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By December 2021, administration of the third dose of COVID-19 vaccinations coincided with the spread of the Omicron variant in Europe. Questions had been raised on protection against infection conferred by previous vaccination and/or infection. Our study population included 252,433 participants from the COVID-19 vaccination registry in Malta. Data were then matched with the national testing database. We collected vaccination status, vaccine brand, vaccination date,infection history, and age. Using logistic regression, we examined different combinations of vaccine dose, prior infection status and time, and the odds of infection during the period when the Omicron variant was the dominant variant in Malta. Participants infected with Sars-Cov-2 prior to the Omicron wave had a significantly lower odds of being infected with the Omicron variant. Additionally, the more recent the infection and the more recent the vaccination, the lower the odds of infection. Receiving a third dose within 20 weeks of the start of the Omicron wavein Malta offered similar odds of infection as receiving a second dose within the same period. Time since vaccination was a strong determinant against infection, as was previous infection status and the number of doses taken. This finding reinforces the importance of future booster dose provision especially to vulnerable populations, peer-reviewed

Over the twentieth century, small island states in the Pacific experienced a dietary shift from traditional foods characteristic of the region to imported foods of poor nutritional quality. In Kiribati, noncommunicable diseases including diabetes and hypertension are now the largest burden of disease in the country and the primary cause of premature mortality. Food and nutritional security in Kiribati are now a major public health challenge. Climate change is likely to negatively affect traditional food production systems. In this study, twelve gender-segregated focus groups in six communities were carried out across Kiribati. Food charts were obtained from each focus group, where all food items mentioned by communities were listed and scored for health and importance. These were analysed using Excel and Stata. Health scores were on average 42.4% lower for imported food compared to local food with strongly significant findings at a p value of

Background In late 2020, the European Centre for Disease Prevention and Control and Epiconcept started implementing a surveillance system for severe acute respiratory infections (SARI) across Europe. Objective We sought to describe the process of digitizing and upgrading SARI surveillance in Malta, an island country with a centralized health system, during the COVID-19 pandemic from February to November 2021. We described the characteristics of people included in the surveillance system and compared different SARI case definitions, including their advantages and disadvantages. This study also discusses the process, output, and future for SARI and other public health surveillance opportunities. Methods Malta has one main public hospital where, on admission, patient data are entered into electronic records as free text. Symptoms and comorbidities are manually extracted from these records, whereas other data are collected from registers. Collected data are formatted to produce weekly and monthly reports to inform public health actions. From October 2020 to February 2021, we established an analogue incidence-based system for SARI surveillance. From February 2021 onward, we mapped key stakeholders and digitized most surveillance processes. Results By November 30, 2021, 903 SARI cases were reported, with 380 (42.1%) positive for SARS-CoV-2. Of all SARI hospitalizations, 69 (7.6%) were admitted to the intensive care unit, 769 (85.2%) were discharged, 27 (3%) are still being treated, and 107 (11.8%) died. Among the 107 patients who died, 96 (89.7%) had more than one underlying condition, the most common of which were hypertension (n=57, 53.3%) and chronic heart disease (n=49, 45.8%). Conclusions The implementation of enhanced SARI surveillance in Malta was completed by the end of May 2021, allowing the monitoring of SARI incidence and patient characteristics. A future shift to register-based surveillance should improve SARI detection through automated processes.

BACKGROUND Background: In late 2020, the European Centre for Disease Prevention and Control and Epiconcept started implementing a surveillance system for severe acute respiratory infections (SARI) across Europe. Our objective is to describe how SARI surveillance was digitised in Malta and describe the characteristics of people included in the surveillance system. We also compare different SARI case definitions including their advantages and disadvantages. OBJECTIVE Objective: To describe the process of digitising and upgrading SARI surveillance in an island country with a centralized health system during a pandemic, discussing the process, output and future for SARI and other public health surveillance opportunities. METHODS Methods: Malta has one main public hospital where, on admission, patient data are entered into electronic records as free text. Symptoms and comorbidities are manually extracted from these records, while other data are collected from registers. Collected data are formatted to produce weekly and monthly reports to inform public health actions. RESULTS Results: From October 2020 to February 2021, we established an analogue incidence-based system for SARI surveillance. From February 2021 onwards we mapped key stakeholders and digitised most surveillance processes. By 30 November 2021, 903 SARI cases were reported, with 380 (42.2%) positive for SARS-CoV-2. Of all SARI hospitalisations, 69 (7.6%) were admitted to ICU, 769 (85.2%) have been discharged, 27 (2.9%) are still being treated, and 107 (11.8%) have died. Among those who died, 96 (89.7%) had more than one underlying condition, the most common of which were hypertension (57; 53.3%) and chronic heart disease (49; 45.8%). CONCLUSIONS Conclusion: The implementation of an enhanced SARI surveillance in Malta was completed by the end of May 2021, allowing monitoring of SARI incidence and patient characteristics. A future shift to register-based surveillance should improve SARI detection through automated processes.

