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

AIM: The coronavirus (SARS-CoV-2) pandemic is a global crisis, with more than 2 million of the world's population infected. Public health authorities across the world are working endlessly to contain the situation. The small nation of Malta has been applauded by the World Health Organization (WHO) Regional Director for Europe for the instituted escalated public health measures that have kept (up till the time of writing) the COVID-19 spread contained with low transmission rate. The aim of this overview is to give a comprehensive summary of the COVID-19 situation, measures, legislations and initiatives for containment, management and safeguarding the Maltese nation that were taken. SUBJECT AND
METHOD: A literature search was conducted using the Google search engine and Maltese online newspapers.
RESULTS: To date (22nd April 2020), the COVID-19 situation in Malta is a total confirmed cases of 444, of which 276 are active cases, 165 have recovered and there were three deaths. Various measures were taken early on, from travel bans to prohibition of more than three-person gatherings, backed up with penalties. Both public and private sectors are working together to ensure containment and provision of services to the population. Solidarity has spread across the country.
CONCLUSION: A number of timely measures have been taken. However, it is down to the nation to continue to follow the restrictions and regulations instituted by the Superintendent of Public Health in conjunction with the health division and the government to overcome this pandemic together. © Springer-Verlag GmbH Germany, part of Springer Nature 2020.

Introduction

The novel virus SARS-CoV-2, also known as COVID-19 or coronavirus outbreak, was first reported in Wuhan, China. It has now spread across the world, causing global crisis and has been declared a pandemic (World Health Organization, WHO 2020a, b). As of 22nd April 2020, a total of 2,575,875 COVID-19 cases, 178,669 deaths and 704,142 recoveries were reported (Worldometer 2020). The USA (up till 22nd April) is the highest COVID-19-affected country, with a total of 819,175 cases (2475 cases per 1 million population), with Spain as the runner up, with a total of 208,389 cases (4457 cases per 1 million population) (Worldometer 2020). The small European country of Malta, on 22nd April, ranked as the 99th country out of the world affected by COVID-19 and the 40th country out of 48 countries in Europe. It has, to date (22nd April), a total confirmed number of cases of 444 (1006 cases per 1 million population), out of which 276 are active cases, 165 have recovered and there were three deaths (Buttigieg 2020; Worldometer 2020). On 28th March 2020, the WHO Regional Director for Europe, Dr. Hans Henri P. Kluge, reported that “Malta’s public health measures were an example to follow” (Grech Urpani 2020). This report aimed to give a comprehensive summary of the COVID-19 situation, measures, legislations and initiatives for containment, management and safeguarding the Maltese nation led by the Maltese Superintendent of Public Health in conjunction with the Ministry for Health and the Government of Malta.

Malta and COVID-19

The Maltese Islands (Malta and Gozo) situated in the middle of the Mediterranean Sea have a land area of 316 km2, with a total population of circa 492,000 and ranks the 7th most densely populated country in the world. Preparations for the possibility of coronavirus spread started early, from January 2020, two months prior to the first actual COVID-19 case reported in Malta on the 7th March 2020 (Times of Malta 2020a; Cordina 2020). Nonetheless, panic shopping and fear among the population started with the first reported COVID-19 case on the sister island of Sicily (Azzopardi and Hudson 2020; Caruana 2020a; Hudson 2020). A progressive increase in cases (age ranged between 1 month old to 92 years) ws observed, with various numbers of cases reported daily by the Superintendent of Public Health, in media briefs, as seen in Fig. 1. As in other countries, a sex disparity in the COVID-19 cases was observed, with 59.23% being male (up till 22nd April 2020) (Buttigieg 2020; Collier 2020). A call for further research to identify the cause of this COVID-19 sex disparity has been made. However, it has been postulated that underlying co-morbidities and unhealthy lifestyle habits may be the reasons for this observation, where the male population tends to predominate (Wenham et al. 2020; Purdie 2020). In fact, this is the case in Malta, where the male population has been reported to be more metabolically at risk than the female population, as seen in Table 1 (Cuschieri et al. 2016a, b, 2017, 2018, 2019; Cuschieri 2020). Of concern is that a substantial proportion of the population (those with diabetes, obesity, cardiovascular disease) are at risk of acquiring complications if infected by COVID-19 (Fang et al. 2020; Simonnet et al. 2020).

Fig. 1

Time trend of reported COVID-19 cases in Malta during the 2 months of the outbreak

Table 1

Prevalence of co-morbidities and smoking habits in the adult Maltese population [14–19]

Co-morbidity/lifestyle	Male*	Female*
Type 2 diabetes	13.56%	6.98%
Impaired fasting glucose	28.18%	18.57%
Overweight	39.39%	31.81%
Obese	36.89%	31.25%
Hypertension	35.04%	25.09%
Global dyslipidaemia**	23.77%	14.62%
Smokers	24.87%	16.37%

*Patients aged 18–70 years representative data from a national health examination survey 2014–2016

**A combination of (i) population reported on statin medication and (ii) no medication but had a dyslipidaemic picture on blood testing

Malta followed the WHO advice to undertake swabbing for COVID-19 to the maximum capacity of the human resources available (WHO 2020c). Initially, swabbing was done only on travellers arriving from abroad and who were symptomatic. However, on establishing local transmission, the swabbing covered anyone with any symptoms as well as random swabbing on healthcare workers, carers working in elderly homes and among inhabitants under lockdown within an immigrant centre. By 14th April, an average of 38.74 tests per 1000 population was reported, placing Malta the third highest testing country in the world after Luxembourg and Iceland (Caruana 2020b). Up to 22nd April, a total of 26,148 swabs had been taken (Buttigieg 2020).

