Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694840407153.pdf (Malta)
Forward Acknowledgements The Country & Its People Health Status Health Systems In Malta History Of Medicine In Malta 2 3 4 7 22 24 Meningococcal Meningitis & Septicaemia 28 Foodborne Illness Tuberculosis & Bacillus Calmette Guerin Vaccine Sexual Health Childhood Immunisations Asthma Breast Cancer Services Cardiac Services 30 34 36 40 42 44 50 Smoking & Its Threat To Health In Malta 54 Drugs & Alcohol Transport Accidents Bathing Water Medicines New Hospital Tourist Health Osteoporosis Dental Public Health Disability Elderly Change And Reform 57 59 62 65 68 73 77 80 83 86 90 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 It is indeed an honour and a privilege to be able to launch this first extensive public health report that provides essential public health information.
The aim of the Report is to give a broad but concise picture of the current health status and a number of health issues on which further public health action may be indicated.

The Health Division seeks continuously to improve the relevance and the quality of the services provided to the public.

It also endeavours to introduce public health policies that are relevant to the population.

I firmly believe that such policies, apart from being focused, need to be affordable and sustainable.
The Public Health Report reflects on the more important health issues on which action has been taken or still needs still to be taken.

The challenge is to build on the exiting information and experience to improve the health of our nation.

The report has been compiled and co-ordinated by the Department of Health Information with contributions by various experts in the different fields covered.

A special word of thanks goes to all.


I hope that in the future I will be in a position to publish further similar reports on a regular basis.

The measure of success of this report will be its appreciation and use by all concerned towards the betterment of our health.

Dr. Ray Busuttil Director General 2 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 I initiated the project of compiling a Public Health Report more than one and a half years ago.
I thank Mr. Arun Nanda, Regional Advisor, WHO Regional Office for Europe for his personal assistance and guidance.

I also thank Dr. Ray Busuttil, Director General Health, for his valuable advice and comments and for, subsequently, appointing an editorial board: Dr. Miriam Camilleri and Dr. Natasha Azzopardi Muscat as members and myself as the chief editor.

I thank both for their dedication, thoroughness and remarkable ideas that have fashioned this report to its present shape!
Dr. Azzopardi Muscat and I are also authors of some of the material included in this report and as such have also been included in the full list of contributors in this report.

Assistance in the compilation of this report was given by my staff, especially Dr. Neville Calleja, Medical Statistician and Ms. Audrey Galea, my secretary.
Special thanks go to all the contributors without whom such a report would not exist (listed below in alphabetical order): Dr. Andrew Amato Gauci Dr. Natasha Azzopardi Muscat Prof. Mark Brincat Ms. Sina Bugeja Prof. Joseph M. Cacciottolo Dr. John M. Cachia Dr. Neville Calleja Ms. Anne-Marie Callus Mr. Joseph M. Camilleri Ms. Emma Cassar Buontempo Dr. Miriam Dalmas Dr. Sandra Distefano Ms. Maria Ellul Dr. Ronald Fiorentino Dr. Ray Galea Dr. Miriam Gatt Dr. Charmaine Gauci Dr. Kenneth Grech Dr. Katheen Grima Dr. Lina Janulova Dr. Lucianne Licari Dr. Jackie Maistre Melillo Mr. Alex Manche Dr. Malcolm Micallef Dr. Yves Muscat Baron Dr. Analita Pace Asciak Dr. Renzo Pace Asciak Dr. Charles Savona-Ventura Ms. Antonella Tonna Ms. Pauline Vassallo Ms. Patricia Vella Bonanno Dr. Stephanie Xuereb Dr. Renzo Pace Asciak Consultant Health Information Chief Editor P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 3 Located in the heart of the Mediterranean Sea, just south of Sicily, the Maltese archipelago basically consists of three islands: Malta, Gozo and Comino.
The largest Island of the group is Malta from which the archipelago takes its name.

The capital city is Valletta, which is the cultural, administrative and commercial centre of the archipelago.

Malta is well served with harbours, the most important being the Grand Harbour and the Malta Freeport.

Historically, Malta’s strategic geographic position made it an attractive base for naval powers.

The harbours put Malta as an important trading position.

The area of the Maltese Islands is 316km2.


The distance between Malta and the nearest point in Sicily is 93km.

The distance from the nearest point on the North African mainland (Tunisia) is 288 km.

On the other hand Gibraltar is 1,826 km on the west and Alexandria is 1,510 km to the east.

The Maltese Islands fall within the following co-ordinates: • Northern Latitude 36 000`00`` • Eastern Longitude 14 036`00`` Gozo is the second largest island of the archipelago.
Topographically it is quite different from Malta.

It is a serene island, attractive for its less industrialised way of life.

Straddled between Malta and Gozo, there is Comino.

It is a popular tourist resort because of a couple of magnificent beaches.

It sustains a very small minority of the Maltese population.

Cominotto, Filfla and St. Paul’s Islands are the other major features of the archipelago.
Every year the Maltese Islands attract thousands of tourists, mainly due to the very good climate especially during the summer months.

There are really only two seasons in Malta: the dry summer season and the mild winter season.

Malta is a Democratic country.

Throughout the years Malta has been occupied by Phoenicians, Carthaginians, Romans, Arabs, Normans, Knights of the Order of St. John, the French and the British.

Its chequered history has bestowed a rich and colourful culture.
It was under the British crown from 1814 to 1964, when it gained independence.

From 1964 to 1979 Malta retained close ties with the United Kingdom, which had a military presence.

In 1974 a republican constitution was adopted, and the President of Malta replaced the Queen of England as the head of state.

The President assents to bills and opens and dissolves Parliament.

Except for rare constitutional matters, the President must act on the advice of the Prime Minister or in accordance with it.
The executive power lies with the Prime Minister and the Cabinet, similar to the United Kingdom.

Legislative power lies with the Parliament and judicial power with the courts.

The appointment of ministers is a prerogative of the Prime Minister, but appointees have to be members of the Parliament (Government of Malta, 1997).

Elections are normally held every 5 years as indicated in the Constitution, which is the supreme law of the country.

Malta is divided into 68 local council districts.


Elections for local councils are held every 3 years.

The national government is responsible for pro v i d i n g health care services.

Malta is a member of the British Commonwealth, the Council of Europe and the United Nations.

In 1990 Malta applied for EU membership (Turner, 1998).
The application was put on hold during the period 1996-1998 in which the Labour Party held office but soon after was re-activated by the Nationalist Government elected in September 1998.

The national language is Maltese.

This is a unique language with Semitic roots mixed with Romance elements and is a good example of the cultural heritage of the country.

Both English and Maltese are official languages.

The official religion is Roman Catholicism, which is taught in all schools.
DEMOGRAPHY Malta’s total population of 394,641 in 2001 makes it one of the smallest countries in Europe.

The population density is high, 1249 people per km2 in 2001, which renders most of Malta urban area.

In 4 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 2001, more than 90% of the population was living in urban areas.

The age pyramid presents the age structure of the population in 1970 and 1997.

The proportion of the population aged 0-14 years decreased to 19% in 2001.
Compared with other countries, the number of people aged 25-34 is relatively small in Malta.

This is partly due to a significant decrease in the birth rate in the 1960s and partly due to emigration (Central Office of Statistics, 1997).

The older age groups comprised a larger proportion of the population in 2001 than in 1970.

The share of population aged 65 years or older increased to about 13%.
The large proportion of the population boom in the mid-1940s during Malta’s "baby boom" will reach the retirement age of 60 years starting in 2005.

At this time the dependency ratio will change significantly, and this is expected to increase welfare problems.

The natural population growth rate in Malta is higher than the EU average and than the rate in most reference countries.
In 2001, the natural population growth was 2.4 per 1000 population in Malta versus 1.1 in the E u ropean Union ( E u rostat, 2002).

The natural population growth rate has been declining, mainly because the crude birth rate is falling, whereas there has been little change in the crude death rate.

There has also been a concomitant decrease in the total fertility rate to 1.5 in 2001.
HOUSEHOLD COMPOSITION & FAMILY STRUCTURE According to the 1995 census, the average household size was 3.25 in 1995, higher than in most EU countries (United Nations Economic Commission for Europe, 1999).

In 2001, 499 of 3859 total births were outside marriage (13%).

The number of marriages in 2001 was 2194 (5.6 per 1000 population) of which 474 were civil marriages (22%) (NSO, 2001) .
The constitution of Malta does not recognise divorce, and only legal separation is therefore possible under the laws of Malta (Central Office of Statistics, 1998).

This may have negative health effects on people who wish to divorce.

large households and the high The relatively population growth could have important implications in improving social cohesion and family health care.
MIGRANT POPULATION & ETHNIC PROFILE Immigrants and ethnic minorities can have specific p a t t e rns of disease and health needs because of cultural, socio-economic and behavioural factors and exposure to a different environment in their country of origin.

Obtaining access to health care that can meet such specific needs and is culturally and linguistically acceptable can also be difficult.
More o v e r, many immigrants have a higher risk of living in relative poverty and being marginalised in their countries of residence, which can result in reduced health status compared with non-immigrants.

Illegal immigrants, in particular, can find it difficult to obtain health care, and following up any care given can be problematic.

Malta has no significant ethnic minorities and in 2001 there were 472 immigrants and 73 emigrants (NSO, 2002).
By the end of 2002 it is believed that in Malta there are around 1000 refugees.

EDUCATION The relevance of educational attainment to health has been well documented.

The literacy rate among the population aged 15 years or older has often been used as T h e C o u n t r y & I t s P e o p l e 5 an indicator, but this is not very useful in Europe.
In Malta the adult illiteracy rate for the population aged 15 years and over in the year 2000 is 8% of total population while between the ages of 15 and 24 is 1.4% ( U N E S C O , 2 0 0 0 ).

In addition, all the re f e rence countries have universal primary education with almost all childre n p a rticipating.

There f o re, the gross enrolment ratio’ for p r i m a ry education is also not a very sensitive indicator for detecting diff e rences in educational levels.
In 2001 the gross enrolment ration at primary level was 107.1%.

There are, however, data on the enrolment ratios in secondary education (such as middle school, high school and vocational and technical schools) and t e rt i a ry education (universities and other higher professional schools).

In 2001, the gross enrolment ratio in Malta was 89.5% for secondary and 32.3% for tertiary education (NSO 2002).
Based on 1995 census data, an estimated 50% of men and 44% of women have completed at least the secondary level of education.

Including people who have some secondary education, the proportions are 65% of men and 57% of women.

Schooling is compulsory for all children aged 5 to 16 years and is provided free of charge by the state.

Thirty- three per cent of children attend non-public schools.

A voluntary contribution is paid for church schools, and the full tuition is paid in private schools.
ECONOMY & LABOUR Malta has a small economy with few natural resources.

The economy depends heavily on trade and tourism.

Although Malta has experienced rapid economic growth recently and the gross domestic product (GDP) per person increased by 20% in real terms from 1993 to 1998, it still has the status of a developing economy (European Commission, 1999).

The GDP per person in Power Purchasing Standard for Malta was 11,900 for 2000 (NSO 2002).
It has increased substantially in recent years but remains low compared with the EU average 22,500.

The share of agriculture and fisheries in the GDP is only 2.4% in 2001.

The industrial sector accounts for less than one third of GDP.

Of this, manufacturing and shipbuilding and repair represent the largest sub- sectors.

The electrical machinery sector continues to be a driving force in terms of exports, investment and employment.
Its share of the total manufacturing including ship repairing and shipbuilding decreased from 27.9% in 1997 to 23% in 2001.

The service sector has grown further in importance over the last decade and today accounts for more than two thirds of the GDP.

The tourism sector is by far the most to i m p o rtant sub-sector, with employment and extensive links to other sectors of the economy.
In 2001, 1.2 million tourists visited Malta of which 82.8% are from the EU and almost half of these (46.2%) are tourists from the United Kingdom (NSO, 2002).

its contribution Most of Malta’s foreign trade is with the EU.

More than half of Malta’s exports go to the EU and about two thirds of Malta’s imports come from the EU countries.

