BACKGROUND: The European Union has been criticized for responding to the COVID-19 pandemic in a reactive, rather than prosilient manner. For the EU bloc to be prosilient, it needs to have the right early warning indicators to allow short-term healthcare system preparedness and agile planning of the public health response. METHOD: The association of COVID-19 disease burden, as measured by mortality (COVID-19 and all-cause), hospital and ICU occupancy, with incidence rate (IR), total positivity rate (TPR) and adjusted TPR as proposed by Vong and Kakkar, was investigated using Poisson regression analysis. This was carried out using both real-time data and time lags of up to 8 weeks to identify potential for early warning of spikes in disease burden. ECDC weekly figures for these indicators were used, and the analysis was repeated for the subset of data after Week 42 of 2020, when the EU Council introduced minimum COVID-19 testing rates. RESULTS: TPR and IR were noted to be the most predictive of COVID-19 disease burden whilst adjusted TPR applied on weekly data was not associated. TPR behaved better at predicting all-cause mortality in both analyses. The TPR and IR were both best associated with hospital and ICU occupancy and COVID-19 mortality with a short time lag (2–3 weeks in the case of TPR with hospital occupancy and COVID-19 mortality). CONCLUSIONS: Monitoring TPR can provide a 2–3-week warning of a spike in hospital occupancy and COVID-19 mortality. This time, if well utilized, could help health systems save countless lives by mobilising resources.
Background: National and international authorities recognize that health surveys are major sources of information on health conditions. Smaller states may prefer using health surveys to registries because they are cheaper to maintain. Nevertheless, smaller states carry out far fewer national health surveys than larger states. One reason could be that the value of surveys depends on the number of people interviewed rather than the proportion of the population. Therefore, survey costs per capita are substantially higher in smaller states. Methods: Malta is a small state with a population of under half a million. It forms part of the European Union, which has provided financial assistance and external expertise in performing international health surveys. We present the European Health Interview Survey in Malta as a case study to review the challenges for small states and the typical adaptations necessary for implementing national health surveys and meeting international health data obligations. Results: We identified the lack of health survey infrastructure, difficulties in recruiting the large samples recommended by international organizations, survey fatigue, and a lack of resources for marketing, incentivization, analysis and dissemination. Low-cost solutions have been devised to address some issues, such as marketing and incentives, which exploit specific characteristics of small states. Conclusion: In the absence of administrative data or epidemiological registers, surveys are important tools for evidence-based policy-making in small states. The experience of Malta could help other small states to minimize the resources required to run national health surveys. ; peer-reviewed
Following EU Accession, Malta has to adopt EU Directives as part of its own legislation. Three such directives concern the conduct of clinical trials in European countries 2001/20/EC, 2003/94/EC and 2005/28/EC. These directives, and the respective guidelines explaining their implementation, have considerably changed the way clinical trials are conducted. While the participation of Malta in clinical trials is to be encouraged for various reasons, these have to be regulated according to the legislation set out by the European Union. In themselves, what these Directives strive to achieve are mainly the safety of the study subject and the protection of the investigators from serious consequences. This short article aims to give a brief overview of these changes to prospective investigators and hospital administrators. ; peer-reviewed
Malta, had a pandemic response plan in place prior to the pandemic, which plan was updated in February 2020. The Superintendent of Public Health holds legislative authority, making recommendations to a Cabinet Interministerial Committee chaired by the Deputy Prime Minister and Minister for Health. In accordance with the Public Health Act (Chapter 465 of the Laws of Malta), a public health emergency was declared on the 1 April with effect from 7 March 2020, the day when the first imported case of COVID-19 was registered in Malta (LN 115 of 2020, Health Promotion & Disease Prevention Directorate, Ministry for Health, Malta.) Legal notices were successively published regularly and with urgency in relation to the public health measures issued by the health authorities, responsible for (a) social distancing measures, (b) closure of public places, (c) non-essential retail outlets and (d) lock down for those at highest risk within society. The procurement of personal protective equipment (PPE), medical equipment and all the requirements related to the pandemic response took place through a single centre to ensure adequate planning for critical resources and accountability of utilisation. ; peer-reviewed
European Union (EU) Member States were required to direct their health practices to ensure implementation of 'Directive on patients' rights in cross-border healthcare' which provides the right for EU citizens to seek treatment abroad. This study recruited Maltese patients, consequently it identified and quantified domains constituting willingness to access cross-border healthcare. Via this analytical approach, the results and recommendations were presented to assist cross-border healthcare policy. ; peer-reviewed
