key: cord-1013651-j5w7wf36 authors: Grech, Victor; Cuschieri, Sarah; Grech, Peter; Farrugia, Ing. Karl; Gauci, Charmaine title: One of COVID-19's many costs: Malta's expenditure in consumables and non-consumables, a population-based study date: 2020-11-17 journal: Early Hum Dev DOI: 10.1016/j.earlhumdev.2020.105260 sha: 1b220821064f5019a4335bf51cc1a9e719ea820c doc_id: 1013651 cord_uid: j5w7wf36 Objective COVID-19 was first detected in China and has now become a global pandemic. Government reactions varied in different countries. In Malta, the authorities took immediate action, assessments scaling of the potential public health threat. The article aims to briefly outline Malta's pandemic preparedness while describing the processes and purchases to face this pandemic. Costings for this exercise in risk mitigation were estimated as a percentage of the country's gross domestic product and the national budget. Results Among many actions, the Intensive Care facilities were ramped up from 20 beds in one area to 100 beds in five areas. Up to 600 extra COVID-19 beds for severely ill patients were also catered for, in addition to creation of several swabbing centers. The Central Procurement and Supplies Department (CPSU) was responsible for the sourcing and distribution of all protective wear and equipment across the country for all Government departments. CPSU was also involved in sourcing alternative clinical locations to house COVID-19 positive patients. In Malta, COVID-19 preparations cost at least €100 million, that is 1.9% of total anticipated government expenditure for 2020. Conclusion The local pandemic preparation ran smoothly apart from a number of hitches that were dealt with swiftly and efficiently, displaying an agility and nimbleness. Malta has been fortunate in that the Government, advised by Public Health, reacted swiftly in order to control local spread. The silver lining is that these preparations and the preparedness exercise will serve in good stead in the setting of future pandemics. Humanity is currently in the grip of the COVID-19 novel coronavirus which was first detected in Wuhan, China, in December 2019 [1] . The virus is now pandemic and has globally resulted in over 10 million infections and well over a half of a million deaths, with many more to come [2] . The first COVID-19 case was identified in Malta on the 7 th March 2020 [3] , and thus far, the country has fared relatively well with less than 700 identified cases and 9 deaths. Malta is one of the smallest countries in the world, comprising a small archipelago in the centre of the Mediterranean with a total population of almost 500,000, a land area of 316 km² and the 7 th highest population density in the world. There is one large National Health Service Hospital with intensive care facilities (Mater Dei Hospital) along with a few other much smaller facilities and private hospitals [4] . By the 12 th March, the country had documented nine COVID-19 cases and mandated immediate childcare, school and university closures along with all mass activities and a slew of other restrictive public health measures, a list which increased over the following weeks [4] . Malta was faced with an urgent demand and an immediate challenge to acquire sufficient protective wear and equipment, together with drugs, in order to safeguard the best interests of Malta's healthcare workers and the health of the citizens of Malta. The Central Procurement and Supplies Department (CPSU) is the sole procurement department responsible for all health-related purchases. The CPSU was therefore tasked by the Government of Malta to take over the sourcing and distribution of all protective wear and equipment across the country for all Government departments. This necessitated the creation of immediate stockpiles for all of the necessary materiel. In the first two weeks during the beginning of March 2020, the CPSU performed a massive market exploration exercise to send in and confirm orders for just over €100 million for all corners of the globe (Table 1) . These items were purchased from multiple sources in order to guarantee availability. Other major items of procurement were equipment necessary to deal with patients that presented with respiratory problems (Table 2) Sterilization equipment was also purchased to decontaminate the respective wards along with air sterilizers to purify and decontaminate room air. were also sought so as to allow any surges to be accommodated. For this reason, beds were rented from smaller private hospitals in the country. Furthermore, services and supplies were sourced to support the engineering changes in the expansion process which occurred over a two-month period at Mater Dei Hospital. This include the aforementioned expansion of hospital beds to accommodate up to 600 COVID-19 patients and an expansion of intensive care facilities from one 20 bedded ICU to 5 ICUs with a total capacity of 100 beds. Facilities were also sourced (private accommodation) for the isolation of healthcare workers who needed to be quarantined due to contact with COVID-19. None of this would have been possible without wholehearted and unstinting support from the other branches of Government, especially from the Ministry of Finance and from Maltese High Commissions and Embassies abroad who helped source all of the above, as well as Air