In recent years the current account of the balance of payments has gone into a considerable deficit, partly because exports have declined (European Commission, 1999).
The population in employment increased from about 132,000 people in 1993 to 145,587 in 2001.

The share of public sector employment is still relatively high: 33% in 2001.

The percentage of the population participating in the labour force is 39.4%, which is rather low compared with most other Euro p e a n countries.

However the unemployment rate of 6.5% in 2001 (NSO, 2002) compares favourably with the EU average of 7.4 (Eurostat, 2002).
The total labour force in Malta was 155,751 people, 29.2% of these were women (NSO 2002).

This is low in international comparison, and one reason may be unfavourable incentives for married women to remain in the labour market.

However, the recent introduction of such measures as reduced hours for working mothers has started to change this situation.
6 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 FERTILITY Fertility patterns have come further down from the plateau that had been reached in the period 1995 to 2000 achieving a new minimum with a total fertility rate in 2001 of 1.5.

The total number of live births in 2001 was 3955 compared to 4377 in 2000.

The mean age at delivery is still rather constant at 27.85 years in 2001, which corresponds to the previous values at around 28 years.
However, the proportion of teenage pregnancies has been slowly rising reaching 6.3% in 2001.

Even so, the majority of births (82%) occurred to mothers aged between 20 and 35.

The proportion of births for mothers giving birth to their first child, primiparas, has increased from 46% in 2000 to 49% in 2001.

During pregnancy, most mothers in Malta get adequate antenatal care with 92% recorded as having had at least one ultrasound scan.

Only 22 mothers had resorted to assisted fertilisation techniques.
The most common pathology during pregnancy was gestational h y p e rtension with 208 affected mothers.

This corresponds to the number of gestationally diabetic mothers, an associated condition, which amounted to 56 in 2001 while 10 had pre-existing diabetes.

The pro p o rtion of vaginal deliveries has been decreasing constantly from 80.2% in 1995 to 72.5% in 2001, this being mainly due to the increase in the caesarian section rate (24.2% in 2001).
90% of these b i rths happened within the public hospitals.

The number of twin deliveries has also decreased sharply from a plateau of around 60 up to the year 2000 to 35 in 2001.

90% of babies born were within the 2500g to 4999g birthweight bracket.

Survival beyond 28 days is also remarkable at 99.5% with most of the remaining 0.5% being accounted for by stillbirths.

Most mothers (70%) were discharged from hospital care within 2 days of delivery.
In 2000, 137 babies (3.2% of live births) were registered as having one or more major congenital anomalies.

There was a fairly equal distribution by gender.

The congenital anomalies noted are broken down by ICD-10 codes in the table below.
Congenital Anomaly ICD-10 code Cases* Prevalence /10,000 births Neural Tube defects Other anomalies of Nervous System Congenital anomalies of the eye, ear, face & neck Anomalies of heart and circulatory system Anomalies of the Respiratory System Cleft lip and palate Congenital malformations of digestive system Anomalies of the genital organs Anomalies of urinary system Malformations and deformations of musculoskeletal system Anomalies of the skin / integument Malformations and syndromes not elsewhere classified Down Syndrome Other chromosomal anomalies Other congenital anomalies Breakdown of congenital anomalies in 2000 Q00-Q01, Q05 Q02-Q04, Q06-Q07 Q10-Q18 Q20-Q28 Q30-Q34 Q35-Q37 Q38 – Q45 Q50-Q56 Q60-Q64 Q69-Q79 Q80-Q85 Q86-Q89 Q90 Q91-Q99 H e a l t h S t a t u s 7 MORBIDITY The hospital activity analysis (HAA) system operates via forms that are filled in with every admission by the hospital staff and sent back to the Department of Health Information.
The figure below shows the distribution of these admissions by age and gender.

It is evident that the highest number of admissions was in the female 25-34 year age group.

This would be mostly due to 90% of deliveries occurring in public hospitals.

53% of these admissions were elective while 35% were 8 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 recorded as emergency admissions.

Admission rates were fairly equal over all months of the year in 2001.
However, admission rates vary between elective and e m e rgency care, and between departments.

The average hospital stay was 4.4 days.

However, the average length of stay is fairly constant between the ages of 10 and 74 & then rises beyond 75, i.e.

in the oldest old population as shown in the figure below.

H e a l t h S t a t u s 9 The table below shows the 30 commonest diagnoses as recorded on HAA forms in 2001.

ICD-10 Code Description of ICD-10 code No.


of Patient Episodes Total Bed Days Average Length of Stay (days) O80.9 R07.4 R10.4 K52.9 K40.9 S09.9 J98.8 J45.9 R06.0 O82.9 J20.9 I50.0 I64.

O82.0 I25.9 R10.1 J44.9 I21.9 I20.0 I48.
D64.9 I50.1 J18.9 F32.9 G45.9 I80.2 L03.9 S72.9 N39.0 M54.9 SINGLE SPONTANEOUS DELIVERY, UNSPECIFIED CHEST PAIN, UNSPECIFIED OTHER & UNSPECIFIED ABDOMINAL PAIN NONINFECTIVE GASTROENTERITIS & COLITIS, UNSPECIFIED UNILAT OR UNSPEC INGUIN HERNIA WITHOUT OBSTRUCT OR GANGRENE UNSPECIFIED INJURY OF HEAD OTHER SPECIFIED RESPIRATORY DISORDERS INCLUDING CHEST INFECTION ASTHMA, UNSPECIFIED DYSPNOEA DELIVERY BY CAESAREAN SECTION, UNSPECIFIED ACUTE BRONCHITIS, UNSPECIFIED CONGESTIVE HEART FAILURE STROKE, NOT SPECIFIED AS HAEMORRHAGE OR INFARCTION DELIVERY BY ELECTIVE CAESAREAN SECTION CHRONIC ISCHAEMIC HEART DISEASE, UNSPECIFIED PAIN LOCALIZED TO UPPER ABDOMEN CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED ACUTE MYOCARDIAL INFARCTION, UNSPECIFIED UNSTABLE ANGINA ATRIAL FIBRILLATION AND FLUTTER ANAEMIA, UNSPECIFIED LEFT VENTRICULAR FAILURE PNEUMONIA, UNSPECIFIED DEPRESSIVE EPISODE, UNSPECIFIED TRANSIENT CEREBRAL ISCHAEMIC ATTACK, UNSPECIFIED THROMBOPHLEBITIS OF OTHER DEEP VESSELS OF LOWER EXTREMTIES CELLULITIS, UNSPECIFIED FRACTURE OF FEMUR, PART UNSPECIFIED URINARY TRACT INFECTION, SITE NOT SPECIFIED DORSALGIA, UNSPECIFIED P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Lung Cancer On average about 124 new cases of lung cancer were registered every year.
The male to female ratio was high at 6:1.

After non-melanoma skin cancer it was the most commonly diagnosed cancer in men.

The number of new cases of lung cancer rise sharply after the age of 45 years in both genders and peak in the 65-74 year age group in males.
New cases of Lung cancer registered between 1996-2000, by gender and age groups Age Groups 1996-2000 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total Males 0 0 1 12 59 114 202 125 17 530 Females 0 0 0 5 12 16 31 22 4 90 The age-standardised rates for lung cancer in the Maltese population were lower than the EU average for both genders.

The incidence of lung cancer in males was highest in the Pays Bas countries followed by Italy and Greece.
In females the incidence was very high in Denmark followed by the United Kingdom and Ireland.

Sweden had an exceptionally low incidence of lung cancer especially in men.

from CANCER INCIDENCE The data collection by the Malta National Cancer Registry (MNCR) uses both active and passive methods from multiple sources.
Active data collection includes review of and extraction the pathology laboratories’ reports databases (histology, cytology and autopsy reports) of cases of cancer, review of the hospital files of known cases and collection of information from the National Mortality Registry (both active and passive).
Passive methods include the receipt of notifications of cancer from the clinicians, a monthly report from the Oncology department on the new cases referred to their department and an annual report on the cases of cancer sent abroad for treatment by the state.

The National Mortality Registry is also housed within the Department of Health Information and linkage between the cancer and mort a l i t y databases is routinely performed.
The mortality registry is the recognised national source on death statistics.

Between 1996 and 2000 (5 years) there were 7467 registrations of malignant neoplasms.

Of these 3829 (51.3%) cases were in males and 3638 (48.7%) cases were in females.

The most commonly registered type of cancer are the non-melanoma skin cancers (NMS).

These accounted to 1358 (18%) cases in this series.
It is common practice in many cancer re g i s t r i e s worldwide to exclude these cancers from the analysis of their cancer incidence.

This permits the burden of the more serious cancers to be assessed more meaningfully.

Excluding the cases of NMS, leaves a remainder of 6109 cases (2980 males and 3129 females) of cancer diagnosed in Malta over this time period.

The following pages illustrate the incidence of selected common cancer sites between 1996 and 2000 by gender and age groups.
The incidence in the Maltese Islands is also compared with the latest published incidence of these cancers in the member states of the European Union.

These common cancer sites include: a.
Lung cancer: male and female b. Colorectal cancer: male and female c. Breast cancer: females only H e a l t h S t a t u s 11 12 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Sources: Rates for Malta: Malta National Cancer Registry, Department of Health Information Rates for EU member states: EUCAN: Cancer Incidence, Mortality and Prevalence in the European Union, European Network of Cancer Registries, (1997 estimates), Lyon, 2002 H e a l t h S t a t u s 13 Colorectal Cancer On average about 139 new cases of colorectal cancer were registered every year.
The male to female ratio was practically 1:1.

Excluding non-melanoma skin cancer it accounted for 11% of all cancers diagnosed.

The number of new cases of colorectal cancer peak in the 65-74 years age groups in both genders.

The age-standardised rates for colorectal cancer in the Maltese population were lower than the EU average for both genders.

The highest rates were in Germany for both males and females.
Apart from the rate of Portuguese males the southern European countries have retained the tendency for lower incidence rates than the northern nations.
New cases of Colorectal cancer registered between 1996- 2000, by gender and age groups Age Groups 1996-2000 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total Males 0 1 5 5 43 85 108 77 17 341 Females 0 0 0 12 60 68 94 90 28 352 14 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Sources: Rates for Malta: Malta National Cancer Registry, Department of Health Information Rates for EU member states: EUCAN: Cancer Incidence, Mortality and Prevalence in the European Union, European Network of Cancer Registries, (1997 estimates), Lyon, 2002 H e a l t h S t a t u s 15 Female Breast Cancer On average about 205 new cases of female breast cancer were registered every year.
Excluding non- melanoma skin cancer it accounted to 33% of all cancers diagnosed in females.

The largest number of new cases of female breast cancer (24%) was in the 45- 54 years age group.

Thirteen percent of the cases were less than 45 years old at diagnosis.

The incidence of female breast cancer is highest in the northern European countries; the Netherlands and the Scandinavian countries and lowest in the southern countries.
The incidence rates for Malta are higher than the European average and approach those of the n o rt h e rn countries rather than the rates of our geographical neighbours.
New cases of female Breast cancer registered between 1996- 2000, by age groups Age Groups 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total 1996-2000 0 2 11 120 249 212 231 162 40 1027 S o u rc e s : Rates for Malta: Malta National Cancer Registry, Department of Health Information; Rates for EU member states: EUCAN: Cancer Incidence, Mortality and Prevalence in the European Union, European Network of Cancer Registries, (1997 estimates), Lyon, 2002 16 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 MORTALITY Mortality patterns here in Malta tend to follow gender patterns as seen in other developed countries, i.e.
with an overall higher rate for males while the female death rate catches up again in the 75-84 age group.

The figures below show the distribution of the attributable death rates per 10000 population in males and females due to circulatory disease, sometimes up to 40%.

The table below each graph shows the total death rate per 10000 population per age group of the respective sex.

This permits an understanding of what proportion of deaths would each particular cause be contributing.
H e a l t h S t a t u s 17 The next two figures show the distribution of attributable death rates for the most common cancers in the two sexes.

According to National Mortality Register data for 20017, the four most common cancers in males were in the following order: lung cancer, colon cancer, prostate cancer and bladder cancer, while the four most common in females were breast cancer, colon cancer, ovarian cancer and lung cancer, in that order.
18 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 The figures below show the distribution of death rates attributable to external causes, i.e.

including transport accidents and falls for males and females.

