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 impact of four dominating variants and vaccine coverage on Covid-19 mortality: the Malta case

Background

Disease burden can be quantified by mortality. The European Islands of Malta experienced a seesaw of Covid-19 surges in mortality and cases across the pandemic. The study aims to assess the impact of Covid-19 mortality across the four phases dominated by different variants while considering the vaccination coverage among the Malta population.

Methods

Covid-19 epidemiological data was obtained up till end of February 2022 from the websites of the Malta Ministry of Health and the European Centre for Disease Prevention and Control. Data was categorised into the four periods according to reported dominant Covid-19 variant. The Years of life lost (YLL) and Case-Fatality-Ratio (CFR) for each period were estimated. Correlations were performed between mortality and vaccinated age-groups.

Results

The original Covid-19 period (54 weeks) had the highest YLL (6633.53), followed by the Omicron variant period (12 weeks; 2,692.17). The Alpha variant period (7 weeks) had the highest CFR (1.89) followed by the Original Covid-19 (1.37). A significant negative correlation was present between two dose vaccination and the 60-69 years (p = 0.01), 70-79 years (p = &lt;0.01), and 80+ years (p = &lt;0.01) age groups, while a positive correlation was present between the booster dose and the 60-69 years (p = 0.01) age group.

Conclusions

Covid-19 variant’s infectivity, transmissibility, and the effectiveness of the vaccine against the variant play an important role in the ultimate outcome. Reducing mortality by embracing mass vaccination that targets current variants along with other non-pharmaceutical interventions remains paramount.

Key messages

• Mortality is an indicator for assessing the burden of an emerging variant within a population.

• The effectiveness of vaccination against emerging variants plays a role in reducing mortality rates.

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.

The impact of Covid-19 on behavioural attitudes in Malta: A year into the pandemic

Background

The Covid-19 pandemic has affected everyone's life as the viral spread dominated the globe, and a number of restrictive measures were instituted. Behavioural attitudes are expected to have been impacted by such measures including the lockdowns. The aim was to explore any behavioural changes since the onset of the pandemic among the adult population of Malta.

Methods

An observational study was conducted through the dissemination of an anonymous survey by using Google Forms on social media (between 1st to 26th of February), targeting the adult residents of Malta. The survey's questions assessed for the increase in smoking and alcohol habits, decrease in physical activity and changes in body weight since the onset of the pandemic. Qualitative and quantitative analyses were performed.

Results

The majority of the participants (n = 1034) did not recall an increase in their smoking (91.30% CI95%: 89.41-92.87) and alcohol (88.68% CI95%:86.60-90.48) habits since the onset of Covid-19. However, 49.32% (CI 95%: 46.21-52.37) reported a decrease in physical activity with a common consensus of: “I used to go to the gym more frequently. But now I go less frequently to avoid people” and “More online meetings at home so my physical activity has decreased”. Indeed, 43.23% (CI 95%: 40.24 - 46.27) recalled an increase in their body weight as: “My food intake increased drastically” and “My eating habits have deteriorated as I now tend to turn to comfort eating”.

Conclusions

The pandemic appears to have had negative effects on risk-associated behaviours. There is an enhanced risk for the development of obesity, a disease that is already highly prevalent within Malta. It is recommended that public health advice and promotion for healthy eating and physical activity, even if under lockdown, is strengthened to prevent the development of prospective health diseases and complications.

Key messages

There is a high risk of an enhanced obesity epidemic with increased sedentary lifestyle since the onset of Covid-19.

Action strategies to encourage healthy eating and physical activity are recommended.

Anxiety and depression levels in Malta: A year into Covid-19 pandemic

Background

Covid-19 pandemic resulted in a number of lifestyle changes and restrictive measures. The aim was to assess for the impact of Covid-19 on anxiety- depression levels and associated behavioural attitudes among the adult population of Malta.