Attention deficit hyperactivity disorder (ADHD) is a common disorder associated with hyperactivity, impulsivity and reduced attention. If left untreated this may possibly lead to various impairments in other areas, such as lack of educational attainment, increased risk of accident-prone behaviour, substance misuse and antisocial behaviours. Although the exact aetiology is still not fully understood, various studies have demonstrated the presence of both a genetic and an environmental component. ADHD is highly hereditable, demonstrating a strong genetic component. Furthermore, increased rates of ADHD have been linked with a low socioeconomic status. The islands of Malta have traditionally been divided for statistical purposes into 6 districts, with certain districts more often being associated with low socioeconomic demographics. The main aim of this study was to assess whether higher prevalence rates of ADHD were present in the districts, which are classically associated with a low socioeconomic status. All persons aged 0 to 18 years attending the governmental clinics, having a documented diagnosis of severe ADHD and therefore being prescribed pharmacotherapy were identified and included in this study. 9 youngsters were living in institutional care and were therefore excluded from the study. A significant difference (p<0.0001) in the point prevalence of ADHD between the 6 Malta districts was found, with higher rates of ADHD occurring in the harbour districts. Though not statistically significant, a positive correlation was demonstrated between the ADHD prevalence and a number of socioeconomic variables, these included; the rate of smoking (p=0.111), number of people classified as at-risk-of-poverty per district (p=0.397), and number of people with no schooling per district (p=0.156). The overall point prevalence for ADHD in Malta obtained was 0.85, a value which is less than the average prevalence noted worldwide. The authors believe this value is an underestimation since the data collection in this study did not include ADHD cases off pharmacological treatment and any ADHD cases assessed and treated in the private sector. ; peer-reviewed
Folic acid is known to be beneficial in pregnancy and has been shown to prevent severe and devastating birth defects including neural tube defects. Health Authorities and Governments around the world have taken several initiatives in order to increase women's peri-conceptional folic acid intake, varying from issuing guidelines, undertaking extensive health promotion campaigns to mandatory food fortification of staple foods with folic acid. These interventions have had varying success in preventing neural tube defects. This paper is a comprehensive review of the current literature, putting together and summarizing the various initiatives undertaken by different countries and their success or otherwise in increasing women's peri-conceptional folic acid intake and preventing neural tube defects. ; peer-reviewed
Introduction: While life expectancy has increased over the past thirty years, such increases have not been constant around election times in Malta. This study seeks to explore the relationship between the time of elections in Malta and specific mortality rates. Aim: To determine if there is an association between mortality and elections in Malta. Method: Yearly age specific death rates for all-cause mortality, mortality from ischaemic heart disease, cerebrovascular disease, other heart diseases and all circulatory diseases as well as suicides were calculated from the Malta National Mortality Register for the period between 1985 and 2013. Years when elections and referenda were held between 1985 and 2013 were obtained from the Electoral Commission.1 The years 1985 – 2013 were coded using dummy variables to categorise them into pre-election, post-election, election year or any other year. Data was analysed using Poisson's regression technique in STATA with Mortality Rate Ratio (MRR) presented as the outcome measure. Results: A significant increase in overall mortality during election years resulted for circulatory disease MRR 1.058 (p<0.001; 95% CI 1.029-1.087), cerebrovascular disease MRR 1.09 (p=0.002; 95% CI 1.032-1.155) and other heart diseases MRR 1.36 (p<0.001; 95% CI 1.276-1.449). A significant increase was also noted during pre- election years in circulatory disease MRR 1.046 (p=0.002; 95% CI 1.017-1.075) and other heart diseases MRR 1.33 (p<0.001; 95% CI 1.248-1.422) and post-election years for cerebrovascular disease MRR 1.08 (p=0.009; 95% CI 1.020-1.150) and other heart diseases MRR 1.19 (p<0.001; 95% CI 1.108-1.273)) relative to the other years. Conclusion: This ecological study provides an indication that mortality patterns may be associated with the electoral cycle in Malta. Further research on individual physical and psychological responses to political events, particularly around election time is warranted. ; peer-reviewed
Objectives: The introduction of laws that make indoor public areas and workplaces smoke-free has resulted in a significant reduction in the incidence of acute coronary syndromes (ACS). Malta was the second European country to introduce the smoking ban legislation in April 2004. The purpose of the study was to investigate the impact of the smoking ban in Malta on ACS morbidity and mortality. Methods: The number of ACS hospital admissions and the number of cardiovascular deaths were retrospectively analysed. The annual data for 5 years prior to and following the introduction of the Tobacco Act were obtained according to age-groups for both genders. Poisson regression analyses were performed to assess for decline in ACS admission and cardiovascular death. Results: The ACS admission rate increased throughout the 5 years following the introduction of the smoking ban. There was no change in mortality rate in the 5 years following the legislation, except in 2007 when a small but significant decline was noted. Conclusions: The Malta smoking ban did not have a significant impact on cardiovascular mortality and ACS admissions rates, indicating the need for proper enforcement of the public smoking ban and increase in public awareness regarding the adverse effects of smoking. ; peer-reviewed