One can note that this forms a large part of the total mortality in the younger age groups.

However, in terms of the highest cause of potential years of life lost, ischaemic heart disease still ranks first, followed by external causes and malignancies.
This is most probably more due to the much higher number of deaths attributable to ischaemic heart disease, rather than the ages of those affected.

A peak is seen in the higher age groups and this is mostly due to falls.

H e a l t h S t a t u s 19 The following charts show the distribution of death rates attributable to lower re s p i r a t o ry tract diseases.

This is a major cause of death in the elderly age g ro u p .
20 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Reference List Janulova L. National Obstetric Information System.

2002, Malta.

National Statistics Office.

Malta at a glance.

1998, Malta.

Futures Group Europe.

Spectrum: DemProj.

2002, Bath, England.

Grima K. National Mortality Register.

2002, Malta.

National Statistics Office.

Demography Review 2000.

2001, Malta.

Dalmas M. Malta National Cancer Registr y.

2002, Malta.

National Statistics Office.

Census of Population and Housing.


1995, Malta.

Distefano S. Hospital Activity Analysis Register.

2002, Malta.

Gatt M. Malta Congenital Anomalies Registr y.

2002, Malta.

H e a l t h S t a t u s 21 The Maltese health care system operates by means of an integrated health service that is organized at a national level.

No formal regional or district tiers of health care exist in the Maltese health care system.
The statutory system is publicly financed from general taxation and is free at the point of use.

All residents irrespective of income or ability to pay have access to comprehensive preventive, investigative, curative and rehabilitation services in the public Health Centres and Hospitals.

The private health care sector also has a significant role in Malta.

Households with a total low income stipulated under the Social Security Act are entitled to free pharmaceuticals.
Moreover all residents who suffer from a specified list of chronic conditions, including c a n c e r, are entitled to free medicines for their condition, irrespective of their financial means.

Primary health care is provided by the state health services and by the private general practitioners.

These two systems of general practice function independently of one another.

It has been estimated that the private sector accounts for about two thirds of the workload in primary health care.
The state run primary health care system covers general practice, community care , immunization and the school health service.

These services are mainly delivered and coordinated from eight government Health Centres that cover an extensive range of preventive, curative and rehabilitative services.

Secondary care and tertiary care are provided from a number of public hospitals.

Most hospital care is presently centred at St. Luke’s Hospital, which is the principal acute general hospital in Malta.
This hospital provides a full range of basic hospital care as well as highly specialized care, including transplant surgery and open heart surger y. Malta has become almost self- sufficient in terms of providing most tertiary care.

A few patients however, are still sent abroad, usually to the United Kingdom, through a bilateral agreement.
Currently, a new big acute general hospital; the Mater Dei Hospital, is being built and it is planned that it will start taking over some of the health care services provided by St Luke’s Hospital towards the middle of this decade.

It is envisaged that over the next few years this hospital will take over all the functions of acute care, both secondary and tertiary.
Oncology and dermatology services are provided in a smaller separate hospital, Sir Paul Boffa Hospital and there is another small public hospital, Zammit Clapp Hospital that provides for acute geriatric rehabilitation services.

Mount Carmel Hospital provides for most of the mental care services in Malta together with the short stay psychiatric unit and the mental out patients services at St. Luke’s Hospital.

Gozo with a population of about 30,000 has its own smaller general hospital.
This hospital provides basic hospital care and some specialized care.

A range of services including both secondary and tertiary care is provided within the private sector.

Inpatient care is carried out in a number of small private clinics as well as in 3 private hospitals that have started to function since 1995.

The number of private facilities has grown in recent years.

Malta has a long tradition of public health medicine, which has much in common with the British public health medicine.
There are 3 government departments, all forming part of the Health Division that have a primarily public health function.
These include: 1. the department of Public Health which works living t o w a rds the promotion of a healthy environment 2. the department of Health Promotion which is responsible for conducting campaigns to promote healthy lifestyles 3. the department of Health Information that is responsible for data collection in order to maintain disease registers, monitor hospital activity and disseminate data about the population’s health status and the health services in general.
22 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Health care financing in Malta is split between the statutory (60%) and the private (40%) systems.

State financing is complemented by private financing through out-of-pocket payment and private insurance.

The current level of GDP spending on health is 8.81% (2001).

to establish an Over the last few years extensive health care reforms have been planned and are currently being implemented.
The main aims and policy orientation of these re f o rms are integrated management approach and to provide more client- oriented, outcome driven (evidence-based) and financially sustainable services.

Presently the Health Division is the main and a direct health care services provider.
These reforms will result in the devolution of the decision-making process together with the financial responsibility to the hospitals and health centre s , whilst the Health Division will strengthen its functions of policy-formulation, resource allocation, monitoring and regulation of health services provision.
H e a l t h S y s t e m s I n M a l t a 23 The civil authorities in Malta have long felt the need to c a refully manage public health issues to control the s p read of disease and care for the diseased and infirm individuals in society.

During the Medieval Period, the responsibility of caring for the sick and infirm was f u rther strengthened with the spreading cult of Christ the Healer which led to sick-nursing being viewed as a Christian duty.
This encouraged royal dignitaries and p h i l a n t rophic individuals to donate funds towards the institution and maintenance of a hospital or hospice, the management of these institutions being often shared by the civil and the religious authorities.

The Maltese Islands have been serviced by a series of hospitals, the earliest dating to the fourteenth century.
To assist the g o v e rnment and hospital authorities in ensuring eff i c i e n t management of the public health and the various institutions, data collection and analysis tools were i n t roduced to audit the practice.

The collection of medical information is today an essential administrative tool, allowing the state, d e p a rtment or the individual practitioner to audit the p revalent practice (financial, managerial and even clinical practice), and to assess the level of health care.
It allows the administrator to identify problems and focus on priorities for improvements.

These objectives can be reached by the collection of event-oriented databases that can have several levels, each with its utility status.

These levels may include (1) demographic data, vital event registration and public health data, and (2) clinical hospital event-oriented and person-oriented data.
DEMOGRAPHIC, VITAL-EVENT, & PUBLIC HEALTH DATA It has been re c o rded that the first count of population in Malta was carried out by the Emir Yusuf-al-Futah in the year 991 for the purpose of securing certain privileges for the inhabitants, while subsequent medieval counts were made by the Bishop of Strasbourg in 1175 and Abbot G i l i b e rtus in 1241.

These population counts were c o n c e rned with taxation.
Population counts made during the period of the Knights of St. John were conducted in connection with the importation of grain f rom Sicily free of export duties.

The The ecclesiastical authorities were also re q u i red to conduct population counts in order to known how many souls were under the Bishop’s care, and the ’s t a t u s a n i m a ru m ’ contains information about population size.
The Synod of Augsburg held in 1548 prescribes four books to be kept by the parish priest “Primum in quo b a p t i z a t o rum; secundum confitentium et communicantium; t e rtium, in quo eorum, qui matrimonium in facie ecclesiae c o n t r a x e runt; et quartum in quo mort u o rum…nomina et c o g n o m i n a … .

d e s c i b a n t u r. ” formal universal p rescription was extended to five parochial registers in 1614 by Paul V in the Rituale Romanun.
The five registers included (1) Liber Baptizatoru m, (2) L i b e r C o n f i rm a t o ru m, (3) Liber Matrimonioru m, (4) L i b e r D e f u n c t o ru m, and (5) Liber de Statu Animaru m. The same n o rm has remained unchanged, though in the 1983 revision of the Codex Juris Canonici, the Liber de Statu A n i m a ru m no longer features among the Libri Paro e c i a l e s. In Malta, long before the official declarations, parish priests had been keeping their own re c o rds.
In fact, the Mdina Baptismal registers start from 1539, while the missing first 38 folios suggest that the original re c o rd s s t a rted in 1528.

The pre s e rved re c o rds from Naxxar date to 1546, those of Birgu from 1552 and of Birmiftuh fro m 1556.

These registers have not to date been utilised to the full, but are am important source for the study of Maltese historical demography.
The socio-biological characteristics of the Maltese population in the late 18th c e n t u ry have been reviewed on the basis of these re g i s t e r s .

Civil registration of births was introduced in Malta by Napoleon Bonaparte by decree of 24 August 1798 which made it obligatory for the doctor or midwife assisting at a birth to present certificates of the birth within 24 hours to the municipality under penalty of suspension fro m practice and infliction of a fine and imprisonment.
Subsequent regular civil registration of vital event data in Malta can be traced to 1863, following similar pro v i s i o n s i n t roduced by the Registrar General’s Office in the United Kingdom in 1837.

Ordinance II of 1870 re q u i red that prior to burial in cemeteries, a certificate showing the cause of death was re q u i red.

Mortality statistics by cause of death started to be published regularly by the Chief 24 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Police Physician in May 1872.
These fortnightly re p o rt s gave the number of deaths by cause, sex and district.

The causes of death were classified into: Z y g o m a t i c , Constitutional, Local, Developmental, and Violent Death.

After April 1873, further information pertaining to age at death was also included.

A Government Notice issued in 1871 re q u i red all physicians and surgeons to submit i n f o rmation to the Superintendent of Police of any communicable disease.
The list of re p o rtable infectious disease was revised in 1899.

The first annual re p o rt on a regular basis was published in 1896 and continued t h roughout the twentieth century.

The first re g u l a r census in a series of decennial censuses was carried out on 21 March 1842.

Demographic data remains the responsibility of the Central Office of Statistics.

Notification of cases of cancer were made a legal re q u i rement following the Cancer Notification Act of 1957.
This database was linked to computerized hospital data in 1984 and is still maintained today.

A D M I N I S T R ATIVE & CLINICAL HOSPITAL DATA The financial control of the various hospitals in Malta and Gozo was always considered a priority and given the i m p o rtance it deserved.

The earliest hospital accounts available in Malta are those belonging to the Medieval Santo Spirito Hospital dated to 1494.
As evidenced by a p rescription list for 1546-47, the apothecary also a p p a rently kept a re c o rd of the medications dispensed to the various hospital patients.

This system of financial audit for Santo Spirito Hospital was maintained even after the Islands fell under the civil administration of the O rder of St. John.

The concept of collecting medical statistics using clinical Event-oriented Data in Maltese hospitals was initially introduced in the early decades of the nineteenth century.
The Civil Hospitals maintained an admissions register that included an admission diagnosis.

The earliest register viewed by the author p e rtains to the Hospital of St. John the Baptist at Rabat, Gozo and covers the period 31st December 1841 to 31st August 1851.
Maternity data is included in this re g i s t e r. Also the practice of keeping clinical registers was also applied in the British Naval Hospitals in Malta in line with the general regulations of the British Naval Authorities, who in 1825 re q u i red the Naval Surgeon to submit regular nosological tables.

One British Naval s u rgeon who worked in Malta published detailed clinical re p o rts of the cases treated at Bighi Naval Hospital in Malta during 1842-1844.
In later decades, the Civil Hospitals amplified their maternity data by the i n t roduction of a Lying-in re g i s t e r. The second volume of Registers of Lying-in Women for the Gozo civil hospital covers the period 29th March 1876 to 11th April 1884.

P resumably the first volume approximately covered the p revious decade.

The maintenance of admission re g i s t e r s of the various Government Charitable Institutions was f o rmalised by the 1851 re g u l a t i o n s .
towards data The hospital clinical data was collected and audited by the Commissioner for Charitable Institutions whose c o n c e rn collection was pure l y administrative and budgetary.

The situation changed after 1937 when the Public Health Department and the Charitable Institutions Department were amalgamated in the Medical and Health Department.

This allowed the medical administrators to audit clinical data and assess medical management in the various hospital clinical d e p a rtments.
The annual re p o rts after 1937 contain appendices detailing audits of clinical depart m e n t s , besides re p o rts from various support services.

In the second part of the twentieth century, the advances in medical sciences and public expectations, and new t rends in administration placed increasing pre s s u re for m o re and for better medical information.
In Malta, the D e p a rtment of Obstetrics and Gynaecology has been in the fore f ront of this development, and its history can s e rve as a model for that of other departments.