Methods

An anonymous survey using Google Forms was disseminated on social media (1st to 26th of February), targeting the adult residents of Malta. The survey's questions assessed for socio-demographic characteristics, changes in physical activity levels, and body weight. The Generalised Anxiety Disorder assessment tool was used to evaluate the level of anxiety and the Patient Health Questionnaire-9 assessment tool was used to evaluate the level of depression among the participants during the pandemic. Quantitative and qualitative analyses were performed.

Results

A total of 1,034 participants responded. Mild anxiety levels (41.20% CI95%:38.24 - 44.23) and minimal depression levels (54.23% CI95%:51.17-57.25) were generally reported. On stratification by employment status, students reported severe anxiety levels (p = <0.01). Indeed, a participant reported, “COVID-19 made me very anxious…not knowing if I will be finishing my degree”. Covid-19 also impacted on behavioural attitudes, “I am eating more, I put on weight…resulting in feeling a bit depressed and have nothing to look forward to”. Indeed, a proportional increase in body weight was reported among those with mild to severe anxiety levels (p = <0.01). An inverse trend with an increase in anxiety and depression scores and decrease physical activity levels was observed (p = <0.01 respectively).

Conclusions

The population's mental health has been impacted differently, with some societal groups more susceptible than others. An increase in body weight and a decrease in physical activity appears to be linked with both anxiety and depression levels.

Key messages

Increase in mental health burden and obesity prevalence is anticipated as a resultant effect of Covid-19.

Enhanced psychological support and prevention strategies targeting mental health and obesity are recommended.

Covid-19 vaccination – Malta’s attitude

Background

Covid-19 vaccines have been anticipated throughout the year 2020. These are envisaged by many as the way forward to beat the pandemic. However, vaccination hesitancy among the population is a public health concern. The aim was to explore the intend to take the Covid-19 vaccine among the adult residents of Malta. The vaccination roll-out in Malta started on 27th December 2020.

Methods

An anonymous survey was distributed through social media platforms during February 2021, targeting adults residing in Malta. Socio-economic data along with the intention to take the Covid-19 vaccine was gathered. Quantitative and qualitative analyses were performed.

Results

A total of 1,034 participants responded, with the majority showing intend to take the Covid-19 vaccine (75.44% CI95%:72.72-77.96). While 13.06% (CI95%:11.13-15.25) reported having already taken the vaccine. The majority of those not intending (n = 119) to take the vaccine were female (77.31% CI95%:68.95-83.96); between 30 to 39 years (42.02% CI95%:33.53-51.00), employed (76.47% CI95%:68.05-83.23) and with a post-graduate degree (36.97% CI95%:28.83-45.94). The commonest reasons for unintentional vaccine uptake were due to concern for its safety and long side effects as well as concerned if it is effective. Notably, 15.22% (CI95%:9.16-24.06) of the females reporting not intending to take the vaccine were concerned about the effect of the vaccine on their pregnancy or else were planning to become pregnant.

Conclusions

A high acceptance rate for the Covid-19 vaccine was observed among the Malta adults. However, an element of hesitancy was evident including among this study's high socioeconomic status group. The unknown future and long-term effects of the vaccine appear to be the main contributors to hesitancy.

Key messages

Covid-19 vaccine is well accepted in Malta, potentially reflecting the population’s desire to protect themselves and their families. Vaccine hesitancy is still evident even in the midst of the pandemic among high socio-economic group, reflecting the need for vaccine transparency.

The impact of Covid-19 on symptomatic back pain – A new surging epidemic?

Background

The Covid-19 pandemic led to global public health advocacy for a population behavioural and daily routine change. Remote work and social distancing were advocated to curb the community spread. A consequential effect on the physical health of the population is expected. The study aimed to explore whether since the onset of Covid-19 back pain complaints have increased while identifying potential reasons, among the Malta adult population.

Methods

An anonymous online survey was distributed on social media (6th to 20th April 2021). The survey enquired about changes in employment, daily routine, physical activity (PA) patterns and for the presence of back pain before (>6 months duration) and during Covid-19. Data on the socio-demographic status was noted. Descriptive, comparative and multivariant regression analyses were performed.