Background: Health Examination Surveys (HESs) can provide essential information on the health and health determinants of a population, which is not available from other data sources. Nevertheless, only some European countries have systems of national HESs. A study conducted in 2006–2008 concluded that it is feasible to organize national HESs using standardized measurement procedures in nearly all EU countries. The feasibility study also outlined a structure for a European Health Examination Survey (EHES), which is a collaboration to organize standardized HESs in countries across Europe. To facilitate setting up national surveys and to gain experience in applying the EHES methods in different cultures, EHES Joint Action (2010–2011) planned and piloted standardized HESs in the working age population in 12 countries. This included countries with earlier national HESs and countries which were planning their first national HES. The core measurements included in all surveys were weight, height, waist circumference and blood pressure, and blood samples were taken to measure lipid profiles and glucose or glycated haemoglobin (HbA1c). These are modifiable determinants of major chronic diseases not identified in health interview surveys. There was a questionnaire to complement the data on the examination measurements. Methods: Evaluation of the pilot surveys was based on review of national manuals and evaluation reports of survey organizers; observations and discussions of survey procedures during site visits and training seminars; and other communication with the survey organizers. Results: Despite unavoidable differences in the ways HESs are organized in the various countries, high quality and comparability of the data seems achievable. The biggest challenge in each country was obtaining high participation rate. Most of the pilot countries are now ready to start their full-size national HES, and six of them have already started. Conclusions: The EHES Pilot Project has set up the structure for obtaining comparable high quality health indicators on health and important modifiable risk factors of major non-communicable diseases from the European countries. The European Union is now in a key position to make this structure sustainable. The EHES core survey can be expanded to cover other measurements. ; peer-reviewed
Background: An infodemic is an overabundance of information—some accurate and some not—that occurs during an epidemic. In a similar manner to an epidemic, it spreads between humans via digital and physical information systems. It makes it hard for people to find trustworthy sources and reliable guidance when they need it. Objective: A World Health Organization (WHO) technical consultation on responding to the infodemic related to the coronavirus disease (COVID-19) pandemic was held, entirely online, to crowdsource suggested actions for a framework for infodemic management. Methods: A group of policy makers, public health professionals, researchers, students, and other concerned stakeholders was joined by representatives of the media, social media platforms, various private sector organizations, and civil society to suggest and discuss actions for all parts of society, and multiple related professional and scientific disciplines, methods, and technologies. A total of 594 ideas for actions were crowdsourced online during the discussions and consolidated into suggestions for an infodemic management framework. Results: The analysis team distilled the suggestions into a set of 50 proposed actions for a framework for managing infodemics in health emergencies. The consultation revealed six policy implications to consider. First, interventions and messages must be based on science and evidence, and must reach citizens and enable them to make informed decisions on how to protect themselves and their communities in a health emergency. Second, knowledge should be translated into actionable behavior-change messages, presented in ways that are understood by and accessible to all individuals in all parts of all societies. Third, governments should reach out to key communities to ensure their concerns and information needs are understood, tailoring advice and messages to address the audiences they represent. Fourth, to strengthen the analysis and amplification of information impact, strategic partnerships should be formed across all sectors, including but not limited to the social media and technology sectors, academia, and civil society. Fifth, health authorities should ensure that these actions are informed by reliable information that helps them understand the circulating narratives and changes in the flow of information, questions, and misinformation in communities. Sixth, following experiences to date in responding to the COVID-19 infodemic and the lessons from other disease outbreaks, infodemic management approaches should be further developed to support preparedness and response, and to inform risk mitigation, and be enhanced through data science and sociobehavioral and other research. Conclusions: The first version of this framework proposes five action areas in which WHO Member States and actors within society can apply, according to their mandate, an infodemic management approach adapted to national contexts and practices. Responses to the COVID-19 pandemic and the related infodemic require swift, regular, systematic, and coordinated action from multiple sectors of society and government. It remains crucial that we promote trusted information and fight misinformation, thereby helping save lives. ; peer-reviewed