The first annual clinical re p o rt for the obstetric department in the main State Hospital was published in 1937.

There has been since a regular series of annual re p o rts issued fro m the department, re p o rts that unfortunately have not always been published form a l l y.
The annual clinical re p o rts were laboriously assembled by hand from the Labour Wa rd Birth Registers (in use since the mid-19th c e n t u ry) and the case re c o rds of patients with a bad obstetric outcome.
While these re p o rts are interesting to the clinicians and the hospital administrators, they are of limited utility epidemiologically since they gave H i s t o r y O f M e d i c i n e I n M a l t a 25 which has since 1999 been linked to the WHO-Euro OBSQID project and extended from the State Matern i t y S e rvices in Malta to all maternity units in Malta and Gozo.

Another unit that availed itself of the person- oriented data system in 1986 was the Diabetes Clinic of the Department of Medicine.
This was after 1989 replaced by the DiabCare computer program launched by the St. Vi n c e n t ’s Declaration.

This later pro g r a m enables health care personnel to re c o rd and analyse data f rom a large number of patients and to compare re s u l t s with those of other centres.

The DiabCare project has been extended to diabetes during pregnancy – D i a b P re g C a re – which has been adopted by the Diabetic P regnancy Joint Clinic at St. Luke’s Hospital.
The person-oriented data system was also piloted for the management of clinical data collection from the Floriana Health Centre, with plans to extend these to all the health centres by 1990.

This system however became defunct in the early 1990s.

Other clinical departments, notably the medical and s u rgical departments, have again started to publish regular annual clinical re p o rts detailing their re s p e c t i v e clinical activities.
Computerised audit systems pert a i n i n g to management have been updated and expanded in the last decade to include data items and systems pert a i n i n g to assessing the work ethos of the general hospital in o rder to ensure the most efficient systems of using the available re s o u rces.

This activity is co-ordinated by a custom-designed unit that was set up in the mid- 1980s adequate and c o m p rehensive data collection.
It only remains for the various clinical and administrative departments and individuals to utilise the re s o u rces that are available.

strengthened ensure since to i n f o rmation only about abnormalities and did not p rovide national standards for comparison.

It was realised that the volume of data that re q u i res to be p rocessed on an annual basis can only be suitably managed by the use of computers.
Data event-oriented data collection using computer services was initiated in conjunction with the International Fertility Researc h P rogramme (USA) in 1981 and with the Govern m e n t Computer Centre (Malta) in 1983.
The collected i n f o rmation facilitated the preparation of a series of detailed annual clinical re p o rts, the evolution of a number of epidemiological studies which helped to identify particular obstetric risk groups in the Maltese situation, and served as a basis of clinical practice audit in the Department.

An event-oriented database is only of general value assisting health planning and hospital re s o u rc e management.

It gives no direct benefits to the individual patient.
During 1986, the Department of Health in conjunction with the World Health Org a n i z a t i o n i n t roduced a computer-based INDIVIDUAL HEALT H PROFILE aimed as a person-based re c o rd for all patients who encountered government medical services with the aim of providing readily available clinical information to medical practitioners on the patients they were tre a t i n g , of scheduling appointments and follow-up pro c e d u re s , of managing immunization and other pre v e n t i v e p rograms, and of conducting surveys and re s e a rch.
The INDIVIDUAL HEALTH PROFILE included socio- medical information about each patient and the medical diagnosis at each encounter.

This profile was eventually t e rmed the Patient Master Index.

This has now evolved in the Patient Administration System [PAS] still in use t o d a y.

Several departments in the Health Division were off e re d the facilities to extend the person-oriented database system to their needs.
The offer was taken up in 1987 by the Department of Obstetrics and Gynaecology, who re - designed the previously used event-oriented data sheets to a person-oriented one.

This data collection system continued until 1991, when it re t u rned to an event- oriented system entitled Maternity Information System, 26 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 References: Savona-Ventura C.: Civil Hospitals in Malta in the last two hundred years.
Historia Hospitalium, 1998-99, 21:p.45-63 Census ’85: Vol 1 - A demographical profile of Malta and Gozo, Central Office of Statistics, Malta, 1986, p.3-9 Establishments of the Government Charitable Institutions of the Islands of Malta and Gozo.

Government Printing Office, Malta, 1851, p.10; Savona-Ventura C. History of Medical Data col- lection in the Maltese Islands.

J. Malta College of Family Doctors.


2000, 18:p.13-17 Fiorini S. Status Animarum I: A Unique source for the 17th and 8th Century Maltese Demography.

Melita historica, 1983, viii(4):p.325-343 Annual Report on the Health Conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1937.

Government Printing Office, 1938, Malta Collezione di bandi prammatiche ed altri avissi ufficiali pubblicati del Governo dell’Isola di Malta e se dipendenze.
Dal 17 Luglio 1784 al 4 Ottobre 1813.

Government Press, Malta, 1840, p.41-43 Ciappara F., 1988: op.

cit., p.33 Ordinance II of 1870.

Malta Government Gazette, 26 July 1870, 2448:p.221 Malta Government Gazette, 31 May 1872, 2522:p.181 Malta Government Gazette, 1871, 2469:p.19; 2482:p.111- 113; Malta Government Gazette, 6 June 1899 Pisani S.L.

Annual Report on the health and sanitary condi- tion of these Islands in 1896.
Malta Government Gazette suppl., 27 November 1897, 3959:p.i-xv Malta Government Gazette, 31 December 1842, 1551:p.57-59 Register of Admissions.

Hospital of St. John the Baptist, Rabat, Gozo.

1 December 1841 to 31 August 1851.

Manuscript previ - ously held at Gozo General Hospital.

Ellul J., Stilon V., Mattei S., Zammit C. Clinical Report of the Maternity & Gynaecological Subdivisions of the Central Hospital, Malta for 1937.
Lux Press, Malta, 1938 G rech E.S., Savona-Ventura C., Fenech Gonzi P. Computerization of Obstetric Data.

In: Grech E.S., Savona- Ventura C., eds.

Proceedings: European Study Group on Social Aspects of Human Reproduction.

Vth Annual Meeting, Malta.

September 1987.

Government Press, Malta, 1988.

D.O.H.

Health Services Development Plan - Malta 1986-1990.
Department of Health, Malta, 1986; Mamo J., Agius Muscat H., Ellul M., Lenicker R. Development of a Health Information System for the Maltese Islands.

Medi-Scope 1989, 13, 1-2,6 Grech E.S., et al, 1988: op.

cit.

Mamo J., et al, 1989: op.

cit.

; Azzopardi J.

The St. Vincent Program in Malta.

Abstracts.

Diabetes Care and research in Europe.

St. Vincent Declaration ten years on.

The Target, The Progress, The Vision.

Diabetes Nutrition & Metabolism, 1999, 12(3):p.224 Mamo J., et al, 1989: op.

cit.
cit.

Savona-Ventura C. The naval career of Sir Thomas Spencer Wells in the Mediterranean: 1842-185.

Maltese Medical Journal, 1998, 10(2):p.41-46 Savona-Ventura C.: Civil Hospitals in Malta in the last two hundred years.

Historia Hospitalium, 1998-99, 21:p.45-63 Savona-Ventura C. A Maternity Unit in Gozo a hundred years ago.
Maltese Medical Journal, 1995, 7(1):p.55-61 H i s t o r y O f M e d i c i n e I n M a l t a 27 During the past few years Malta continued to be hyper- endemic for meningococcal disease (MD).

The incidence of re p o rted cases of MD has incre a s e d markedly from 0.8 per 100,000 persons in 1994 to 8.1 per 100,000 in 2000 - the highest rate since 1942.

In the year 2001, the incidence rate dropped to 5.5 per 100,000 Maltese population.
The figure below shows the general trend of an escalating crude annual incidence rate of MD since 1994 obtained fro m notifications received at the Disease Surveillance Unit of the Department of Public Health.

The two main sources of data on the incidence of MD in Malta are through: 1 .Disease Surveillance - Off i c i a l n o t i f i c a t i o n s of MD to the Disease Surveillance Unit of the Department of Public Health.
The adopted clinical case definition is that suggested by the WHO Recommended Surv e i l l a n c e S t a n d a rds.

However, suspected cases without petechial or purpural rash were not included.

Deaths attributed to meningococcal disease are also notified to the Disease Surveillance Unit through the D e p a rtment of Health Information, which pro c e s s e s all death cert i f i c a t e s .
2 .L a b o r a t o ry Surveillance - Laboratory re p o rt s s u b m i t t e d f rom the state hospital microbiology laboratory of the D e p a rtment of Pathology at St. Luke’s Hospital.

L a b o r a t o ry diagnostic methods used for confirm i n g MD include micro s c o p y, rapid antigen scre e n i n g , c u l t u re and sero g rouping.

Serotyping and subtyping is c a rried out at the Public Health Laboratory Service - Meningococcal Reference Unit, in Manchester.
N o n - residents and cases of MD other than meningitis and /or septicaemia are excluded from epidemiological e v a l u a t i o n .

28 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Data on sero g rouping in Malta is available from 1995.

S e ro g roup B accounts for the highest pro p o rtion of cases in each year.

The age-specific incidence rate is highest in c h i l d ren less that 5 years of age, particularly infants and in the 10 - 19 year age gro u p s .
Data on sero g roup is not available in all cases.

Most of these cases are given antibiotics prior to a lumbar p u n c t u re.

Since the general policy for the management of clinically suspected meningitis is to give antibiotics i m m e d i a t e l y, it is inevitable that sero g roup typing and sub-typing are not possible in every case.

A c ross Europe the annual incidence of meningococcal infection is generally in the range of 1-3 per 100,000 persons per year, although it fluctuates.
An overall tre n d is suggested from the re p o rted incidence rates, especially since 1993.

More o v e r, meningococci sero g roup B remains the predominant cause of MD in Europe as a whole.

Over a short period of time, Malta has experienced a significant increase in MD activity p a rticularly since 1996.

Malta can be placed with the Republic of Ireland and Iceland as countries with markedly higher incidence rates than other Euro p e a n countries.
It has been shown that increased transmission of meningococci occur in closed and semi-closed communities.

Similar explanations may possibly apply to isolated and densely populated communities on a wider level.

The following epidemiological determinants can be c o m p a red to other European countries: S e a s o n - As in Europe most cases of MD in Malta (58%) occurred in winter.
This suggests that incre a s e d transmission may be facilitated by closer personal contact, lack of ventilation and catarrhal and influenza-like illnesses frequently occurring in winter.

Indeed, influenza A infection has been associated with subsequent MD.

A g e - The highest age-specific attack rate found in infants is consistent with other findings across Euro p e and the USA.

A secondary peak of teenagers was found in Malta during 1994-1996 as well as in 2000.
When the incidence of disease rises suddenly an u p w a rd shift in the age distribution of cases is often o b s e rved consistent with the hypothesis that a cohort of individuals susceptible to a part i c u l a r, perhaps new meningococcal strain, has accumulated within the population over a period of years.

G e n d e r - No statistically significant diff e rences in disease occurrence was observed between the two sexes.
The usual preponderance of male cases in n o rt h e rn Europe and the USA has not been observ e d in Malta.

Type of meningococcal disease - Diff e rent countries in E u rope re p o rt varying pro p o rtions of septicaemia and meningitis cases.

More o v e r, there may also be variations due to differing definitions used to classify MD by type.

Hence, comparisons with other Euro p e a n countries may be diff i c u l t .
Though the majority of individual cases can be tre a t e d s u c c e s s f u l l y, the prevention and control of MD pre s e n t s a major public health challenge.

The importance of constant enhanced surveillance, particularly to monitor any changes in the sero g roup on the meningococci causing disease, cannot be overemphasized.

The verification of the causative organism is of utmost i m p o rtance in the management of cases and contacts.
M o re o v e r, the identification of sero g roup, serotype and subtype is of great public health relevance.

Clinicians are encouraged to provide nasopharyngeal swabs and in addition petechial scrapings to blood and c e re b rospinal specimens.

The yield of fluid meningococci from nasopharyngeal swabs in cases is about 50% and is less affected by prior antibiotics.