Results

A total of 388 responded with 30% (CI 95%: 25.55-34.64) reporting chronic back pain pre-Covid-19 while 49% (CI 95%:44.28-54.18) reported back pain since the onset of Covid-19. A significant change in daily routine and physical activity (p < 0.01 respectively) to a more sedentary pattern was observed. Out of those reporting back pain since Covid-19, 51.83% (CI 95%:44.78-58.81) reported a shift to remote working/learning. Indeed, continuously sitting down (OR: 15.53 p = <0.01), no PA (OR:4.22 p = <0.01), once a week PA (OR:5.74 p = <0.01), 2-3 times PA a week (OR:2.58 p = 0.05) and 4-5 PA a week (OR:3.46 p = 0.02) were associated with experiencing back pain since onset of Covid-19, when adjusted for sex, age, education and employment status.

Conclusions

The pandemic led to behavioural changes that have enhanced a sedentary lifestyle with a consequential negative impact on back pain. Those working/learning remotely may be experiencing non-optimal ergonomic conditions intensifying musculoskeletal strain with back pain complaints. Such occurrence is anticipated to increase the burden on the healthcare systems and the disability adjusted-life years.

Key messages

Covid-19 has impacted on behavioural attitudes and daily routines resulting in enhanced sedentary lifestyles with anticipated consequential effects including back pain.

Covid-19 is anticipated to increase the burden on healthcare systems with enhanced chronic diseases occurrences including back pain.

The state of health in the European Union in 2019

Background

The European Union (EU) faces many health-related challenges. Accurate and timely data on mortality and morbidity from diseases and injuries and their trends over time are essential for health planning and priority setting.

Methods

We use the GBD 2019 study estimates and 95% uncertainty intervals for the whole EU and each country to evaluate age-standardized death, YLL, YLD and DALY rates for Level 2 causes. We evaluate trends by comparing estimates for the year 2019 with those for the year 2010.

Results

In 2019, the age-standardized death and DALY rates in the EU were 465.8 and 20 251.0 per 100 000 inhabitants, respectively. Between 2010 and 2019, there were significant decreases for age-standardized, death and YLL rates across EU countries. However, YLD rates remained mainly unchanged, with increases in the Netherlands and the ‘. The largest decreases in age-standardized DALY rates were observed for HIV/AIDS and sexually transmitted diseases and transport injuries (both -19%). On the other hand, only diabetes and kidney diseases showed a significant increase for age-standardized DALY rates in the EU (3.5%). Mental disorders showed an increasing age-standardized YLD rate, as well.

Conclusions

Overall, there was a visible trend of improvement in the health status in the EU with substantial differences between countries. EU health policy makers need to tackle incidence of diseases and injuries, with specific attention to causes such as mental disorders. There are many opportunities for mutual learning among otherwise similar countries with different patterns of disease.

Inequalities in non-communicable diseases across the European Union: current state and trends from 2000 to 2019

Background

Non-communicable diseases (NCDs) remain the leading cause of disease burden in the European Union (EU). However, this burden varies across Member States, driven by the socioeconomic and demographic structure of the populations, as well as health care and social support systems in each country. This geographical gradient in the burden of NCDs represents health inequalities that may have expanded as a result of population ageing, migration, and economic crisis, and historic backgrounds.

Methods

Using data from the GBD 2019 study, we quantify the inequality gap between EU countries, characterize the geographical gradient of total and individual NCDs, and analyze the trends over the last 20 years.

Results

A considerable gap exists in the rates of NCD-related DALYs between the country with the lowest burden (Slovenia in 2019) and the highest (Bulgaria in 2019), with a constant (p-trend &gt; 0.05) ratio of 1.6 (95%CI, 1.57; 1.64) since the year 2000. The largest inequality was observed for the burden of stroke between the lowest (France in 2019) and the highest (Bulgaria in 2019) with a ratio of 7.47 (6.78; 8.24) Increasing steadily (p-trend &lt; 0.001) since 2000. Using the relative index of inequality to characterize the gradient of inequalities across the EU, a decreasing trend (p &lt; 0.001) can be observed for NCD-related DALYs rates from 1.56 (1.44; 1.7) in 2000 to in 1.42 (1.33; 1.52) 2019.

