Comorbidity in primary care - causal or casual? A longitudinal observational study in family medicine.

BACKGROUND: Comorbidity is increasingly important in the medical literature, with ever-increasing implications for diagnosis, treatment, prognosis, management and health care. The objective of this study is to measure casual versus causal comorbidity in primary care in three family practice populations. METHODS: This is a longitudinal observational study using the Transition Project datasets. Transition Project family doctors in the Netherlands, Malta and Serbia recorded details of all patient contacts in an episode of care structure using electronic medical records and the International Classification of Primary Care, collecting data on all elements of the doctor-patient encounter, including diagnoses (1,178,178 in the Netherlands, 93,606 in Malta, 405,150 in Serbia), observing 158,370 patient years in the Netherlands, 43,577 in Malta, 72,673 in Serbia. Comorbidity was measured using the odds ratio of both conditions being incident or rest-prevalent in the same patient in one-year dataframes, as against not, corrected for the prior probability of such co-occurrence, between the 41 joint most prevalent (joint top 20) episode titles in the three populations. Specific associations were explored in different age groups to observe the changes in odds ratios with increasing age as a surrogate for a temporal or biological gradient. RESULTS: The high frequency of observed comorbidity with low consistency in both clinically and statistically significant odds ratios across populations indicates more casual than causal associations. A causal relationship would be expected to be manifest more consistently across populations. Even in the minority of cases where odds ratios were consistent between countries and numerically larger, those associations were observed to weaken with increasing patient age. CONCLUSION: After applying accepted criteria for testing the causality of associations, most observed primary care comorbidity is due to chance, likely as a result of increasing illness diversity. TRIAL REGISTRATION: This study was performed on electronic patient record datasets made publicly available by the University of Amsterdam Department of General Practice, and did not involve any patient intervention.

A Good Night's Sleep in Malta in 2023: A Cross-sectional Study Exploring Sleep Quality and its Determinants via Social Media.

BACKGROUND: Sleep quality is affected by a plethora of different factors, although its relationship with chronic diseases is still unclear. This study explored perceived sleep quality and its associated determinants among the adult population of Malta. Study Design: A cross-sectional study. METHODS: An anonymous online survey was distributed through social media targeting adults residing in Malta. Data pertaining to socio-demographic, medical history, lifestyle, well-being, sleep, and daytime sleepiness were gathered, and descriptive, univariant, and multiple binary logistic regression modelling analyses were performed. RESULTS: A total of 855 adults responded, out of whom 35.09% (95% confidence interval [CI]: 31.90, 38.41) reported sleep difficulties, especially females (81.33%; 95% CI: 76.36, 85.49), while 65.33% (95% CI: 59.61, 70.65) reported suffering from chronic disease(s). Sleep problems were positively associated with multimorbidity (odds ratio [OR]: 2.17; 95% CI: 1.38, 3.40; P=0.001), sleeping<6 hours (OR: 3.79; 95% CI: 1.54, 9.30; P=0.040), and the presence of moderate anxiety symptoms (OR: 1.99; 95% CI: 1.10, 3.59; P=0.020). They were also related to the presence of mild (OR: 2.25; 95% CI: 1.46, 3.45; P=0.001), moderate (OR: 2.40; 95% CI: 1.24, 4.64; P=0.010), and moderately severe (OR: 15.35; 95% CI: 4.54, 31.86; P=0.001) depressive symptoms after adjusting for confounders. CONCLUSION: Chronic conditions, including anxiety and depression, along with short sleep duration, appear to contribute to poor sleep quality in Malta. A multifaceted approach is required to deal with the issue holistically and safeguard the health of current and future generations.

Cardiovascular Risk Factors Among First-Degree Relatives of Patients with Premature Cardiovascular Disease in Malta. Baseline Findings from the CRISO Project.