With the availability of vaccines against serogroup B meningococci, vaccination will become of major importance in preventing MD in Malta.
However this vaccine is still in the experimental stages and not yet available for use.

Meanwhile, the main methods of control remain the early treatment of cases and the prevention of secondary cases 29 F o o d b o rne illnesses are routinely re p o rted to the Disease Surveillance Unit of the Public Health Department.
Besides this form of passive surveillance, medical officers also perf o rm active surv e i l l a n c e whereby cases are identified from hospital wards and from laboratory confirmed results.

In accordance with the Prevention of Disease Ordinance medical practitioners are obliged to notify cases of food poisoning.
The licensee of a medical diagnostic laboratory is obliged by the Medical and K i n d red Professions Ordinance the Superintendent of Public Health of any infectious disease notifiable under the Prevention of Disease Ordinance.

inform to necessary, for analysis at the Public Health Laboratory.

A final report of the investigation is forwarded to the Disease Surveillance Unit through the Manager Health Inspector.
Regional Health Inspectors, who take legal action as is deemed necessary if the re q u e s t e d alterations are not taken in hand urgently, later follow this up.

In Malta, the total number of reported cases (sporadic and outbreaks cases) of foodborne illnesses reached a peak in 1996 with a downward trend after that.

During that year, 553 Maltese residents were involved in o u t b reaks of Salmonellosis.
A single caterer was responsible for 15 of these outbreaks affecting 203 cases, hence giving rise to this high number of cases in 1996.

The Disease Surveillance Unit investigates such notifications.

An inspection is performed by Health Inspectors posted at the Food Safety Unit at the suspected source of food.

Samples are elevated as These statistics are probably underestimates.
Although no studies have been performed locally to determine if this is a true estimate, many factors may be responsible 30 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 for decreasing the notification rates.

In Malta, there is a v e ry strong general medical practice with general practitioners taking care of families in their private practice.
When a doctor notifies a case of suspected food poisoning this is investigated by the Disease Surveillance Unit of the Public Health Department, many times with the help of a health inspector.

Traditionally people associate health inspectors with enforcement of the law and so would not like to be notified.

This means that general practitioners may not notify cases to avoid conflicts with their patients and to avoid losing them from their patient list.
Another factor is that doctors claim to be too busy to spend time filling in notification forms.

These factors may be responsible for an underestimate in the likely burden of illness in Malta as seen in other countries.

T R E N D S O F F O O D B O R N E D I S E A S E The source of food that is implicated in causing foodborne illness varies.
The Disease Surveillance Unit of the Public Health Department in Malta, investigates both sporadic and outbreak cases of foodborne illness by using a standard questionnaire.

This includes taking a history of the food ingested and the source of this food.

Hence the Disease Surveillance Unit has information of food histories of the foodborne illnesses which are notified.
Patients do not always seek a doctor’s advise for gastro- enteritis but will instead go to the pharmacist for over the counter medicines, including oral rehydration salts.

These cases of food poisoning may never reach a doctor’s attention.

Patients also tend to be reluctant to submit stools for culture, so laboratory diagnosis of cases is not always possible.

The spectrum of foodborne diseases is constantly changing.
For example typhoid fever was extremely common at the beginning of the 20th century with peaks during World War I and another higher peak during World War II.

It is now almost completely for- gotten since very few cases occur.

The last two cases occurred in 1997.

F o o d b o r n e I l l n e s s 31 D ATA A N A LY S I S Over the period 1990-1994, data was analysed for 56 of the outbreaks of foodborne illness.
Of these 29 in commercial catering pre m i s e s (52%) were (restaurants, canteens, hotels and holiday complexes), 17 (30%) were associated with food prepared in private homes, and 10 (18%) in hospitals and residential institutions.

For 1996-1999, a high percentage of sporadic cases diagnosed as Salmonella had consumed food from their homes, these included 44% of cases in 1996, 44% in 1997, 60% in 1998 and 59% in 1999.
Similarly, for outbreaks of food poisoning during the same period, a high percentage of outbreaks were associated with food pre p a red in private homes, contributing to 41% of the outbreaks in 1996, 30% in 1997, 46% in 1998 and 30% in 1999.

In 2000, the implicated source of food-borne illness in 24% of cases was of household origin.

In 2001, the implicated source of food-borne illness in most cases (50%) was of household origin.
Hence, case investigation by the Disease Surveillance Unit revealed that most of the cases are due to poor food safety practices in their homes.

This directs control strategies towards the consumer in the home.

A local study was performed in 1999 to assess the level of consumer knowledge and attitudes toward safe foodhandling in home in order to design a local health promotion campaign.
Three focus groups and a small case control study were carried out to gather i n f o rmation about local consumer knowledge and attitudes towards safe food handling in the home.

These studies showed that persons or their dependants that were exposed to Salmonellosis had a higher level of awareness to certain elements of food safety.

Also persons have to be convinced that food safety measures do have an effect before they will act upon messages.
32 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 BRUCELLOSIS AND H E PAT I T I S A The incidence of Brucellosis during the 1980’s was low with 7 cases in 1991.

A sudden resurgence of the disease occurred in 1995 with 225 notified cases (mean annual incidence of 59.8 per 100,000 population).

99% of the cases gave a history of ingestion of raw cheeslets made from unpasteurised milk sometime during the previous few months to a year before the onset of symptoms.
There have been no notified cases during 1999, 2000 and 2001.

Hepatitis A shows a slowly upgoing trend since 1995.

During the period 1995-2000 there were four individ- ual outbreaks affecting a total of 17 persons.

In 2001 there were no cases of Hepatitis A. F o o d b o r n e I l l n e s s 33 Tuberculosis (TB) is a contagious disease caused by a micro-organism called Mycobacterium tuberculosis.
In 1993 WHO took an unprecedented step and declared TB a global emergency: • One third of the world’s population is infected with TB • 7 to 8 million people around the world become sick with TB each year • 2 - 3 million people die of TB each year.

TB kills more youths and adults than any other infectious disease in the world today.

Although the disease is more common in developing countries, the number of cases of TB increased in USA and many Western countries.
The main factors contributing to the rise of TB are: recent • The the Human Immunodeficiency virus (HIV) infection.

HIV infection reduces immensely the body’s defences against TB.

HIV and TB form a lethal combination each speeding the other’s progress.

TB accounts for almost one third of all Acquired Immune Deficiency Syndrome (AIDS) deaths world-wide.

pandemic of • Refugees, illegal immigrants and displaced people.

Untreated TB spreads quickly in crowded refugee camps and shelters.
It is difficult to treat mobile populations.

As many as 50% of the world’s refugees may be infected with TB.

As they move, they may spread TB.

• Tourism and travel to countries where TB is still very common.

• Foreign workers coming from countries with a high incidence of TB.

Some of these subsequently develop the disease some time after arrival.

• Poorly managed TB programmes that are threatening to make TB incurable.
Although the introduction of TB antibiotics in the middle of the last century has made TB curable, poorly supervised and incomplete treatment of patients with TB are threatening to make TB incurable again because of the development of resistance.

The incidence rate of TB among the Maltese population is one of the lowest from a global perspective with a preponderance of cases in the elderly denoting mostly old infection (as opposed to new infection in the younger age groups).
It has not followed the upward trend shown in many neighbouring countries such as Italy, UK, Libya, Algeria, Spain and Switzerland.

Also drug resistant strains have not yet featured among the Maltese population.

However there must be increased awareness of TB as a re-emerging disease.

The AIDS epidemic in Malta is still in its initial phase and a larger impact on TB may occur if HIV infection increases.
Also we are still open to imported TB including multidrug resistant strains which are very difficult and very expensive to treat.

TB control in a country depends on prompt detection and proper treatment of cases, contact tracing and directly observed treatment strategy (DOTS).

Bacillus Calmette Guerin (BCG) vaccination serves as an adjunct to TB control.
In Malta BCG is offered to the following people up to the age of 45 years: • school children aged 12 –14 years • contacts of TB • healthcare workers • teachers • children born to parents from high risk countries • prisoners and prison staff • intravenous drug users • travellers going to a high risk country for longer than 3 months or living in a high-risk setting like health facilities, prisons and homeless shelters.
Tu b e rculosis vaccination is becoming even more important in a world where HIV infection is rising.

Here in Malta, we can say that the incidence of tuberculosis has been reduced to a stable low level as shown in the graph on the opposite page.

34 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Malta has one of the lowest incidence rates of TB and the future challenge is to actively maintain all the necessary safeguards against this ‘global emergency’ and avoid its re-emergence.
S e x u a l H e a l t h 35 Over the immediate post-war decades, the European epidemiology of sexually transmitted diseases closely followed the behaviour of troop movements and their encounters.

The sexual revolution and new social mores of the sixties and seventies saw these infections (gonorrhoea, Chlamydia and papilloma virus amongst others) occurring more in teens and twenty year olds.

More recently however, with the spread of HIV/AIDS, sexual health has acquired new prominence.
Changing social conditions, which have in turn led to changes in sexual behaviour and relationships, include tourism (often accelerating urbanisation, mass including holiday sex as an objective), an earlier start to puberty together with a rising mean age of marriage, rising separations or divorce rates leading to more people living on their own, rapid spread of mass media across all cultural boundaries, a declining extended family and a general loosening of traditional family values.
The growth of women’s independence, the wider use of contraceptives, the changing attitudes and increasing tolerance of gay people and their rights, and the overall more liberal approach to sex have challenged the traditional values that have long focused on the church’s teachings of sex being primarily a vehicle for procreation.
36 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Apart from the traditional ‘venereal diseases’ and the age old problem of unwanted pregnancy (which, as anecdotal evidence increasingly suggests, is resulting in some women resorting to abortion both locally and abroad) and childbirth occurring too early among girls who then marry while too young and immature (often to even more immature young men), a number of other medical problems arising from irresponsible sexual behaviour have intensified.
These include infection with HIV, infertility and other morbidity due to undiagnosed sexually transmitted diseases, sequelae f rom unsafe the psychological trauma to the mother and the child that room’ abortions and ‘back results from unwanted children.

In addition adolescent m o t h e rhood usually means an end to adequate education or training and therefore worsens future economic opportunities for herself and her family.
The adolescent mother may not be in a position to provide adequate childrearing and usually does not have much support from the father – who may himself be an adolescent.

This leads to increasing social pressures on the grandmothers or institutions that may care for such c h i l d ren - shifting scarce re s o u rces from other important problems such as the care of the elderly in the community.
Recent growing fears about HIV and AIDS, as well as the massive Eastern European epidemic of STIs, that followed the decline of their traditional values, have led to serious concerns about the public health consequences of the present state of affairs in Maltese society.
S e x u a l H e a l t h 37 Source: Disease Surveillance Unit The general population has increasing risks of these sexual health problems; however there are sub- populations that are known to be more vulnerable to problems – especially the infectious diseases.
These are: young persons (especially the less mature who are willing to experiment); men who have sex with men, including married bisexual men; drug users; prisoners; and then those working in the tourism industry, men who work for extended periods abroad (such as sailors), sex workers and their clients.

• Psychological consequences of sexual coercion and abuse; • Poor educational, social and economic opportunities for teenage mothers; • Psychological consequences of illegal abortion.
Poor sexual health undoubtedly costs the country a lot of money.

Preventing poor sexual health has significant potential not just for better health, but also for the better use of finite resources.
The consequences of poor sexual health are well known: • Pelvic inflammatory disease, which can result in ectopic pregnancies and infertility; • Recurrent genital herpes; • HIV infection; • Cervical and other genital cancers; • Hepatitis, chronic liver disease and liver cancer; • Bacterial vaginosis and premature delivery; • Unintended pregnancies and abortions; The objectives of a national sexual health policy are to: 1.
Ensure that all young people in Malta receive appropriate and effective education about sex and relationships as part of their personal and social development; 2.

Improve young persons’ attitudes to suitable moral values with respect to sexual matters; 38 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 3.

Ensure that all sexually active people in Malta have access to appropriate good quality sexual health services, support and advice; 4.
Reduce teenage pregnancies and re d u c e unintended pregnancy rates; 5.