Background: Rare cancers pose challenges for diagnosis, treatments, and clinical decision making. Information about rare cancers is scant. The RARECARE project defined rare cancers as those with an annual incidence of less than six per 100 000 people in European Union (EU). We updated the estimates of the burden of rare cancers in Europe, their time trends in incidence and survival, and provide information about centralisation of treatments in seven European countries. Methods: We analysed data from 94 cancer registries for more than 2 million rare cancer diagnoses, to estimate European incidence and survival in 2000–07 and the corresponding time trends during 1995–2007. Incidence was calculated as the number of new cases divided by the corresponding total person-years in the population. 5-year relative survival was calculated by the Ederer-2 method. Seven registries (Belgium, Bulgaria, Finland, Ireland, the Netherlands, Slovenia, and the Navarra region in Spain) provided additional data for hospitals treating about 220 000 cases diagnosed in 2000–07. We also calculated hospital volume admission as the number of treatments provided by each hospital rare cancer group sharing the same referral pattern. Findings: Rare cancers accounted for 24% of all cancers diagnosed in the EU during 2000–07. The overall incidence rose annually by 0.5% (99·8% CI 0·3–0·8). 5-year relative survival for all rare cancers was 48·5% (95% CI 48·4 to 48·6), compared with 63·4% (95% CI 63·3 to 63·4) for all common cancers. 5-year relative survival increased (overall 2·9%, 95% CI 2·7 to 3·2), from 1999–2001 to 2007–09, and for most rare cancers, with the largest increases for haematological tumours and sarcomas. The amount of centralisation of rare cancer treatment varied widely between cancers and between countries. The Netherlands and Slovenia had the highest treatment volumes. Interpretation: Our study benefits from the largest pool of population-based registries to estimate incidence and survival of about 200 rare cancers. Incidence trends can be explained by changes in known risk factors, improved diagnosis, and registration problems. Survival could be improved by early diagnosis, new treatments, and improved case management. The centralisation of treatment could be improved in the seven European countries we studied. ; peer-reviewed
Background: In 2015, the second cycle of the CONCORD programme established global surveillance of cancer survival as a metric of the effectiveness of health systems and to inform global policy on cancer control. CONCORD-3 updates the worldwide surveillance of cancer survival to 2014. Methods: CONCORD-3 includes individual records for 37·5 million patients diagnosed with cancer during the 15-year period 2000–14. Data were provided by 322 population-based cancer registries in 71 countries and territories, 47 of which provided data with 100% population coverage. The study includes 18 cancers or groups of cancers: oesophagus,stomach, colon, rectum, liver, pancreas, lung, breast (women), cervix, ovary, prostate, and melanoma of the skin in adults, and brain tumours, leukaemias, and lymphomas in both adults and children. Standardised quality control procedures were applied; errors were rectified by the registry concerned. We estimated 5-year net survival. Estimates were age-standardised with the International Cancer Survival Standard weights. Findings: For most cancers, 5-year net survival remains among the highest in the world in the USA and Canada, in Australia and New Zealand, and in Finland, Iceland, Norway, and Sweden. For many cancers, Denmark is closing the survival gap with the other Nordic countries. Survival trends are generally increasing, even for some of the more lethal cancers: in some countries, survival has increased by up to 5% for cancers of the liver, pancreas, and lung. For women diagnosed during 2010–14, 5-year survival for breast cancer is now 89·5% in Australia and 90·2% in the USA, but international differences remain very wide, with levels as low as 66·1% in India. For gastrointestinal cancers, the highest levels of 5-year survival are seen in southeast Asia: in South Korea for cancers of the stomach (68·9%), colon (71·8%), and rectum (71·1%); in Japan for oesophageal cancer (36·0%); and in Taiwan for liver cancer (27·9%). By contrast, in the same world region, survival is generally lower than elsewhere for melanoma of the skin (59·9% in South Korea, 52·1% in Taiwan, and 49·6% in China), and for both lymphoid malignancies (52·5%, 50·5%, and 38·3%) and myeloid malignancies (45·9%, 33·4%, and 24·8%). For children diagnosed during 2010–14, 5-year survival for acute lymphoblastic leukaemia ranged from 49·8% in Ecuador to 95·2% in Finland. 5-year survival from brain tumours in children is higher than for adults but the global range is very wide (from 28·9% in Brazil to nearly 80% in Sweden and Denmark). Interpretation: The CONCORD programme enables timely comparisons of the overall effectiveness of health systems in providing care for 18 cancers that collectively represent 75% of all cancers diagnosed worldwide every year. It contributes to the evidence base for global policy on cancer control. Since 2017, the Organisation for Economic Co-operation and Development has used findings from the CONCORD programme as the official benchmark of cancer survival, among their indicators of the quality of health care in 48 countries worldwide. Governments must recognise population-based cancer registries as key policy tools that can be used to evaluate both the impact of cancer prevention strategies and the effectiveness of health systems for all patients diagnosed with cancer. ; peer-reviewed
