences were observed by age, gender, income earning, educational status or residential area. No significant relationship was observed in vaccine behaviour and confidence in government, health sector and experts. Social value orientations, particularly conservation and self-transcendence value orientations determined positive vaccine behaviour (r s = 0.180, p < 0.01 and 0.136 p < 0.01 respectively), yet conservation was the only predictor that contributed significantly to the regression model (B = 0.158, p < 0.01). The findings indicate that, despite the uncertainties around COVID-19 vaccinations, the prosocial value orientations were instrumental in achieving a high COVID-19 vaccine coverage. Further theoretical and conceptual exploration of vaccine behaviour in crisis situations is needed to inform future pandemic situations. The vaccination rollout and behaviour change strategies also need an examination of social value orientations in order to achieve a high coverage and sustain pro-vaccine behaviour post-pandemic.

Outcomes from colonoscopy following referral from New Zealand general practice: a retrospective analysis.

BACKGROUND: New Zealand has high rates of colorectal cancer (CRC) but poor outcomes. Most patients with CRC are diagnosed following referral from general practice, where a general practitioner (GP) assesses symptoms according to national guidelines. All referred patients are then re-prioritised by the hospital system. The first objective of this study was to identify what proportion of patients referred by general practice to surgical/gastroenterology at Waikato District Health Board (DHB) had a colonoscopy. The second objective was to determine what proportion of these referrals have an underlying CRC and the factors associated with the likelihood of this diagnosis. METHODS: This study is a retrospective analysis of e-referral data for patients aged 30-70+ who were referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy at Waikato DHB, 01 January 2015-31 December 2017. Primary and secondary outcome measures included the proportion and characteristics of patients who were having colonoscopy, and of those, who were diagnosed with CRC. Data were analysed using chi square and logistic regression. RESULTS: 6718/20648 (32.5%) patients had a colonoscopy and 372 (5.5%) of these were diagnosed with CRC. The probability of having CRC following a colonoscopy increased with age (p value < 0.001). Females (p value < 0.001), non-Maori (p value < 0.001), and patients with a high suspicion of cancer (HSCan) label originating from their GP were more likely to have a colonoscopy, while the odds ratio of Maori having a colonoscopy was 0.66 (95% CI 0.60-0.73). The odds ratio of a CRC diagnosis following colonoscopy was 1.67 (95% CI 1.35-2.07) for men compared to women, and 2.34 (95% CI 1.70-3.22) for those with a GP HSCan label. Of the 585 patients referred with a GP HSCan, 423 (72.3%) were reprioritised by the hospital and 55 patients had their diagnosis unnecessarily delayed. CONCLUSIONS: If a GP refers a patient with an HSCan, and the patient receives a colonoscopy, then the likelihood of having CRC is almost 15.0%. This would suggest that these patients should be routinely prioritised without further triage by the hospital. Further research is needed to understand why Maori are less likely to receive a colonoscopy following referral from general practice.

A sero-epidemiological study after two waves of the COVID-19 epidemic.

BACKGROUND: The COVID-19 situation in Maldives have evolved since the epidemic began in March 2020 with unprecedented increase in cases since mid-July 2019 with over 8000 cases at the end of August 2020. OBJECTIVE: The aim of the sero-epidemiological investigation is to obtain a sense of the population exposure to the SARS-CoV-2 by measuring the seroprevalence of antibodies to COVID-19 in the general population. METHODS: A population-based, age-stratified prospective method was employed to find out the key epidemiological and serologic characteristics of COVID-19 virus in this study. RESULTS: The results showed that seroprevalence in the population was 13%. The factors that were associated with antibody results included age (OR: 4.0, CI: 1.7-9.0), nationality (OR: 12.9, CI: 8.3-19.7), being diagnosed for COVID-19 (OR: 24.7, CI: 15.9-38.4) and having symptoms of COVID-19 (OR: 2.0, CI: 1.5-2.8). There was a gradual decrease in the antibody levels from 19 days to 250 days. The mean duration of the presence of antibodies in this study was found to be 124 days. CONCLUSIONS: While the seroprevalence provides a measure that can be used to predict community transmission risk of the disease, the extent of functional immunity provided by antibody titres is still not clear. It is acknowledged that other mechanisms of protection such as T cell mediated immunity will play an important role in providing individual protection.

Navigating the health system in responding to health workforce challenges of the COVID-19 pandemic: the case of Maldives (short case).

Being a small island and low-middle income country (LMIC) heavily dependent on global markets for sustaining its basic needs and health system, Maldives faced specific challenges during the COVID-19 pandemic. This was reinforced through tensions between the heavily centralized healthcare delivery and a partially decentralized public health system. Using the pillars of pandemic response proposed by the World Health Organisation, this article explores the planning assumptions, resource estimations and strategies adopted to equip the health system with resources for the pandemic response. The resource need estimates based on projections for COVID-19 identified a shortfall of medical professionals to care for patients while maintaining 55% of the workforce for regular healthcare across the atolls. The findings show that while the policy of lockdown bought time to increase hospital beds and devices, the country was unable to increase the healthcare workforce. Furthermore, as the lockdown eased, the exponential increase of cases took Maldives to the global one per capita incidence. Despite this, with cautious planning and use of resources, the country has so far managed to maintain low mortality from COVID-19. The lessons from this experience are paramount in future pandemic response planning, not only for Maldives, but other small island LMICs.

Management of the first severe case of COVID-19 in the small islands of Maldives.

The first cases of COVID19 in the Maldives was reported on 7th March 2020 with a total of 13 cases by 27th March from number of resort islands and were confined to the islands in which the cases were detected. This report describes the clinical course and management of the first severe case that required intensive care. Treatment strategy adopted was supportive and patient improved wit timely symptomatic management. This case highlights the importance of epidemiological surveillance and active case finding to detect and diagnose the case at an early stage for appropriate clinical management for positive outcomes in high risk groups.

Surveillance for non-communicable disease risk factors in Maldives: results from the first STEPS survey in Male.

OBJECTIVE: To identify the major risk factors for non-communicable diseases (NCDs) among the population of the capital city Male. METHODS: We undertook a cross-sectional survey among the 25-64-year-age group using a multi-stage sampling method with households as sampling unit. Information on behavioral, physiological, and biochemical risk factors was obtained through standardized methods as recommended by the STEPS survey guideline of the World Health Organization. Age-adjusted prevalence was calculated using the census figures for the year 2000. RESULTS: Among 2,028 individuals who participated in the survey, complete biochemical data were available for 1,506 subjects. The prevalence of NCD risk factors was high among both men and women in low education group: current smoking (39.9, 9.9%); overweight (BMI ≥ 23 kg/m(2)) (60.8, 65.5%); abdominal obesity (24.2, 54.1%); raised blood pressure (29.7, 32.9%); raised blood glucose (4.3, 4.7%); hypercholesterolemia (53.7, 54.9%). CONCLUSION: The significant burden posed by the NCD risk factors along with the gender and socioeconomic differentials point to the need for public health action. The Ministry of Health has already initiated a comprehensive response to this threat. The experience and lessons from this survey will be useful for developing a comprehensive and sustainable surveillance system in the country.