Reduce the prevalence of undiagnosed HIV and STIs and therefore the complications that may result from these; 6.
Reduce illegal abortions; Prisoners and Detainees, Abortion Serv i c e s , Counselling and Psychosocial Support Services, Social Legal and Ethical Issues, Gynaecology Services, Role of the Family Doctor, Specific Services for Sex Workers, Specific Services for men who have sex with men, Specific Services for victims of rape and sexual abuse and future Research Needs.
The first draft of the document is expected to be sent out for consultation in the first months of 2003 and a conference to discuss the contents and implications will be held later on next year.

7.

Reduce the transmission of HIV and sexually transmitted infections and the incidence and prevalence of these STIs in Malta; 8.

Promote a more supportive environment which encourages and understanding about sexual issues and fosters good sexual health; knowledge openness, 9.
Reduce the stigma associated with HIV and STIs; 10.

Strengthen monitoring, surveillance and conduct research to support future planning of sexual health services and interventions; 11.

Improve health and social care for people living with HIV.

The sexual health policy currently being prepared provides an overview of the epidemiology of disease – present and future trends, some assessment of sexual behaviour and knowledge and the initiatives carried out so far.
A discussion of the ethical and moral aspects and of the determinants of better sexual health is included.

The policy then focuses on what needs to be done in the respective areas.
These include the National Education and Information campaigns, School Based Sexual Health Education, Training needs, Monitoring Surveillance and Research needs, Specific HIV and STI Interventions, Contraception Services, C h i l d h o o d I m m u n i s a t i o n s 39 In Malta, these immunisations are provided by the National Immunisation Services section, as per the following schedule: Age Vaccine Remarks At 2 months of age At 3 months of age At 4 months of age At 15 months of age Diphtheria/Tetanus/Pertussis Polio Haemophilus Influenza type-B Diphtheria/Tetanus/Pertussis Polio Haemophilus Influenza type-B Diphtheria/Tetanus/Pertussis Polio Haemophilus Influenza type-B Measles Mumps Rubella nil nil nil nil During the 4th year of life (31/2 to 4 years) Diphtheria/tetanus Polio 3 years after third dose of basic course During the 7th year of life Measles Mumps Rubella To all children At 9-10 years (during the 5th year of junior school) Hepatitis B To all children - at day 0, 1 month later and then 6 months from day 0.
At 12-14 years BCG - Tuberculosis To all children At 16 years Diphtheria/tetanus Polio nil 40 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 LOCATION OF IMMUNISATION OF CHILDREN BORN IN 1999 WHO WERE VACCINATED DIP-TE-POL III PERTUSSIS III HAEMOPHILUS III MMR-1 % Vaccinated by Gov.

68.26 68.48 68.59 76.14 Priv.

31.74 31.52 31.41 23.86 Overall it is fair to say that the present vaccination p rogramme is strong but there is no room for complacency.
The importance of MMR-I and especially MMR-II should be further emphasised, and we need to maintain momentum on promoting childhood cover with the hepatitis B vaccine.

public a health A multidisciplinary National Advisory Committee on forum Immunisation Policy provides for paediatricians, specialists, m i c robiologists, virologists and infectious disease specialists to discuss and debate the latest scientific reports on all aspects of vaccines and immunisation.
The recommendations of this committee are received by the Director General who then would direct the Primary Health Care Services to implement what ever is necessary.

The National Immunisation Services is a section within the Primary Health Care Services department.

The mission of the National Immunisation Services is to ensure that the public and private health services provide the best protection vaccines can offer our society within the limits of the available resources.
In Malta, WHO’s Health 21 Targets for immunisation have been adapted as the local targets.

Thus the coverage for Diphtheria and Tetanus, three doses (DiTe III) and Polio three doses (Polio III) at two years is 94.67%, while for Mumps 84.22%, Pertussis three doses 92.85%, H. Influenzae Type B three doses 93.57% and Rubella 84.22% (all figures for the year 2000).
Although these can be improved upon, they compare well with what is expected and we feel confident that we can look forward to achieving all the Health 21 targets related to these diseases.

For measles the situation is slightly less favourable with the rates for the first dose (MMR-I) at 2 years old being 84.22% (for the eradication we need at least 90%) and for the second dose (MMR-II), the official figures lie at less than 1 per cent in 9 year olds (again we need to cover around 90%).
It is still too early to comment on the national Hepatitis B vaccine programme.

Most of the vaccination occurs within the government National Immunization Services based in the local Health Centers.

C h i l d h o o d I m m u n i s a t i o n s 41 INTRODUCTION Asthma is a persistent disorder of the airways that is characterised by inflammation.

It affects persons of all ages and onset can occur at any age.
The disease varies in severity not only among individuals but also in the same individuals; indeed it may be quiescent for periods of time.

This chronic illness not only impairs the physical status of patients but also their emotional and social functions.

Asthma also has an adverse impact on the family and is the cause of morbidity ranging from mild anxiety to marked disability.

It is also a frequent cause of absenteeism from school among children and sick leave among adults.
In Malta asthma is a common disease and from several studies it may be estimated that around 10% of the population suffers from this condition.

In a study among Maltese teenagers around 11% were told that they had asthma while just over 20% had exercise- related wheezing.

The prevalence of the condition is on the increase worldwide and a similar trend may be observed in Malta.
PUBLIC HEALTH PROBLEMS At a population level there are three major factors that contribute to asthma morbidity; underd i a g n o s i s , inadequate treatment and poor adherence to treatment prescribed i.e.

compliance.

The first two issues were addressed at a national level through the publication and dissemination of guidelines for the management of asthma published in February 1998.

These were the first national the management of a condition.
These guidelines were evidence-based and represented a broad consensus between a wide spectrum of health workers in the field of asthma.

therapeutic guidelines for Poor compliance to treatment in asthma is widespread and it is thought that this is a major cause of b reakdown in control of asthma and consequent hospitalisation for stabilisation of the condition.
Of the patients admitted to hospital because of asthma nearly 80% were due to poor compliance to inhaled steroid medication; 58% of these individuals regularly missed their medication.

The rate is high compared to other E u ropean countries.

At a diff e rent level, non- compliance creates significant increases in both direct and indirect healthcare costs.

THE COSTS OF ASTHMA CARE Uncontrolled asthma inflates the cost of care for this condition and in the main this is due to hospital care.
It is estimated that 10% of patients with asthma account for 50% of the total costs for asthma care.

The direct costs of care include medications, consultations with doctors and health centre and hospital use.

It is estimated that in Malta the mean hospital stay necessary to stabilise a patient with asthma is 5.5 bed days.

The individual costs of care are mostly due to time spent off-work and time spent by carers at home.
Severe asthma may be the cause of early retirement and occasionally premature death.

Mortality from asthma as such, averages 3-4 patients per year and detailed examination of the circumstances suggest that such deaths are usually due to sudden fulminating attacks and in practice are unavoidable.

The close proximity of acute health care facilities in the Maltese island ensure that death from asthma due to lack of medical attention is rare indeed.
Intangible costs of asthma include impairment in the quality of life and studies among Maltese patients show that over 90% of patients suffering from asthma report some form of impairment.

In this respect there are also gender differences in that female patients suffering from asthma reported an overall poorer quality of life than male asthmatics.

Unquantifiable costs of asthma include fear, worry and personal and family upset.
THE SERVICES AVAILABLE TO PATIENTS WITH ASTHMA A key-component of asthma care in Malta is the availability of free-of-charge medication for all those 42 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 suffering from asthma, irrespective of their income.

Adult (over 14 years of age) patients suffering from asthma are seen at out-patient clinics run by respiratory physicians.

This ensures continuity of care and treatment according to standard protocols.
Patients with asthma are seen at out patient clinics which are held on every day of the week.

Acute care for patients suffering from a breakdown in control of asthma is provided in the first instance by family physicians.

Patients also attend regional health c e n t res for acute treatment, principally involving inhaled therapy with a nebulised bro n c h o d i l a t o r. When patients are difficult to manage or are in need of repeated acute care, they are referred to the Hospital Casualty Department.
Hospital care of patients with asthma is delivered according to a protocol set out in the “Malta Guidelines for Asthma Management”.

All adult (14 –59 years) patients with acute severe asthma are now admitted under the care of a consultant re s p i r a t o ry physician as this has been shown to improve the quality of care given.
CHALLENGES The principal challenge to improve asthma care is the wider diffusion of health education about the condition together with the need for patients to enter into a partnership with health care providers.

This needs to be targeted primarily at patients themselves as only if they understand their condition and the need for regular treatment will compliance improve.

Patients need to play a more active role in decisions taken related to their condition.
Other target groups would need to include parents of asthmatic children and teachers who have children suffering from asthma in their class.

The formation of a patient-led and managed asthma society would be a major step in asthma care in Malta as this would not only serve to educate, inform and empower patients themselves but also would serve to completely remove the taboos that were form e r l y attached to this respiratory condition.
A s t h m a 43 THE LOCAL SITUATION Breast cancer is the most common cancer and leading cause of cancer deaths among women worldwide.

Malta is no exception, with breast cancer being the commonest cancer in Maltese women.

Data published by the Malta National Cancer Registry demonstrates that between 1998 and 2000: • The mean incidence of breast cancer in female Maltese residents was 211 new cases per year.

This accounts for 32% of all newly diagnosed cancers in females.
• 1 woman out of 12 has the risk of developing breast cancer in her lifetime.

• Breast cancer accounted for 27% of all cancer deaths in females.

• Over the three-year period, an average of 88 women per year died from breast cancer.

Therefore 1 woman out of 31 has the risk of dying from the disease.

• Cancer of the breast is rare in men, with one case in males for every 84 cases in females.

• The likelihood of developing breast cancer increases with age.
Age-specific incidence rates show an increase with age, peaking in the 80-84 age group.

• The median age at diagnosis was 61years and the largest number of new cases was seen in the 50-54 age group.

AETIOLOGY AND RISK FACTORS Although the cause of breast cancer is not understood a number of risk factors have been identified.

i.
i.

A positive family history in a first degree relative (10% of cases): • mothers have a significantly greater risk of 2.0 and sisters of 2.6, with the risk increasing where breast cancer is diagnosed at an early age (Olsen JH et al, 1999).

• about 10% of breast cancer cases are directly due to inherited mutations in breast cancer related genes (BRCA1 and BRCA2 genes).

ii.

Hormonal factors: h o rmones produced by the ovaries appear to i n c rease a woman’s risks of developing bre a s t cancer.
Therefore factors which are associated with an increased risk include: • early onset of menstruation (before 12 years of age) • late menopause (after the age of 50) • nulliparity (no children) / a 1st pregnancy after the age of 30 • use of oral contraceptives for prolonged periods at young ages iii.

Women lifestyles: some associations have also been found with: • Obesity after menopause • Low fibre and a high fat diet • Lack of exercise iv.
No known cause (in 50% of cases) TRENDS IN BREAST CANCER The incidence of female breast cancer is generally increasing worldwide.

Although this can be partially attributed to earlier detection due to an increase in awareness and in the availability of screening services, there also seems to be a real increase internationally.

An i n c rease of around 1.5% in most countries was reported at the 3rd European Breast Cancer Conference (March 2002).
There is a high incidence of breast cancer amongst developed countries, apart from Japan.

In general, the countries of northern and western Europe tend to have higher rates than those of southern Europe.

The incidence of female breast cancer in Malta is slightly higher than the European average and mortality rates are in the range of northern Europe countries rather than our geographically neighbouring countries.
44 45 Sources: Rates for Malta: Malta National Cancer Registry, Department of Health Information Rates for EU member states: EUCAN: Cancer Incidence, Mortality and Prevalence in the European Union, European Network of Cancer Registries, (1997 estimates), Lyon, 2002 BREAST CANCER DETECTION & DIAGNOSES The two most important factors in reducing the number of women who die of breast cancer are : I .
early detection I I .

e ffective tre a t m e n t .

In fact studies show that survival rates drop dramatically when women present with advanced cancer (Kols 2 0 0 2 ) .

women to seek medical care promptly once a bre a s t lump is suspected.