Conclusions

Despite overall improvements in health, spatial disparities related to NCDs in the EU persist. Our estimates provide a baseline to inform future equitable health policies.

A snapshot of Malta’s Covid-19 acute and post-acute symptoms

Background

The end of the year 2019 saw the emergence of a novel coronavirus (Covid-19) with patients presenting with severe pneumonia in China. Infected individuals with Covid-19 were noted to present with different symptoms, if at all. Some remained with symptoms even after testing negative for Covid-19. The aim was to explore for the most common acute and post-acute Covid-19 symptoms among adult residents in Malta.

Methods

Using Google forms, an anonymous survey was distributed on social media (1st to 26th February 2021) targeting the adult residents of Malta. The survey assessed for previous/current Covid-19 infection and for acute and post-acute (>4 weeks after negative test) symptoms. Quantitative and qualitative analyses were performed.

Results

Out of the 1,034 participants, 6.38% (CI95%: 5.04-8.95) reported to have been positive for Covid-19, with a female predominance (71.21% CI95%:59.30-80.79; p = <0.01). Various combination of symptoms was reported. However, asymptomatic (13.64% CI95%: 7.12-24.15) dominated followed by the combination of fever, cough, headaches, fatigue, loss of taste and smell, aches and pains, and diarrhoea (10.61% CI95%:4.94-17.60). Although the majority did not report post-acute symptoms, a proportion reported the continuation of aches and pains with fatigue or the loss of taste and smell (6.06% CI95%:1.94-14.01; respectively).

Conclusions

Although small case numbers were evaluated in this study, it is clear that Covid-19 is affecting a proportion of the population. Asymptomatic Covid-19 is common, enforcing the fact that infectivity rate is higher than reported. However, multi symptomatic representation is also common, possibility requiring medical attention. Within this cohort, post-acute symptoms did not appear to be dominating. Health system resilience is essential to continue caring for both acute Covid-19 and other conditions including long Covid-19 patients.

Key messages

Covid-19 community spread is higher than reported due to a substantial proportion of asymptomatic individuals.

Preventive mitigation measures should continue to be encouraged as well as strengthening health systems to care for acute and long Covid-19 along with other co-existing conditions.

Pfizer-BioNTech vaccine side effects among healthcare workers in Malta

Background

COVID-19 vaccination is critical to protect healthcare workers (HCWs) from serious infection. The first vaccine approved for emergency use was the Pfizer-BioNtech vaccine. European countries received their first supplies at the end of December 2020. The European country of Malta started its vaccination roll-out immediately targeting HCWs. The aim of this study was to evaluate side effects.

Methods

An anonymous online Google Forms survey was disseminated to all HCWs via work e-mail addresses (29th March to 9th April 2021). This gathered demographic data and side-effects regarding pain, redness, and swelling at the injection site, fever, chills, fatigue, muscle/joint pains, headache, vomiting, and diarrhea severity following each dose (Likert scale). Descriptive, comparative, and multiple binary regression analyses were performed.

Results

There were 1480 responses (response rate 30.30%). The commonest side-effect (SE) was pain at the injection site (88.92% CI95%:87.21-90.42), with the majority reporting it as mild (51%) and moderate (43%). Fatigue reported by 72.97% (CI95%:70.65-75.17), with 42% reporting it as mild and 41% as moderate. Headaches reported by 44.28% (CI95%:41.74-46.80), with 51% claiming to be mild and 34% as moderate. Females had significantly (p = <0.01 respectively) more pain (OR:1.90), redness (OR:2.49), swelling at the injection site (OR:1.33), fever (OR:1.74), chills (OR:2.32), fatigue (OR:2.43), muscle (OR:1.54) and joint pains (OR:2.01), headache (OR:2.07) and vomiting (OR:3.43) when adjusted for age and HCW role. Younger individuals (18-34 years) reported higher SE rates than older adults. Localised SE was reported following both vaccine doses, unlike systemic SE that was mostly reported following second doses.

