key: cord-0823964-beqb5osb
authors: Cuschieri, Sarah; Grech, Victor
title: Protecting our vulnerable in the midst of the COVID-19 pandemic: Lessons learnt from Malta
date: 2021-08-11
journal: Public Health
DOI: 10.1016/j.puhe.2021.07.043
sha: 733b1b9aa8713e5efcf09f864494c92d9d6583ee
doc_id: 823964
cord_uid: beqb5osb

Objectives COVID-19 is a health burden threatening the elderly and those with co-morbidities. Malta is an ageing and cardiometabolic country. The study depicts how Malta protected the elderly and the effect of vaccination on this sub-population. Study design Observational study with quantitative analyses. Method Data were obtained from Malta’s COVID dashboard, Institute for Health Metrics and Evaluation and Maltese newspapers. The case-fatality ratio (CFR) and Years of Life Lost (YLLs) for COVID were calculated. Comparisons were made between COVID-19 mortality and YLL to the pre-COVID leading mortality causes. Comparative observations were made between positive and mortality cases stratified by age groups in relation to the cumulative vaccination doses. Results The elderly were cocooned during the first wave (CFR 0.98) through the Vulnerable Act, with only 10.80% of positive cases and 7 out 9 deaths above 65 years. The Vulnerable Act was not reinstated again, with 13.68% of positive cases and 91.34% (n=369) of deaths above 65 years during the second wave (CRF 1.39). The elderly were given priority in COVID vaccination rollout leading to an inverse relationship between positive cases/mortality and vaccination coverage. Conclusion The elderly should be protected with timely restrictions to reduce morbidity, mortality and burden on healthcare systems. Vaccination is key to protecting the elderly, although mitigation measures, such as physical distancing, are still required to prevent resurgence of infections and hospitalizations especially in this group.

The elderly were cocooned during the first wave (CFR 0.98) through the Vulnerable Act, with only 10.80% of positive cases and 7 out 9 deaths above 65 years. The Vulnerable Act was not reinstated again, with 13.68% of positive cases and 91.34% (n=369) of deaths above 65 years during the second wave (CRF 1.39). The elderly were given priority in COVID vaccination rollout leading to an inverse relationship between positive cases/mortality and vaccination coverage.

The elderly should be protected with timely restrictions to reduce morbidity, mortality and burden on healthcare systems. Vaccination is key to protecting the elderly, although mitigation measures, such as physical distancing, are still required to prevent resurgence of infections and hospitalizations especially in this group.

Coronavirus; Elderly; Mortality; Morbidity; Vaccination; Malta J o u r n a l P r e -p r o o f 2 Background COVID-19 is ruthless, dispassionate and opportunistic, avid for non-communicable diseases (NCDs) and multimorbidity (presence of two or more concurrent chronic diseases), with poorer outcomes for such individuals 1 .

Malta is a small European country (population circa 500,000) with high prevalence of cardiovascular problems, diabetes and obesity 2 . Supplement table 1 presents the Malta population stratified by age-groups for the year 2018. Indeed, multimorbidity was reported to affect more than a quarter of the adult population 4 , and the top leading mortality causes for 2019 were cardiovascular disease, stroke, chronic respiratory disease and diabetes 5 . This study demonstrates how Malta protected the vulnerable (defined as elderly population ≥65 years), and the outcome of vaccination on this sub-population. The impact of premature death through the Years of Life Lost (YLL) metric for COVID-19 in Malta was compared to the YLLs of the commonest occurring non-communicable diseases (cardiovascular disease, stroke, chronic respiratory disease, diabetes) and road traffic injuries in Malta 5 . Furthermore, the Case-Fatality Ratio (CFR) was calculated for the three major pandemic phases: (i) first wave (weeks 10-19, 2020); (ii) transitional period (weeks 20-32,2020) (iii) second and consecutive waves (week 33,2020 to week 17, 2021). This was lifted on the 5 th of June (transitional phase) when consecutive low daily cases were reported 7 . During this Vulnerable Act period, only 10.80% of the positive reported cases were > 65 years 8 . While 7 deaths out of a total of 9 deaths were above 65 years, all deceased J o u r n a l P r e -p r o o f had multimorbidity 6, 8 . This period also saw postponements and cancellations of planned hospital appointments, surgeries and screening programmes 6 . These services were slowly restarted as Malta moved into transition phase (May 2020).

August (2020) saw the emergence of the second wave in Malta, and the Vulnerable Act was not reinstated 9 . High community transmission with a spill off to nursing homes was reported 9 . From 5 th June 2020 (end of Vulnerable Act) to date (9 th May 2021), 13.68% of the reported positive cases were above the age of 65 years 8 J o u r n a l P r e -p r o o f COVID-19 vaccination was initially met with some vaccine hesitancy. However, vaccination is highly protective as shown in this study. Vulnerable individuals may also have been more careful and more familiar with restrictions by this time.

In the midst of the COVID-19 pandemic and the vaccination rollout race, it is still important to follow the WHO Director-General's advice to "strike a find balance between protecting health, preventing economic and social disruption and respecting human right" 11 

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Institute for Health Metrics and Evaluation (IHME). Global Health Data Exchange

COVID-19 panic, solidarity and equity-the Malta exemplary experience

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

COVID-19 Public Health Response Team -Ministry for Health. COVID-19 Data Management System

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Ministry of Health Malta

World Health Orgainzation. WHO Director-General's opening remarks at the Mission briefing on COVID-19 -12

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