Manual palpation of the breast includes regular bre a s t self-examination (BSE) and clinical breast examination (CBE).
CBE has the advantage that professionally trained personnel can even detect some lumps that are missed by mammograms, especially in younger women whose dense breast tissues can obscure x-rays.

Early detection: Educating women about breast cancer may encourage High quality mammography is the most eff e c t i v e technology presently available for breast cancer 46 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 detection.
There have been numerous adjustments to mammography utilisation policies to improve the i n h e rent problems of sensitivity and specificity linked to mammography as a screening tool.

The costs of mammography are high and policy makers are faced with the difficult decision of weighing the health benefits of such a screening programme against the costs and benefits of addressing other pressing health pro b l e m s (Kols A, 2002).
Ultrasound is used to distinguish between solid tumours and fluid filled cysts.

It can also be used to evaluate lumps that are hard to see on a mammogram.

However ultrasound is not used for routine breast cancer s c reening, as it does not consistently detect early signs of cancer such as micro calcifications.

other words, mammography detects some cancers “earlier” but many of these are not potentially lethal and their detection may cause needless anxiety.
Clinical b reast examination is more likely to detect cancers that a re potentially lethal.

The only study that has addressed the question as to whether the detection of non-palpable cancers re d u c e s the mortality from breast cancer has been the second Canadian national breast screening study (Miller AB et al, 2000).

After a follow up of 13 years, there was no sign of mortality being lower in the women subjected to m a m m o g r a p h y.
However critics of the above study claim that over 30% of the mammograms were technically suboptimal and although the organisers of the study have refuted these charges the debate continues.

EFFECTIVENESS OF SCREENING PROGRAMMES FOR BREAST CANCER As outlined in the 3rd European Breast Cancer C o n f e rence held in Barcelona (March 2002), the issue a round screening for breast cancer is still contro v e r s i a l .
This controversy is also evident in the degree of implementation of national screening programmes by d i ff e rent countries.

A recent assessment of the impact of the UK bre a s t - s c reening programme on mortality from breast cancer in women aged 55-69 years, showed a reduction in m o rtality of 21%.

6% was estimated to be due to a dire c t e ffect of screening, whilst the remaining 15% was attributed treatment and earlier p resentation outside the screening programme (Blanks RG et al, 2000).
improved to H o w e v e r, other evidence suggests that clinical bre a s t examination is as effective as mammography in re d u c i n g m o rtality from breast cancer (Mitra et al 2000).

Any benefit of mammography over clinical examination is mainly in those invasive cancers that are < 1cm in size.

ESTABLISHING SERVICES FOR PATIENTS WITH BREAST CANCER B e f o re launching on a screening pro g r a m m e , diagnostic, treatment and palliative services must be fully in place (Kols A, 2002).
The 2nd European Breast Cancer Conference held in Brussels (September 2000) established that breast cancer should be managed in multidisciplinary clinics.
The setting up of a dedicated breast clinic and treatment by surgeons with a special interest in breast cancer, confers the added benefit of a higher patient survival rate (Gillis CR, Hole DJ, 1996) LOCAL PUBLIC HEALTH ACTION In 1999, the Ministry of Health set up a National A d v i s o ry Committee on Breast Screening to investigate the high local incidence of breast cancer.
An in-depth review of the epidemiological situation of b reast cancer in Malta was carried out and the outcomes of possible screening methods were assessed.

After considering the overall benefits and the cost-effectiveness of a national breast cancer s c reening programme, the Committee concluded that it was not currently feasible to embark on such a p rogramme.
F u rt h e rm o re Klemi et al (1992) showed that mammographically detected cancers show better p rognostic signs than the clinically detected cancers.

In Recommendations were however put forward by the Committee and these included: B r e a s t C a n c e r S e r v i c e s 47 • An improvement in the current diagnostic and therapeutic services with a multidisciplinary a p p roach being adopted to give a more personalised holistic serv i c e .
• The introduction of an organised pro g r a m m e of care for women at higher risk, including the establishment of definition criteria and a computerised re c o rd system.

This would enable women to be followed up and re c a l l e d for any necessary investigations, as well as p rovide for epidemiological studies.

information • Ta rgeting of the general female population by educational health promotion campaigns, as well as i n c reasing awareness amongst medical and paramedical staff .
includes Management of patients review at multidisciplinary Breast Care Group Clinical Meetings attended by surgeons, oncologists, radiologists, pathologists and breast care nurses.

The aim of these meetings that are held once a fortnight is to discuss specific clinical cases, which pose diagnostic and/or therapeutic difficulties, as well as to set up guidelines and protocols in the different specialities.
Patients receiving treatment at the Breast Care Unit are re g i s t e red and data is entered in a database.

In collaboration with the Cancer Registry at the D e p a rtment of Health Information, further data analysis will provide a baseline for the ongoing assessment of high risk in the local context and the eventual establishment of relevant screening criteria.

The Committee for the Implementation of Breast Care S e rv i c e s was set up in June 2000.
The aim of this committee was to implement the re c o m m e n d a t i o n s put forw a rd by The National Advisory Committee on B reast Scre e n i n g .

Top priority was given by the committee to i m p rove the existing services being off e red to women with breast disease.

A multidisciplinary b reast care unit and service impro v e m e n t s t a rgeted at operating at maximum possible e fficiency were recognised to be key factors in the p rovision of a specialised high quality serv i c e .
BREAST CARE UNIT The Breast Care Unit operates from the Surg i c a l Outpatients’ Department at St. Luke’s Hospital.

Bre a s t c a re nurses are available for patients and their families to offer support, advice and information.

The functions of the Breast Care Unit include: • C o - o rdination of any investigations re q u i red and patient follow-up by the multidisciplinary team.
• Establishment of treatment guidelines and p ro t o c o l s • Continuing patient education and support • Collection of data and audit.

SERVICE IMPROVEMENTS • Ensuring the availability of an efficient service with minimum delays.

A general practitioner or a general surgeon presently refers the patient to hospital.

Through the Customer Care Unit the patient is immediately offered an appointment at Surgical Out Patients.

Delays in investigation are now negligible especially for clinically urgent cases.
• Maximum utilisation of the available mammography e q u i p m e n t .

As can be seen from the Annual R e p o rts issued by the Department of Institutional Health, 2584 mammograms were perf o rmed in 2001 and 2662 mammograms were perf o rmed in 2000, as compared to 1655 mammograms c a rried out in 1999.

There f o re utilising the same equipment an additional 1000 mammograms per annum could be carried out.
This resulted in a for dramatic decrease m a m m o g r a p h y, from several months down to 3- 4 days.

It also opened up slots for emerg e n c y investigations, with urgent appointments being often carried out on a same day basis.

the waiting list in • The nurses at the Breast Care Unit are a referral point for patients and their families, providing continuity of care as well as any relevant support, information, education, advice and counselling where and when necessary.
48 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 • Te m p o r a ry breast pro s t h e s e s a re off e red prior to discharge of patients who have undergone surgery for breast disease.

This prosthesis is supplied free of charge and fitted by professional nurses experienced in the field of breast disease.

A permanent prosthesis is supplied at a later date.
• Action has also been taken to secure long-term sustainability so that the services being developed at St. Luke’ s Hospital will continue at the new Mater Dei Hospital.

• Close liaison with support gro u p s, who have contributed to an increased awareness about breast cancer.

FUTURE CHALLENGES The final overall recommendation of the National Advisory Committee on Breast Screening was that the policy situation would be reviewed in the year 2005.
Based upon findings of the Cancer Registry, the database of the Bre a s t C a re Unit and medical and technological developments, a decision will then be taken whether to introduce a national b re a s t - s c reening programme.

As yet there is no evidence to suggest that changes are re q u i red to the above policy re c o m m e n d a t i o n s .
Meanwhile all information should be made available to women with the aim of increasing awareness about bre a s t cancer and also to empower them in making well- i n f o rmed choice.

References Blanks RG, Moss SM, McGahan CE, Quinn MJ and Babb J (2000) Effect of NHS breast screening programme on mortality from breast cancer in England and Wales, 1990- 1998: comparison of observed with predicted mortality.
British Medical Journal 321: 665-669 Gillis CR, Hole DJ (1996) Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland.

British Medical Journal 312: 145-8 Humphrey LL, Helfand M, Chan B and Woolf SH (2002) Breast cancer screening: a summary of the evidence for the US Preventive Services Task Force.
Annals of Internal Medicine 137: 347-360 Klemi PJ, Joensuu H, Toikkanen S, Tuominen J, Rasanen O and Tyrkko J (1992) Aggressiveness of breast cancers found with and without screening: British Medical Journal 304: 467-469.

Kols A (2002) Breast cancer: increasing incidence, limited options.

Outlook Vol19 No 4: 1-8.

Olsen JH, Seersholm N, Boice Jr JD, Kruger Kjaer S and Fraumeni Jr JF (1999) Cancer risk in close relatives of women with early-onset breast cancer – a population-based incidence study.
British Journal of Cancer 79 (3/4): 673 – 679 Malta National Cancer Registry (2002) Cancer in the Maltese Islands 1998-2000.

Ministry of Health (2000) Report by the National Advisory Committee on Breast Screening.

Miller AB, To T, Baines CJ, Wall C. (2000) Canadian national breast screening study –2: 13 year results of a randomised trial in women aged 50-59 years.
J Natl cancer Inst 92:1490- 1498) Mittra I, Baum M, Thorton H and Houghton J (2000) Is clinical breast examination an acceptable alternative to mammographic screening?

British Medical Journal 321: 1071- 1073.

Second European Breast Cancer Conference: Bru s s e l s Statement – September 2000.

Third European Breast Cancer Conference Press Release – March 2002.

C a r d i a c S e r v i c e s 49 when compared with other units abroad, both for mortality and morbidity.
Hospital stay and overall costs have been streamlined as operating sessions have increased.

In summary, cardiac surgery has become a routine and accepted practice by the local population.

Cancellations due to lack of intensive care facilities were the most important issue during the first 4 years of operation.

Since the opening of a custom-designed cardiac intensive care unit, efficiency has increased from 73% in 1998-99 to 98% in 2001-02.
Separation of a cardiac intensive care unit from the general ITU has also resulted in a significant decrease in serious MRSA infections.

There is place for a dedicated cardiac theatre and this should become available with the opening of the new Mater Dei Hospital, furt h e r increasing output and efficiency.
The following graphs illustrate certain trends over 7 years including annual activity and average waiting times for surgery, mean postoperative hospital stay, risk stratification, expressed using the Parsonnet system and its relation to mortality, and projected versus actual deaths for various stratification groups.

Overall mortality for isolated coronary artery bypass grafting was 0.65% (2.3% for the Italian National Cardio- Anaesthaesia Database).
The mean postoperative stay was 4.25 days in 2001 (8.5 days for the UK National Adult Cardiac Surgical Database Report 1999-2000).

C a rdiovascular disease is a major contributor to p re m a t u re death in We s t e rn countries, especially amongst middle-aged men.

Malta is no exception and indeed the high prevalence of risk factors including smoking, diabetes and hypertension accounts for an elevated incidence of ischaemic heart disease when compared with most European countries.
Invasive intervention, necessary at an advanced stage of the disease, includes coronary angioplasty and stenting, as well as coronary artery bypass grafting.

This report deals with the surgical treatment.

Maltese patients have availed themselves of cardiac surgery since the early eighties, travelling to the UK for t reatment or undergoing operations perf o rmed in Malta by visiting British teams.

This was funded by the Maltese government under the reciprocal agreement with the UK.
This service was of a high standard but emergencies could not be dealt with and, in the absence of a fully fledged resident investigative programme, the condition was under diagnosed.

The situation evolved in the mid to late nineties with the establishment of a resident cardiology and cardiac surgery service, now functioning as a separate entity as the Department of Cardiac Services.
A resident surgical team has enabled surgical practice to expand in the parallel fields of adult valvular heart disease, transplantation and thoracic surgery.

Close ties have been established with cardiology and respiratory medicine, and new practices in intensive care and step- down management have influenced change in St Luke’s Hospital.

A database was created from the outset and this enabled the perf o rmance of audit and the publication of an annual report, highlighting activity, results and cost.
Staff training has resulted in the expansion of the unit, particularly at consultant level, strengthening the philosophy of a consultant-based service.