Conclusions

Females and young adults appeared to be more susceptible to SE among this study's cohort, however the nature of these SE was mostly mild or moderate. This is encouraging and should allay vaccine apprehension/hesitancy.

Key messages

Vaccination benefits outweigh the minor side effects experienced. Caring physicians should be notified of the female higher susceptibility to side effects.

Vaccination should be encouraged among all eligible population.

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.

The burden of low back pain in Malta at a population level

Background

Low back pain (LBP) is a leading global cause of all-age years lived with disability (YLD). Studies conducted in Malta reported that musculoskeletal complaints were the commonest in primary care. The aim was to estimate for the first time the burden of LBP at population level in Malta in terms of disability-adjusted life years (DALYs) and compare to estimates obtained by the Global Burden of Disease (GBD) study.

Methods

LBP prevalence data were obtained from the Maltese European Health Interview Survey dataset for 2015 through representative self-reported history of chronic LBP for 12 months in combination to the extent of daily activities limitation. Proportions of LBP severity (with and without leg pain -mild, moderate, severe and most severe) and their corresponding disability weights followed values reported in GBD study. YLDs for LBP were estimated for the whole population by sex. Since LBP does not carry any mortality, YLDs reflected DALYs. The estimated local DALYs per100,000 were compared to the GBD study for Malta for the same year.

Results

Point prevalence of LBP causing a limitation was of 6.3% (5.6% males; 7.0% females), contributing to a total of 27,006 Maltese suffering from LBP. Global LBP DALYs were of 783 per100,000. Females experienced higher LBP burden per100,000 (876 DALYs) than males (689 DALYs). On comparing these DALYs to those reported by GBD study, a discrepancy was observed per 100,000 (Global LBP 1,828 DALYs; Males 1,657 DALYs; Females 1,999 DALYs).

Conclusions

LBP imposes substantial burden in Malta, which is expected to increase with the ageing population. Since etiology of LBP is multifactorial, it is suggested that a multi-disciplinary targeted preventive and management approach is considered. Differences observed between local estimates and those of the GBD study suggest the integration of locally sourced data into the model in order to improve the DALYs estimates of each country.

Key messages

Low back pain is a public health burden. Locally sourced data is suggested to be integrated with the GBD study to improve the DALYs estimation for each country.

The fourth decade of life: the age for preventive strategies?

Background

Non-communicable diseases (NCDs) have been on the health agenda for decades. As the 2020's decade sets in, most of the set health strategies and targets are ending while new goals are expected. Investigating a European country hub known for its high prevalence of NCDs provides evidence-based data that can be used for these new strategies. The aim was to explore potential NCDs trends and associations that could provide evidence for new preventive strategies and goals.

Methods

Data was obtained from a national representative cross-sectional study through a health examination survey (2014-6). The self-reported data and the results of the examination were used to diagnose participants with type 2 diabetes, dyslipidaemia, hypertension, overweight and obesity. The study population was stratified by ten years and sex for both descriptive and analytic analyses.

Results

The male population was significantly more metabolically unhealthy that the female counterparts across all age groups (p = &lt;0.01). The females had the highest newly diagnosed diabetes prevalence across all age groups. It was observed that type 2 diabetes, dyslipidaemia and hypertension were present as of the 30-39 years group. Conversely, on binary multiple logistic regression analysis, this age group was negatively associated with NCDs even after adjusting for confounders (Diabetes OR:0.06 CI95%:0.02-0.21 p = &lt;0.01; hypertension OR: 0.16 CI 95%: 0.05-0.55 p = &lt;0.01; overweight OR: 0.21 CI 95%: 0.11 - 0.40 p = &lt;0.01).

Conclusions

The fourth decade of life might be the starting point for metabolic dysregulation. Hence, subject to long-term health and economic burdens, with a potential extension of the metabolic impact on their offspring. Although further research is recommended, this study sets the ball rolling whether preventive action including screening for dysglycaemia and dyslipidaemia should be implemented at a population level from a young age.

Key messages

Preventive action should start from fourth decade of life. Targeting the fourth decade of life would also ensure a healthier new generation.