Purpose: A family history of premature atherosclerotic cardiovascular disease (ASCVD) confers a greater risk of developing ASCVD. However, the prevalence of ASCVD risk factors among asymptomatic Maltese adults with parental or fraternal history of premature ASCVD is unknown. The study aimed to evaluate and compare their risk with the general population. Patients and Methods: Posters to market the project were distributed in cardiac rehabilitation areas. Patients with premature cardiovascular disease facilitated recruitment by informing their relatives about the project. Medical doctors and cardiac rehabilitation nurses referred first-degree relatives. Posters were put up in community pharmacies, and an explanatory video clip was shared on social media for interested individuals to contact researchers. Those eligible were enrolled in a preventive cardiology lifestyle intervention. Their data were compared with the risk in the general population. Results: Many first-degree relatives had a suboptimal risk profile, with 60% (N = 89) having a total cholesterol level of >5.0 mmol/L; 54% having a low-density lipoprotein-cholesterol level of >3 mmol/L; 70.5% being overweight/obese, with 62% having a waist circumference greater than the recommended values; 34.8% having hypertension; 56.2% being inadequately adherent to the Mediterranean diet; 62% being underactive, with 18% being sedentary; and 25.8% being smokers. First-degree relatives had significantly higher proportions of underactive lifestyle (p = 0.00016), high body mass index (>25kg/m2) (p = 0.006), and systolic blood pressure (p = 0.001) than the general population, with 30% having metabolic syndrome. Conclusion: This study determined the prevalence of lifestyle, biochemical, physiological, and anthropometric cardiovascular risk factors among asymptomatic first-degree relatives of Maltese patients with premature ASCVD. First-degree relatives had considerable prevalences of an underactive lifestyle, hypertension, and obesity, suggesting better screening and early risk factor intervention are needed to modify their risk of ASCVD.

This study was done to evaluate factors that can increase the risk of heart disease in siblings and offspring of Maltese patients who developed atherosclerotic cardiovascular disease (ASCVD) at a young age. Relatives were invited to meetings during which a risk evaluation was performed. The researchers found that relatives had a high prevalence of cardiometabolic risk factors, meaning they were at increased risk of developing the disease. The researchers have concluded that reducing the risk of ASCVD in individuals at increased risk requires developing and testing potentially sustainable risk factor modification strategies.

Identifying co-morbidities and risk in people with epilepsy: The Maltese experience.

BACKGROUND: People with epilepsy are at increased risk of multiple co-morbidities that may influence risk of adverse outcomes including impact on quality of life and premature mortality. These risk factors include potentially modifiable clinical characteristics associated with sudden unexpected death in epilepsy (SUDEP). For services to tackle risk, the clinical complexity of the target epilepsy population needs to be defined. While this has been comprehensively studied in large, economically developed countries little knowledge of these issues exist in small economically developed countries, like Malta (population: 500,000). METHODS: This was a single centre study focused exclusively on patients attending Gozo General Hospital (GGH) Malta. STROBE guidance for reporting cross sectional studies was used to design and report the study. This was a retrospective review of standard care and SUDEP and seizure risks provided to all adults (over 18 years) with epilepsy attending GGH (2018-2021). RESULTS: The review identified 68 people and 92% were compliant with their anti-seizure medication. A fifth (21%) had an intellectual disability. Despite only one patient having a psychotic illness, 19% were on antipsychotic medication. Only 18% of patients had a specific epilepsy care plan, 6% nocturnal surveillance and none had received advice on SUDEP. DISCUSSION: Patient outcomes may be improved with increasing rates of personalized epilepsy care plans, appropriate nocturnal surveillance and reducing the prescription of antipsychotic medication as it is associated with greater risk of mortality. Issues such as stigma and shame appear to play a significant role in small communities and their access to care.

Association between a polygenic lipodystrophy genetic risk score and diabetes risk in the high prevalence Maltese population.

BACKGROUND: Type 2 diabetes (T2DM) is genetically heterogenous, driven by beta cell dysfunction and insulin resistance. Insulin resistance drives the development of cardiometabolic complications and is typically associated with obesity. A group of common variants at eleven loci are associated with insulin resistance and risk of both type 2 diabetes and coronary artery disease. These variants describe a polygenic correlate of lipodystrophy, with a high metabolic disease risk despite a low BMI. OBJECTIVES: In this cross-sectional study, we sought to investigate the association of a polygenic risk score composed of eleven lipodystrophy variants with anthropometric, glycaemic and metabolic traits in an island population characterised by a high prevalence of both obesity and type 2 diabetes. METHODS: 814 unrelated adults (n = 477 controls and n = 337 T2DM cases) of Maltese-Caucasian ethnicity were genotyped and associations with phenotypes explored. RESULTS: A higher polygenic lipodystrophy risk score was correlated with lower adiposity indices (lower waist circumference and body mass index measurements) and higher HOMA-IR, atherogenic dyslipidaemia and visceral fat dysfunction as assessed by the visceral adiposity index in the DM group. In crude and covariate-adjusted models, individuals in the top quartile of polygenic risk had a higher T2DM risk relative to individuals in the first quartile of the risk score distribution. CONCLUSION: This study consolidates the association between polygenic lipodystrophy risk alleles, metabolic syndrome parameters and T2DM risk particularly in normal-weight individuals. Our findings demonstrate that polygenic lipodystrophy risk alleles drive insulin resistance and diabetes risk independent of an increased BMI.