Background The effect of ambient temperature on respiratory mortality has been consistently observed throughout the world under different climate change scenarios. Countries experiencing greater inter–annual variability in winter temperatures (and may not be lowest winter temperatures) have greater excess winter mortality compared to countries with colder winters. This study investigates the association between temperature and respiratory deaths in Malta which has one of the highest population densities in the world with a climate that is very hot in summer and mild in winter. Methods Daily number of respiratory deaths (7679 deaths) and meteorological data (daily average temperature, daily average humidity) were obtained from January 1992 to December 2017. The hot and cold effects were estimated at different temperatures using distributed lag non-linear models (DLNM) with a Poisson distribution, controlling for time trend, relative humidity and holidays. The reference temperature (MMT) for the minimum response-exposure relationship was estimated and the harvesting effects of daily temperature (0–27 lag days) were investigated for daily respiratory mortality. Effects were also explored for different age groups, gender and time periods. Results Cooler temperatures (8–15 °C) were significantly related to higher respiratory mortality. At 8.9 °C (1st percentile), the overall effect of daily mean temperature was related to respiratory deaths (RR 2.24, 95%CI 1.10–4.54). These effects were also found for males (95%CI 1.06–7.77) and males across different age groups (Males Over 65 years: RR 4.85, 95%CI 2.02–11.63 vs Males between 16 and 64 years: RR 5.00, 95%CI 2.08–12.03) but not for females. Interestingly, colder temperatures were related to respiratory deaths in the earliest time period (1992–2000), however, no strong cold effect was observed for later periods (2000–2017). In contrast, no heat effect was observed during the study period and across other groups. Conclusions The higher risk for cold-related respiratory mortality observed in this study could be due to greater inter-annual variability in winter temperatures which needs further exploration after adjusting for potential physical and socio-demographic attributes. The study provides useful evidence for policymakers to improve local warning systems, adaptation, and intervention strategies to reduce the impact of cold temperatures.

Food security is identified as one of the main challenges for the 21st century. In the Pacific islands this is especially the case due to natural, topographical, social, environmental, and economic constraints and the influence of globalisation that has forced many populations to resort to imported food. While hunger is rarely experienced by households, poor nutrition leads to a considerable noncommunicable disease burden. The effects of climate change will further exacerbate food security challenges in the region. Kiribati has one of the highest prevalence rates for obesity, diabetes and hypertension anywhere in the world. While past studies have explored regional and state-level food security challenges, there is comparatively little literature on household-level decision making processes related to food. Through focus group discussions and semi-structured interviews, we identified several themes describing challenges to achieving food security in the island nation, including several environmental challenges that hinder food security. We also include some policy recommendations based on these findings. These challenges and policy recommendations may be applicable to other atoll island communities in the Pacific and other remote coastal communities worldwide.

Small island developing states such as Kiribati in the Equatorial Pacific are among the most climate vulnerable places on Earth. While there is a considerable body of literature on the scale of the problem, there is very little research on the lived experiences of communities, their concerns and priorities, and how they are coping with environmental and climate hazards. As a result, a top-down approach is often adopted in adaptation projects that may not meet the real needs of communities, endangering the long-term sustainability and viability of interventions. Through a series of participatory focus groups carried out in Kiribati in 2019, this study explores what communities prioritise and wish to see implemented to cope and build resilience to present and foreseeable future challenges. The outcomes of this research show environmental risks and hazards faced by communities are strongly associated with climate projections. Communities are currently trying to adapt to challenges, both old and new, with technologies and materials available. While there is a degree of spontaneous adaptation occurring, these problems are insurmountable without solving present challenges in Kiribati, such as access to better technology and markets without becoming over-reliant. Including communities in co-designed interventions can also ensure sustainability in climate adaptation projects. The findings of this research can inform policy and climate change adaptation measures in other similar atoll islands in the Pacific.