Is depression a cause of metabolic abnormality? A European Small State experience

Background

A relationship between depression and metabolic syndrome has been reported. Considering the diabesity rates effecting the small state of Malta it was considered appropriate to explore for links between these diseases, their metabolic determinants with depression.

Methods

A national health examination survey was conducted. A validated questionnaire note down (1) self-reported depression (2) anti-depressive medication (3) PHQ-9 depression symptoms score (&gt;5 positive for depression). Participants with the presence of one or more of these variables were labelled as having depression. Body mass index (BMI), waist circumference (WC) and blood pressure (BP) were measured. Blood testing for fasting blood glucose (FBG) and lipid profile were performed. The biochemical (FBG, Lipid profiles) and anthropometric profiles (BMI, WC, BP) of the depression population were compared to those without this disease. Univariant and multivariant binary logistic regression models were performed.

Results

The depression population (17.2% of the total population) had significantly higher median LDL, triglyceride (TG) and total cholesterol (TC) levels when compared to those without the disease (p = &lt;0.01). On univariant modelling each variable (LDL OR:1.15 p = 0.01; TG OR:1.16 p = 0.01; TC OR:1.64 p = &lt;0.01) showed a positive association with having depression even after adjusting for confounding factors (sex, age, education, smoking, alcohol habits). On multivariant modelling only an increase in TC was associated with increased risk of having depression (OR: 1.36 CI95%: 1.05-1.76 p = 0.02) after adjusting for confounders.

Conclusions

The various components of the metabolic syndrome appeared not to be associated with a diagnosis of depression. Only high cholesterol level exhibited a metabolic link with depression. Although further research is merited, it is suggested that physicians incorporate a depression screening tool as part of their consultation when examining high-risk patients.

Key messages

A metabolic syndrome profile is not linked with depression. A high cholesterol level is linked with depression, making these individuals susceptible to potential cardiovascular disease.

Which body weight status is associated with depression? Results from a European population study

Background

A bidirectional relationship has been reported between depression and obesity. Malta, a European small state, is a highly prevalent country for obesity making this population ideal to study this relationship. The aim of this study was to identify the adiposity characteristics of a population-based depression sub-group and explore for any relationships between depression and an increase in adiposity.

Methods

A nationally representative health examination survey was conducted in Malta. Body mass index was measured while a validated questionnaire was used to establish the presence of depression and the sociodemographic characteristics of the participants. The study population was categorized into different sub-populations according to their adiposity status (normal, overweight, obese) and their self-reported depression. Multivariate logistic regression analyses were performed to identify independent adiposity status and socio-demographic factors associated with depression.

Results

The prevalence of self-reported depression was 10.44% (CI 95%: 9.52 - 11.43) with a female predominance and an overweight-obese profile. Extreme obesity (&gt;50Kg/m2) was only present in individuals without depression. Only the overweight status (OR: 1.35 CI95%: 1.03 - 1.78 p = 0.03) was statistically linked with depression along with being female, having a low education level, being unemployed or retired and being a smoker.

Conclusions

The adiposity driver for the growing depression epidemic appears to be overweight rather than obesity. Stressful social determinants including unemployment, retirement, low education and being female have a role in this growing health concern. This calls for preventive action plans targeting overweight status, depression along with unfavourable sociodemographic characteristics.

Key messages

Overweight status was found to be linked with depression. Targeted action plans to prevent overweight and depression should be implemented with special attention to population with unfavourable sociodemographic characteristics.

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.

Do we practice what we preach? Assessing the food environment in Malta’s only state hospital

Introduction

Food environments are likely to be key contributors to the development of diabetes and obesity. Hospitals should strive to create a model food environment that facilitates and promotes a healthy eating behaviour among visitors, patients and staff. The study objective was to evaluate foods and beverages available for purchase in vending machines at Malta’s only state hospital.

Methods

An observational study gathered data regarding location, type of food and beverage items available in the vending machines found within the public areas within the only state hospital in Malta. All items on sale were categorized into ’healthy’ and ’unhealthy’ food and beverage according to pre-defined criteria.