The prevalence of perinatal mental health disorders and psychosocial characteristics of women in Malta: A cross-sectional study.

BACKGROUND: Perinatal mental health disorders (PMHDs) are associated with a myriad of negative outcomes for women, infants, and the rest of the family unit. Understanding the prevalence of these conditions is important to guide prevention and treatment pathways. Indeed, the burden of PMHDs has been studied in many countries, but for Malta, an island with an annual birth rate of 4500 births, this burden is still to be determined. The main objective of this study was to address this gap, determine the prevalence of PMHDs among postpartum women in Malta, and study associated psychosocial determinants for this population. METHODS: A cross-sectional epidemiological study was conducted between March and April 2022 to determine the point prevalence of postpartum PMHDs in Malta. A representative, random sample of 243 postnatal mothers were recruited and screened for mental health issues using a two stage approach incorporating symptom scales and a diagnostic interview. RESULTS: The point prevalence of postnatal PMHDs in Malta, according to a diagnostic interview, was found to be 21.4%. Anxiety disorders were the most prevalent conditions (16.8%), followed by obsessive-compulsive disorder (6.1%) and borderline personality disorder (5.6%), respectively. A higher rate of 32.1% was identified with self-report measures. CONCLUSIONS: PMHDs are highly prevalent, affecting approximately 20% of women in Malta across the first postnatal year. The value of this finding accentuates the need for service availability and the implementation of perinatal mental health screening programs.

The epidemiology of CHD in Malta.

BACKGROUND: CHD refers to structural cardiac abnormalities which comprise the commonest group of congenital malformations. Malta is a small island in the central Mediterranean with excellent diagnostic and therapeutic facilities. It is unique in the European population as termination of pregnancy is illegal. This study was carried out to ascertain patterns in CHD prevalence in comparison with EUROCAT data (European Surveillance of Congenital Anomalies). METHODS: Anonymised data were obtained from the EUROCAT website for 1993-2020. RESULTS: There were a total of 22,833,032 births from all EUROCAT Registries, of which 121,697 were from Malta. The prevalence rate for Malta CHD was 32.38/10,000 births (at the higher end of the range). Malta had a significant excess of commoner, comparatively non-severe CHDs. For most of the severe lesions analysed rates reported were higher than EUROCAT average, however, apart from Ebstein's anomaly, they all fell within the ranges reported from the different registries. DISCUSSION: Wide variations in reported CHD prevalence are known, and the Malta rates may be higher for milder defects due to quicker pickup prior to spontaneous resolution. There may also be a higher pickup of milder forms of more severe conditions. For the more severe conditions, lack of termination may be the explanation. These factors may result in the higher neonatal mortality observed in Malta.

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.

Clinical features and diagnostic challenges of mpox (monkeypox) outbreak in Malta: a retrospective cohort study.

BACKGROUND: In May of 2022, an mpox (formerly known as monkeypox) outbreak was reported from countries where the disease is not endemic, rising worldwide concern. Malta, the smallest European Union member state, faced unique challenges, with high infection rates compared to the rest of Europe. The aim of the study is to describe the clinical characteristics, diagnostic challenges, and unique demographics of mpox patients diagnosed in Malta. METHODS: This is a retrospective analysis of medical records of all mpox cases recorded from May to September 2022. Demographic data, sexual behaviors and practices, travel history, comorbidities, and HIV status were investigated. RESULTS: In the study period, we recorded 33 mpox cases, 97% of them were male, in the age group 30-39 (39%). Ninety percent were gay or bisexual men and 76% non-Maltese. The most common clinical presentations included skin rash (78%), lymphadenopathy (71%), anogenital lesions (67%), and fever (67%). Twenty-seven percent of the patients were people living with HIV. In terms of coinfection with STIs, 27% of patients tested positive for gonorrhea, 12% for syphilis, 15% for chlamydia, 9% for herpes simplex virus, and 3% for hepatitis C virus. CONCLUSION: The results shed light on unique challenges faced by the local sexual health clinic and call for more resources in response to the global emerging of infectious diseases.

A glimpse into Long COVID characteristics and the mental health impact within a highly vaccinated population: a Malta observational study.