Malta, the country's national air carrier for transport of supplies. Gross Domestic Product (GDP) is the monetary value of all finished goods and services made within a country during a specific period and is typically specified as per year or per quarter. The value provides an economic snapshot and changes over time and used to measure a country's economic growth. Malta's GDP is 14.8 billion US dollars (12.8 billion Euro) and represents 0.01 percent of the world economy. The country typically spends 9.3% of GDP (2017 Eurostat data) on health, very close to the EU average of 9.9% [12] . Total government expenditure is currently €5.3 billion [13] . COVID-19 preparations cost at least €100 million, that is 1.9% of total anticipated government expenditure for 2020. to nonarable zones such as forests in proximity to bats, known reservoirs for coronaviruses [14] . For these reasons, pandemics have played out several times in the past decades with influenza repeatedly arising from poultry and pig factory farms globally [15] . A modelling exercise for the insurance industry concluded that the annual risk of an influenza outbreak on the scale of the 1918 pandemic lies between 0.5% and 1.0% [16] . The U.S. intelligence community has almost annually reported of the devastating consequences of a viral pandemic in its worldwide threat assessment: results in increased human and animal intermingling and hastens crossover of diseases from one population to the other. No one can predict which pathogen will be the next to spread to humans or when or where this will occur. However, humans remain vulnerable, especially when a pathogen with the potential to cause a pandemic emerges.... If ... influenza or any other novel respiratory pathogen that kills or incapacitates more than 1 percent of its victims were to become easily transmissible, the outcome would be among the most disruptive events possible. approximately two year" [17] s. The medical community has also frequently warned of the need "to create a preparedness plan for Disease X. Disease X is caused by Pathogen X, an infectious agent that is not currently known to cause human disease, but an aetiologic agent of a future outbreak with epidemic or pandemic potential. We have identified crucial areas for acceleration in medical countermeasure product development and international coordination. We have also reviewed novel platforms and process improvements related to manufacturing, which could revolutionize the response to the next pandemic. Finally, we created several coordination and engagement guides. These guides range from the rational design of an intervention target product profile, to the key facets of vaccine and therapeutic development, to accelerated manufacturing and regulatory mechanisms" [18] . Even a coronavirus pandemic was predicted: -it is highly likely that future SARS-or MERSlike coronavirus outbreaks will originate from bats, and there is an increased probability that this will occur in China‖, concluding that -the investigation of bat coronaviruses becomes an urgent issue for the detection of early warning signs, which in turn minimizes the impact of such future outbreaks in China…and eventually we aim to predict virus hotspots and their cross-species transmission potential‖ [25] . But sadly, despite being told that the world was unprepared, we still weren't. A pandemic arose in China, spread across the world with few of the anticipated checks anticipated in pandemic preparedness plans to check viral spread both internationally and within many countries. The local pandemic preparation ran smoothly and while a considerable number of hitches were encountered, these were dealt with swiftly and efficiently, displaying an agility and nimbleness that we were unaware of possessing. Clinical features of patients infected with 2019 novel coronavirus in Wuhan COVID-19 and potential global mortality -Revisited Superintendent of Public Health, Ministry of Health Malta, First COVID-19 Case in Malta COVID-19 panic, solidarity and equity-the Malta exemplary experience COVID-19 and finance: Agendas for future research Macroeconomic Policy in the Time of COVID-19: A Primer for Developing Countries Modelling fatality curves of COVID-19 and the effectiveness of intervention strategies COVID 19 in Malta, a small Island population Malta's healthcare escalation for COVID-19 Nation-wide initiative to buy 45 oxygen concentrators launched -Newsbook, Newsbook COVID-19 and Italy: what next? Trading Economics, Malta Government Spending | Pandemics: Known Unknowns and Our Failure to Prevent Our Unwilling Participation in a Dystopian SF Scenario Influenza Cataclysm Pandemics: risks, impacts, and mitigation, in: Dis. Control Priorities Statement for the Record: Worldwide Threat Assessment of the US Intelligence Community Disease X: accelerating the development of medical countermeasures for the next pandemic Bill Gates has warned about a pandemic like coronavirus for years, Fast Co European Centre for Disease Prevention and Control, Why is pandemic preparedness planning important? Shining light on "Dark Winter" Post-Ebola reforms: ample analysis, inadequate action Bat Coronaviruses in China A risk balancing act -tourism competition using health leverage in the COVID-19 era Financial support. None reported.Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.