'Cocooning' the vulnerable - a main pillar of Malta's COVID-19 response

Issue

Early epidemiology established higher risk of morbidity & mortality amongst infected older individuals or those having specific chronic diseases, consuming most hospital care. Also where demand exceeding supply of healthcare, mortality was very high. As an island nation with one central main hospital, not overwhelming the healthcare system whilst avoiding total lockdown was key.

Description

On the 27-03-2020, the Superintendent of Public Health enacted the Protection of Vulnerable Persons Order, specifying that these categories (or subcategories thereof) of persons are to be granted vulnerable status: age >65; pregnant; persons suffering from diabetes; immunosuppressed; cancer; end stage renal failure; respiratory disease; cardiac disease; heart failure. Such persons were entitled to stay at home, to be granted special leave from work, entitled to a monthly allowance by social services. One could go out only to attend to essential or urgent personal matters, e.g. groceries, medicines, medical needs, bank etc. with mitigation measures. Exemptions were only granted to special categories such as healthcare workers, farmers, or headship positions. In addition, the carers & staff of most nursing homes voluntarily decided to isolate themselves inside the homes for periods of 2/3 weeks. Thanks to a very active family support network, offspring, relatives or neighbours ran basic errands for them, or else organised deliveries. This legal status has been lifted on the 5th June 2020.

Results

This status was granted to 126 000 persons, including 14000 employed persons. Only 9 deaths occurred in Malta out of 664 cases in a population of 500000 up till 20th June 2020, with a case fatality rate of 1.35% - one of the lowest in Europe.

Lessons

Protection of vulnerable individuals can be a cornerstone of COVID-19 public health response if mobility is effectively restricted in this subpopulation.

Key messages

Protection of the vulnerable reduces healthcare & mortality burden.

Effective legal & economic support measures, & extensive societal engagement required.

The diagnosis of pleural effusions

Pleural effusions arise from a variety of systemic, inflammatory, infectious and malignant conditions. Their precise etiological diagnosis depends on a combination of medical history, physical examination, imaging tests and pertinent pleural fluid analyses; including specific biomarkers (e.g., natriuretic peptides for heart failure, adenosine deaminase for tuberculosis, or mesothelin for mesothelioma). Invasive procedures, such as pleuroscopic biopsies, may be required for persistently symptomatic effusions which remain undiagnosed after the analysis of one or more pleural fluid samples. However, whenever parietal pleural nodularity or thickening exist, image-guided biopsies should first be attempted. This review addresses the current diagnostic approach to pleural effusions secondary to heart failure, pneumonia, cancer, tuberculosis and other less frequent conditions.

Use of cholinesterase activity as a biomarker of pesticide exposure used on Costa Rican banana plantations in the native tropical fish Astyanax aeneus (Günther, 1860)

In Costa Rica, thousands of tones of agricultural pesticides have been used for decades and their use is continuously increasing due to intensive and expanding production of coffee, pineapple, rice, ornamental plants and bananas. The objective of this study was to evaluate whether choline esterase (ChE) activity could be used as a biomarker of exposure to pesticides in the Costa Rican native fish Astyanax aeneus (characidae). Three methods used in order to evaluate the ChE biomarker were as follows: Laboratory studies where A. aeneus was exposed to organophosphate pesticide (ethoprophos); In situ 48 hr exposure assessment using caging experiments with fish exposed upstream and downstream of banana plantations and ChE activity estimation of in fish captured directly at sites with different degrees of pesticide exposure. Results from the laboratory studies showed that ChE activity in both brain and muscle tissue was significantly lower in fish exposed to ethoprophos than in controls. Fish from the caging experiments showed no difference in ChE activity neither in brain nor in muscle tissue between the four tested sites and was attributed to the short duration of the exposure. Asignificant difference in ChE activity was determined in muscle of fish captured from Laguna Madre de Dios compared to fish from Canal Batán. Although our laboratory results revealed that ChE activity in A. aeneus was highly responsive to ethoprophos, results from field experiments were less conclusive and showed that the captured fish showed large variability in ChE activity and that more research is needed before ChE activity can be used as reliable biomarker of pesticide exposure.

Thoracic malignant fibrous histiocytoma metastatic to the tongue and skin of the face

A 60-year-old white man was found to to have metastatic malignant fibrous histocytoma in the tongue and facial skin 15 months after diagnosis of the primary lesion in the thorax. This is believed to be only the fourth reported case of this tumor metastatic to the oral cavity and the first lingual metastasis from outside the jaws.