BACKGROUND: Post-acute COVID-19 consequences are gaining global recognition. This study explores Long COVID characteristics and associated mental health impact/s among the highly vaccinated adult population of Malta. METHODS: A social media survey gathered demographics, vaccination, and COVID-19 data. Generalised Anxiety Disorder and Patient Health Questionnaire-9 assessment tools were used for anxiety and depression. Quantitative analyses were performed. RESULTS: 41% reported Long COVID, mostly female, 30-39 years, absence of chronic disease/s and vaccinated. Shortness of breath commonest persistent symptom among males, and fatigue for females. Significantly higher depression scores were present in Long COVID cohort compared to no persistent symptoms (p=0.001) and never acquiring COVID-19 (p=<0.01). A significant higher anxiety scores was present for Long COVID cohort than never acquiring COVID-19 (p=<0.01). CONCLUSIONS: Long COVID occurs even in healthy individuals and vaccinated, while exacerbating mental health burdens. Urgent action is required to manage Long COVID and preventing the sequela.

Genetic landscape of ALS in Malta based on a quinquennial analysis.

Genetic risk for amyotrophic lateral sclerosis (ALS) is highly elevated in genetic isolates, like the island population of Malta in the south of Europe, providing a unique opportunity to investigate the genetics of this disease. Here we characterize the clinical phenotype and genetic profile of the largest series of Maltese ALS patients to date identified throughout a 5-year window. Cases and controls underwent neuromuscular assessment and analysis of rare variants in ALS causative or risk genes following whole-genome sequencing. Potentially damaging variants or repeat expansions were identified in more than 45% of all patients. The most commonly affected genes were ALS2, DAO, SETX and SPG11, an infrequent cause of ALS in Europeans. We also confirmed a significant association between ATXN1 intermediate repeats and increased disease risk. Damaging variants in major ALS genes C9orf72, SOD1, TARDBP and FUS were however either absent or rare in Maltese ALS patients. Overall, our study underscores a population that is an outlier within Europe and one that represents a high percentage of genetically explained cases.

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.

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.

Assessing the impact of the four COVID-19 variants and the vaccine coverage on mortality in Malta over 2 years: An observational case study.

Background: Mortality may quantify a population's disease burden. Malta, like other European countries, experienced COVID-19 surges in cases and mortality across the pandemic. This study assesses COVID-19's mortality impact, while exploring the effects of the four dominant COVID-19 variants and that of the vaccination coverage on the Maltese population. Methods: COVID-19 data (cases, mortality, positivity, and vaccination rates) was obtained from the websites of the European Center for Disease Prevention and Control and the Malta Ministry of Health. Data was categorized into the four periods according to reported dominant COVID-19 variant. Years of life lost (YLL) and Case-Fatality-Ratio (CFR) for each period were estimated. CFR was also estimated for the pre-vaccine and post-vaccine periods. Results: The original COVID-19 period (36 weeks) had the highest YLL (4,484), followed by the Omicron variant period (12 weeks; 1,398). The Alpha variant period (7 weeks) had the highest CFR (1.89%) followed by the Original COVID-19 (1.35%). The pre-vaccine (1.59%) period had higher CFR than the post-vaccine period (0.67%). Conclusion: Various factors contributed to mortality, but the variant's infectivity, transmissibility, and the effectiveness of the vaccine against the variant play an important role. Reducing mortality by embracing mass vaccination that targets current variants along with other non-pharmaceutical interventions remains paramount.

On the way between Africa and Europe: Molecular taxonomy of ticks collected from birds in Malta.

The Maltese Archipelago is situated in the middle of the Mediterranean Basin, between Europe and Africa, therefore representing an important stopover site for migratory birds between these two continents. Despite this, up-to-date information is not available on tick species associated with birds in Malta. Therefore, in this study, birds mist-netted for ringing by BirdLife Malta were examined for the presence of ticks between September, 2019 and May, 2021. Ticks were identified morphologically and molecularly, using three genetic markers. During the study period, 57 individuals of 22 bird species were found tick-infested, from which altogether 113 ixodid ticks were collected. The majority of developmental stages were nymphs, but 13 larvae and one female were also found. These ticks belonged to nine species: Ixodes cumulatimpunctatus (n=1), Ixodes ricinus (n=2), Ixodes acuminatus (n=2), Ixodes frontalis (n=5), Ixodes festai (n=1), one species of the Amblyomma marmoreum complex (n=8), Hyalomma rufipes (n=78), Hyalomma marginatum (n=7) and Hyalomma lusitanicum (n=1). Eight Hyalomma sp. ticks could only be identified on the genus level. Regarding seasonality, all Palearctic Ixodes species were carried by birds exclusively in the autumn (i.e., north to south), whereas H. rufipes (with predominantly Afrotropical distribution) was exclusively collected in the spring (i.e., carried south to north). Two tick species that occurred on birds in Malta, i.e., a species of the A. marmoreum complex and I. cumulatimpunctatus are only indigenous in the Afrotropical zoogeographic region. This is the first finding of the latter tick species in Europe, and four tick species were identified for the first time in Malta. In conclusion, the diversity of tick species regularly arriving in Europe from Africa is most likely higher than reflected by data obtained in Mediterranean countries of mainland Europe. Most notably, ticks of the genus Amblyomma appear to be underrepresented in previous datasets. Ticks of the subgenus Afrixodes (represented by I. cumulatimpunctatus) might also be imported into Europe by migratory birds.