Background: Climate change is recognised as having a ‘multiplier effect’ on food insecurity and adverse health experiences of communities in the Pacific region. Islands are especially at risk due to their limited land availability, population pressures and, in the case of atolls, their low-lying topography making them vulnerable to sea level rise. Aim: This review examines the literature describing the relationship between climate change, food security and health in Kiribati. Method: A narrative review was conducted, looking at both peer-reviewed and non-peer-reviewed literature available online from 1 January 2008 to 14 August 2018, the search date. Sources from three databases of peer-reviewed literature, Google and additional sources from reference lists were included in the review. Results: Thirty-seven items were included in this review. These show climate change is having a noticeable impact on food security and health in Kiribati. Four themes were identified from the literature that provide different perspectives to the problem outlined. Conclusion: Climate change is a pressing concern for the government of Kiribati and communities alike, and yet the problem is worsening, not improving. Further research is required to look at effective policies and cultural perspectives to address this problem.

The funding for this research was obtained as part of IMaGenX – and ItaliaMalta co-financed EU project Operational Programme 2007–2013., AIM AND BACKGROUND: Environmental exposures are known to play a role in the development of cancer, including breast cancer. There are known associations of breast cancer with environmental factors such as sunlight exposure, diet and exercise and alcohol consumption as well as physiological factors. This study examines the prevalence of risk factors for breast cancer related to dietary intake, environment and lifestyle in the female population of Malta. Malta has had little research in this area, and therefore an exploratory study was carried out. METHODS: A retrospective case-control design was applied. Two hundred cases and 403 controls were included. Both cases and controls were subjects without a known family history for breast cancer. Controls were age-matched to cases in an age-decade category roughly at a 2:1 ratio. Interviews were carried out face-to-face using a questionnaire designed by Maltese and Sicilian researchers, encompassing various factors including diet, lifestyle, physiological factors and medical history. Breast cancer risk was then analysed using both univariate and multivariate analyses. For factors having a metric scale, the Mann-Whitney test was used to compare mean scores, while for categorical factors, the chi-square test was used to compare percentages between the case and control groups. Statistical modelling was carried out using binary logistic regression to relate the likelihood of breast cancer to over 50 risk/protective factors analysed collectively. RESULTS: Univariate analysis showed around 20 parameters of interest, 14 of which were statistically significant at a 0.05 level of significance. Logistic regression analysis identified 11 predictors of interest that were statistically significant. Tomato, coffee and canned meat consumption were associated with lower likelihood of breast cancer (OR = 0.988, 0.901, 0.892, respectively), whereas beans and cabbage consumption and low sodium salt were positively associated with breast cancer (OR = 1.045, 1.834, 1.028, respectively). Premenopausal status was associated with a lower risk of breast cancer compared to postmenopausal status (OR = 0.067). Not having experienced myocardial infarction was associated with lower odds of breast cancer (OR = 0.331). Increased height was also found to have a strong association with risk of breast cancer, with the odds of having breast cancer increasing for every centimetre increase in height (OR = 1.048). In terms of quantity, odds of having breast cancer were lower in those exposed to sunlight (OR = 0.891). The odds of having breast cancer were also lower in those not using the oral contraceptive pill (OR = 0.454). CONCLUSIONS: Various factors in this exploratory study were found to be associated with development of breast cancer. While causal conclusions cannot be made, tomato consumption is of particular interest, as these results corroborate findings found in other studies. A negative association of breast cancer with sunlight exposure and oral contraceptive pill use corroborates findings in other studies. Other associations with dietary intake can be explained by dietary changes. More robust studies in this area, including possible longitudinal studies, are warranted., peer-reviewed

The role of human papillomavirus in breast cancer pathogenesis is an area of considerable debate following differing results from all over the world. This study analyzed paraffin embedded tissue from 19 patients with benign or malignant breast disease. Standard PCR with GP5+/6+ and FAP primers, proved negative in all cases. However, qRT-PCR using the SF10 primer set detected HPV DNA in 2 out of these samples. Whilst our data does not support a major role for HPV in the pathogenesis of breast disease in Malta, it definitely does not exclude it totally. This study also clearly shows that the method of analysis is one of the variables resulting in the range of differing results witnessed worldwide in this area of study., peer-reviewed