Results

There were 33 vending machines: sixteen offered beverage options, and the remainder contained food items, which displayed exclusively confectionary items. The beverage machines were identically stocked so that bottled water contributed 17%, diet soft drinks 33% and regular soft drinks 50% of overall beverage choices. Fresh vegetables or fruit were not available for sale (except for 1 beverage machine offering fresh squeezed orange juice) with most items on display classified as ‘unhealthy’.

Conclusions

Hospital food environments should complement health professionals’ efforts in promoting healthier lifestyles, however, the majority of foods and beverages available for purchase at Malta’s only state hospital through vending machines is unhealthy. Urgent action is required to rectify the current situation.

Key messages

Vending machines offered ’unhealthy’ choices to patients, relatives and staff. Hospital food environment should promote healthier food and beverage options.

Beyond the diabetes epidemic – a public health challenge

Introduction

Various factors pertain to the development of type 2 diabetes (T2DM). While exploring the risk factors and links to T2DM at a population level, certain unexpected relationships were identified in a cross-sectional study representative of adults in Malta (2014-6).

Methods

A health examination study was conducted among a representative sample of adults in Malta (18-70 years). Validated medical data was collected for fasting glucose (FBG) and lipid profiles. Self-reported Diabetes (T2DM) and a fasting glucose level(FBG) &gt;7mmol/L were labelled as T2DM. Regression analysis explored T2DM and components of the lipid profile while adjusting for confounding factors (age, gender, residing locality, education level, employment status, use of statins). Separate analysis compared non-diabetic and metabolically healthy sub-populations as a reference to T2DM population respectively.

Results

A negative association was found between an increase in LDL-C (OR: 0.76 CI 95% 0.65 - 0.89, p = &lt;0.01) and a diagnosis of T2DM when the non-diabetic sub-population was the reference category. A negative association was also present for total cholesterol (OR: 0.79 CI 95% 0.69 - 0.91, p = &lt;0.01). On the contrary, a positive relationship with T2DM was present for both parameters (LDL-C OR: 4.15 CI 95%: 2.79 - 6.17, p = &lt;0.01 and Total cholesterol OR: 2.45 CI 95%: 1.84 - 3.33, p = &lt;0.01) when the metabolic healthy sub-population was the reference category. Similar results were present after adjusting for confounders.

Conclusions

Individuals without an established diagnosis of T2DM but with a biochemical and/or anthropometric abnormality are still at metabolic risk. Hence, preventive policies targeting metabolically at-risk persons at the community level need to be explored in order to target the health inequalities gap.

Key messages

Health inequalities are present in individuals with normoglycemia but with biochemical and/or anthropometric abnormality. Preventive policies need to target metabolically unhealthy population irrelevant of their glucose status.

The depression phenotype in a European population-based study

Introduction

Depression is a growing public health concern and associated with a number of co-morbidities including diabetes mellitus. The aim was to estimate the prevalence of depression at a population level across different glycaemic statuses while establishing phenotypic characteristics of this sub-population.

Methods

A national representative cross-sectional study was conducted in Malta (2014-6). Participants were categorized into different sub-populations according to their glycaemic status. Depression prevalence rates and bio-socio-economic characteristics for each sub-population were established. Multiple regression analyses performed to identify links between glycaemic status and depression.

Results

Depression was prevalent in 17.15% of our study population (CI 95%: 16.01 - 18.36) with a female predominance. The normoglycaemic sub-population had the highest depression rates. Persons with known diabetes had a higher probability of having a history of depression (OR:2.36 CI 95%:1.12 - 4.96), as well as with being of female gender, having lower educational status, smoking tobacco and having established cardiovascular disease.

Conclusions

Depression was highly prevalent among the normoglycaemic population. Primary care physicians should implement a depression screening tool as part of their routine health check-ups, with special attention to those with cardiovascular co-morbidities and low socioeconomic status.

Key messages

Depression prevalent mostly in the normoglycemic population. Screening for depression should be part of routine health check-ups.

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.