Preventive measures and legislations

The Superintendent of Public Health, in conjunction with the Ministry for Health and the Government of Malta, instituted escalated preventive measures and legislations before the first COVID-19 case to pick up early-onset cases, contain the spread and prevent overwhelming the health services. In fact, to date (22nd April), only two COVID-19-positive patients are receiving treatment within the intensive care unit, of which one required invasive ventilation.

A number of measures were instituted, as summarised in Fig. 2, which included travel bans and mandatory self-quarantine for anyone arriving in Malta for 15 days with a capital fine of €1000, which was then increased to €3000 for breaching (Costa and Azzopardi 2020; Superintendent of Public Health 2020a; Times of Malta 2020b; Diacono 2020b); closure of schools, universities, childcare centres, religious activities, sport or political activities, and non-essential retailer and services (Superintendent of Public Health 2020b; Diacono 2020a, c); as well as bans on group gatherings of more than 3 persons, with a fine of €100 per person if larger group gatherings were observed. A €10,000 fine was implemented for any COVID-19-positive individuals kept in the community but found in breach of their mandatory self-isolation during the spot checks carried out by health inspectors and the local police force (Commissioners for Justice Act 2020). Simultaneously, increases in ventilator machines, intensive care beds and hospital beds capacity were inclemently implemented within the state hospital of Mater Dei, as well as other public and private hospitals (Azzopardi 2020). Furthermore, plans for a prefabricated hospital to increase COVID-19 intensive treatment unit beds among other services are underway (Vassallo 2020). The COVID-19 swabbing sites increased from one within Mater Dei hospital and in an off-site premise to a total of four (three in Malta and one in Gozo). Attendance to these sites is through an appointment system after symptomatic individuals call the COVID-19 helpline (Caruana 2020b). Similar to other countries, a vulnerable person public health act legislation was set up to protect these groups (Superintendent of Public Health 2020c). Those falling under the vulnerable persons category were to be confined to their homes and only to leave the premises for essential requirements. A strong advocacy campaign was set up by the Superintendent of Public Health, backed up by the Directorate of Public Health, Ministry for Health and the Government of Malta for social distancing, staying at home, encouragement of employers to provide telework facilities to all employees, as well as to maintain a good personal hygiene measures, including regular washing of hands with soap etc. (Ministry for Health Malta 2020).

Fig. 2

Timeline of Malta COVID-19 events and preventive measures over a period of 7 weeks

Initiatives and solidarity

Helplines

A number of governmental helplines were set up to aid in this crisis. There are dedicated helplines for coronavirus symptoms, for mental health, for general support, for the elderly, for assistance in quarantine and assistance for those stuck abroad. Organizations and non-governmental organisations also set up telephone and social media accounts for those feeling lonely, mental health advice and counselling (Malta Together 2020).

Public health division

The public health professionals including the Health Promotion and Disease Prevention Directorate and the Malta Association of Public Health Medicine (MAPHM 2020) have been working endlessly as part of the COVID-19 team in swabbing, contact tracing, advocating and providing reliable evidence to the population (MAPHM 2020; Ministry for Health Malta 2020; Calleja 2020).

Assistance for food and basic needs

A number of organisations set up food banks or food/basic aids services for those that have been economically challenged due to COVID-19 (Malta Together 2020).

Financial aid packages

The Government of Malta instituted three financial aid packages for the various companies, entities and families that experienced an economic disparity due to COVID-19 (KPMG 2020; PwC Malta 2020a, b).

Other initiatives and solidarity

A number of non-governmental organisations, local companies, professionals and individuals are giving a helping hand in this crisis, such as local manufacturing company changing their line of production to healthcare masks and qualified local chefs volunteering to cook for the healthcare professionals since the hospital’s canteen had to undergo infrastructure changes due to COVID-19 (Aguis 2020; Caruana 2020c).

Solidarity being part of the Maltese soul could be observed, as the majority of the population joined together to lend a hand in this crisis while following the social distancing regulations. Such acts ranged from neighbourhoods setting up weekly roof and balcony gatherings to local artists conducting moving concerts across towns on Easter Sunday (Cassar 2020).

The good, the bad and the evil

The COVID-19 pandemic has challenged the daily living and normality of each population. Yet, it has brought about solidarity and appreciation to the front lines that, although have always been there working for the population, were previously ‘invisible’ to the public eye. Preventive measures initiated have reduced the air pollution and the frequency of asthma attacks in Malta (Watson 2020; Abela 2020). Furthermore, the restrictions applied in Malta appear to be working, since the spreading rate of COVID-19 is on the low side, with an R0 of 1.5. However, it is down to the population to abide to the directives and restrictions set up by the authorities, with special attention to social distancing, to keep this low spread constant and try to reduce the R0 value (Borg 2020). Nevertheless, this pandemic has brought fear, uncertainties, isolation and death. Countries’ economies have hit rock bottom, which may be unsustainable over a long period of time. It is only through a global effort of containment, vaccine research and solidarity shall this pandemic be overcome.

Conclusion

The small country of Malta has shown a resilience across centuries and the COVID-19 pandemic is of no difference. The public health measures instituted have been praised by the World Health Organization (WHO) Regional Director for Europe and their effect could be seen in the low sheer numbers of daily COVID-19 cases. The support and work by various public and private entities are providing the required services and order during this period. Ultimately, it is down to the each and every individual to thoroughly follow the preventive measures and restrictions to keep the COVID-19 containment and substantial good outcomes in place.