A Year of COVID-19 Pandemic Roller-Coaster: The Malta Experience, Lessons Learnt, and the Future.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic had a global impact. The study explores the various COVID-19 experiences in Malta over the past year and provides a snapshot of acute and post-acute COVID-19 symptoms, as well as national vaccination roll-out and hesitancy. METHODS: Data on medical access, lifestyle habits, acute and post-acute COVID-19 symptoms, and vaccination hesitancy was gathered through a social media survey targeting adults of Malta. COVID-19 data were gathered from the Malta Ministry of Health COVID-19 dashboard. RESULTS: Malta controlled COVID-19 spread exceptionally well initially. Since August 2020, the positivity rate, mortality, and hospital admission rates saw a fluctuating incline. From COVID-19 onset, a decrease in physical activity and an increase in body weight was reported. Most participants acquiring COVID-19 were asymptomatic but nontrivial proportion experienced post-acute symptoms. The majority opted to take the COVID-19 vaccine with only a minority expressing safety concerns. CONCLUSIONS: Malta has experienced roller coaster events over a year. The population faced elevated levels of morbidity, mortality, and economic hardship along with negative and positive risk-associated behaviors. Vaccination in combination with population adherence to social distancing, mask wearing, and personal hygiene are expected to be the beacons of hope in the coming months.

Gender, migration and violence among third country nationals accessing the sexual health clinic in Malta.

BACKGROUND: In 2020, the number of displaced people worldwide reached 41.3 million (IOM, 2020). Among them, are many migrants and refugees at risk of sexual and gender-based violence (SGBV). Healthcare providers have a key role to play in identifying migrant victims/survivors of violence. OBJECTIVES: This paper seeks to assess STIs prevalence, sexual health and sexual violence among third country nationals (TCNs) attending the GUC in Malta. METHODS: This is a mixed methods study carried out at the Genitourinary Clinic (GUC), which is the only public sexual health clinic in Malta. Demographic data, sexual history and diagnoses of patients attending the GUC between January 2018 and December 2019 were collected and retrospectively analysed. A SGBV risk assessment was performed through a semi-structured questionnaire. RESULTS: In the 24-month study period, a total of 12 654 patients accessed the GUC in Malta. Demographic data were collected on age, gender, nationality, marital status and sexual orientation. 16.4% (n = 2064) of these were extra-European migrants, predominantly male. 80 different nationalities were recorded, with the 5 most common being Nigerian, Filipino, Libyan, Syrian and Brazilian. The average age was 32.6 years. Over 110 sex workers were visited at the GUC in the study period - 20 were foreign, primarily from China. The presence of a 'massage parlour owner' during consultation, lack of control over passports and other factors were identified as warning signs of trafficking. 5 cases of sexual violence and forced prostitution involving girls from Sub-Saharan Africa and, in 2 cases, boys recently arrived in Malta by boat, were encountered. 6 African women accessing the service exhibited a type of female genital mutilation (FGM). CONCLUSIONS: Migration, sexual health and SGBV overlap in important ways. Further research and training in SGBV and migration in the healthcare setting and awareness-raising about existing services among the migrant population are required.

Managing COVID-19 in four small countries: Initial response to the pandemic in San Marino, Montenegro, Malta and Cyprus.

The aim of this paper is to compare the impact of the COVID-19 pandemic on four small countries in the southern half of Europe with similar public health systems: San Marino, Montenegro, Malta and Cyprus, the latter two being island states. There are advantages and disadvantages in being a small nation amidst this crisis. The centralized public health administration means that small countries are faster at adapting as they learn and evolve on a weekly basis. However, small countries tend to be dependent on their bigger neighbours, and the networks they belong to, for trade, food, medical supplies as well as policies. The risk threshold taken by a small country for the transition strategy has to be less than that taken by a bigger country because if things go wrong in a border region, there is less resilience in a small country, with immediate impact on the whole country. The blow to the tourism industry, which plays a main role especially in small countries, negatively impacted the economy, and it has been a feat to reach a balance between allowing the flow of inbound tourists and keeping the local infection rates under control.