The overall results of this investment is an independent and comprehensive cardiac surgery unit providing cost-effective treatment with short waiting times, all to the benefit of local patients.
Results are very favourable 50 51 52 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 A programme of beating heart surgery was started in 1999.

The results have found that it compare s favourably with on-pump surgery.

The international debate continues and ongoing studies are in place to evaluate this better.
is With regard to morbidity the incidence of major low: peri-operative myocard i a l complications i n f a rction 0.6%, cere b rovascular accident 0.7%, transient ischaemic attack 0.7%, temporary dialysis 0.7%, re-sternotomy 0.8%.

Costs have been streamlined as much as possible, always keeping patient safety a priority.

The estimated saving of over Lm9 million over 7 years reflects our local costs as compared to those of transferring patients to the UK.
The competitive package prices are such that several patients have travelled to Malta to undergo c a rdiac surg e ry.

It is hoped this service will be expanded in the future.

C a r d i a c S e r v i c e s 53 INTRODUCTION In Health Vision 2000, the Health Division had described smoking as the foremost preventable cause of pre m a t u re death and disease in Malta.

In its resolution WHA52.18, the World Health Organisation expresses concern about the increase in tobacco use worldwide.
Smoking is estimated to result in at least 4 million deaths annually and is projected to cause 10 million deaths by the year 2030 if not controlled, 70% of which will occur in developing countries.

The World Bank has issued similar projections.

Current trends reveal that the number of smokers will exceed 6 billion by 2025.

In the high-income nations, smoking has been in overall decline, although it continues to rise in some groups especially youths and low-income individuals.
In the low- and middle- income countries, cigarette consumption has been increasing mainly due to freer trade.

BURDEN OF TOBACCO ON SOCIETY The addictive pro p e rties are well documented.

Scientific documentation reveals that in high-income countries, a substantial number of former smokers have successfully quit with the help of cessation programmes.

Smoking causes fatal and disabling diseases and compared with other risky behaviours, the risk of premature death is extremely high.
Half of all long- term smokers will eventually be killed by tobacco, and of these, half will die during productive middle age, losing 20 to 25 potential years of life.

Causes include cancers of the lung and other organs, ischaemic heart disease and other circulatory diseases and respiratory diseases such as emphysema.
Deaths due to smoking in Malta in 1995-2001 (NMR, 2002) 54 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 PASSIVE SMOKING E n v i ronmental tobacco smoke (ETS), mixture of irritants and mutagens, is classified as an ‘A’ class that harms non-smokers grievously c a rcinogen irrespective of age.

In adults, passive smoking increases the risk of lung cancer in non-smokers.

The same is apparently true for ischaemic heart disease, chronic respiratory disease, asthma and stroke.
Babies born to smoking mothers have lower birth weights and face greater risks of respiratory disease and sudden infant death syndrome than other babies do.

The non-smoker’s right to breathe clean air has resulted in smoking bans and a smoke-free policy on public transport, workplaces, public places and entertainment venues.

Malta’s current legislation gives minimal protection to the non-smoker from ETS and the issue deserves a more comprehensive approach with the appropriate enforcement.
SMOKING IN ADOLESCENCE - PROJECTIONS ON SMOKE-RELATED DEATHS & DISEASE Smoking usually starts in adolescence or early adulthood.

Even when they are given information, youths do not always use it to make sound decisions.

Apart from this, most new recruits underestimate the risk of becoming addicted to nicotine.

The Psychosocial Theory provides an explanation for the uptake of smoking in young people as part of adolescence.
Identity issues, rejection of authority, peer pressure, risk taking, image/relationships issues and hedonism may all lead to smoking.

Age is regarded in many studies on tobacco use as an important influencing factor.

UK studies (DoH,1998; G o d d a rd,1990) and others in Malta (Caritas- Malta,1992,1998) showed that smoking occured albeit at a very low prevalence among children aged 11 or under.
According to the Health Behaviour Survey in Schoolchildren in 2002, 7.7% of males and 4.9% of females under the age of 11 have smoked at some point in life.

At the age of 13, the prevalence of smoking in girls exceeds that in boys, with 31% as compared to 25% of boys.

This higher prevalence also holds true for 15 year olds where 39% of girls versus 38% of boys experiment with tobacco.

In Malta, daily smokers aged 12 -17 years almost doubled between 1991 and 1998.
Amongst those under 13, there were 3%, soaring to 23% by age 17 (Caritas-Malta, 1992; 1998).

The Hibell, et al (2000) study found that the UK had the highest rates of daily smoking in 15 -16 year olds, with a higher prevalence in females (16% in males) and 24% in females).

Malta occupied the 13th place with 9% of males and 10% of females.

31% of males and 33% of females aged between 11-17 years smoked at least once during the previous year (Caritas-Malta, 1998).
The regular smoking patterns for young people seems to evolve from a more haphazard smoking behaviour at an earlier age, where more young people tend to ‘dabble’ with smoking on an occasional basis, possibly for social acceptance (Balding, 1999; HEA/MORI, 1992a).

In a survey conducted in the GF Abela Junior College in 2000, a significantly greater proportion of males reported cigarette smoking compared to females (42% vs. 29%).
There were three males for each female in the heavy smoking category (66+ cigarettes).

Similar p ro p o rtions of male and female students (23%) reported a mean use of 5 cigarettes per day or less.

Regular smoking patterns are significantly higher in males.

72% of males smoked at least once compared to 65% for females.

In the ‘experimenters’ category, one in four of those males who ever smoked (25%) tried it once or twice.
In females, close to one half (43%) of those who ever smoked tried smoking once or twice.

Of those who have ever smoked, 46% of males and 25% of females reported that they smoke regularly.

2 in 3 such males reported that they would like to quit while 3 in 4 such females reported the same.
S m o k i n g & I t s T h r e a t T o H e a l t h I n M a l t a 55 FUTURE CHALLENGES IN TOBACCO CONTROL Currently governments are negotiating a treaty for c o n c e rted and comprehensive action in tobacco control, called the Framework Convention on Tobacco Control (FCTC).

This will be ratified in 2003.


If Malta joins this treaty, we will be obliged, as a signatory to the convention, to put in political will and commitment, since its various implications are cross government and not only on legal measures.

The FCTC addresses both the supply and demand of tobacco control.
It is t h e re f o re a comprehensive approach that aims to eventually reduce the prevalence of smoking and its resultant disease burden, addressing sale to minors, labelling, taxation, tobacco growing, health education, smuggling, bans on advertising and sponsorship and p rotection from ETS amongst others.
Within a E u ropean context Malta is also implementing the European Strategy for a Tobacco Free Europe (2002- 2007) as part of the Warsaw Declaration endorsed by the European Ministers of Health in 2000.

However, Malta’s efforts in tobacco control at national scale are still re q u i re much strengthening before a measurable benefit to public health is elicited.
low-level operations that QUITTING SERVICES Smokers seek ways of quitting their habit for various reasons including health, financial concerns as well as p re s s u re from family and friends.

The combined physical and psychological pressures are strong, yet many are successful even though they smoked heavily.

Scientific research shows that smokers can benefit greatly from the combination of smoking cessation aids and support groups.

Pharmaceutical aids range from nicotine replacement e.g.
patches, gums to nicotine- free medication e.g.

ibupropion.

Suitability depends on age at onset of smoking and the level of addiction of the individual.

The free availability of aids to potential quitters should be seriously explored by governments since the cost benefit derived from quitting are tru l y e n o rmous compared to the treatment re q u i red for l i f e - t h reatening diseases caused by tobacco smoking.
As yet the Health Division does not supply smoking cessation aids to smokers as part of the national health scheme.

However smoking cessation classes a re organized by the Health Promotion Depart m e n t as a free service.

References Crofton and Simpson.

Tobacco: a global threat.

Macmillan Education 2002 Spiteri M. Alcohol, tobacco and illegal drugs in adolescence - a study of Maltese students’ perceptions and experiences.

Unpublished doctoral thesis, University of Southampton.
2002 Curbing the Epidemic: Governments & the economics of tobacco control.

A World Bank Publication 1999 56 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 In Malta, there is evidence that an incre a s i n g number of young people are consuming larg e amounts of alcohol and dabbling with dru g s ( E S PAD ’99).

The World Health Org a n i s a t i o n defines alcohol as a drug of abuse that at times, w reaks havoc in people’s lives.
Over the past few years there has been a marked increase in the number of drinkers aged 25 and less re f e rred to the alcohol services of Sedqa.

The cohort of those continually exposed to alcoholic beverages is also on the increase, and trends show that this p roblem will increase.

Lacking the necessary regulations and enforcement, much is left to the i n d i v i d u a l ’s attitude and will whether or not to indulge in substance abuse.
Tight laws and enforcement are currently in place for illegal drug abuse.

One of the outcomes of the P revalence Survey carried out by the National Commission 2002 reveals an estimated 2,300 problem drug abusers in Malta.

In a recent report issued by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Malta has the highest rate of individuals undergoing treatment with methadone.

A total of 935 persons are on methadone treatment.


In the European School Survey Project on Alcohol and other Drugs (ESPAD ‘99), 94% of 16-year old students reported drinking alcohol on more than one occasion.

In comparison with our European counterparts, we fall into the highest category of drinkers.

Maltese youths appear to favour wine and spirits to beer.
D r u g s & A l c o h o l 57 offering services are studying and suggesting potential proposals to the current Criminal Justice System for consideration.

On a ministerial level (Ministry of Social Policy) a t h o rough evaluation of existing services has been commissioned and is being carried out with the aim of creating a more effective network service system of all service providers.
these Various inter-agency initiatives are being ventured to find plausible ways to render a more professional and initiatives are e ffective service.

Among discussions hosted by Sedqa with active participation of the Probation Services and the Police Force to adopt a compatible system the existing criminal to procedures of substance misusers.

A prompt arrest referral system has been suggested and is being piloted.
In this system, arrests related to petty crime are promptly referred to the agency for substance misuse for screening.

The aim is to facilitate entry into addiction services In line with the Stockholm Young people and Alcohol Declaration and the European Alcohol Action Plan 2000-2005: The World Health Organization’s current Alcohol Action Plan for the European Region emphasizes the need for a coherent strategy, which each country should adopt in order to maximize its efforts to reduce alcohol-related harm.
The National Alcohol Policy would cover five main areas: Education, Market regulation, Public safety including BAC levels, Drinking and The Workplace, and Treatment.

In the same ESPAD study, 92% of Maltese youths reported that they had never used an illicit drug during their lifetime.

Comparing the findings of the same survey carried out in 1995, there was a significant increase in the numbers reporting illicit drug use of amphetamines and ecstasy.
Compared to other European countries, we have the lowest number of students reporting illicit drug use.

The proportion of our students who reported that they used cannabis was half (7% vs. 16%) that of the average for all European countries as was also the proportion reporting the use of illicit drugs other than cannabis (3% vs. 6%).

The use of inhalants is still as it was in 1995, rather high and above the European average of all the other European countries (16% vs. 9%).
The use of alcohol in combination with pills was above the European average, 12% as compared to 8%.

The use of tranquillisers, referred to locally as “Kalmanti”, was reported to be close to the European average (5% vs. 7%) and not much different from that reported in the 1995 exercise.

results highlight areas These for pre v e n t i o n programmes needed within the community.
School programmes are targeting contextual issues rather than utilising material formulated in different social contexts and countries.

Sedqa, is the National Agency working with drugs, alcohol and gambling and as such, it is the Government’s executive arm in this sector.

It compiles, on a bi-monthly basis, pertinent data that offers a clear insight into the addiction problem.
The contributors are: all Sedqa services related to Drugs, Alcohol and Gambling; some NGO’s in the addiction field; the Department of Family Welfare; the Mental Health Hospital; the Armed Forces; the Correctional Facility; the Police Drug Squad; the Juvenile Court; the Malta Law Courts; the Probation Services; the Customs Anti Drug Squad; and the Public Health Department - Syringe Distribution System and AIDS cases register.
Currently the President of Malta is hosting a Drugs’ Forum in which all Agencies directly involved in 58 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 At the end of September 2002, there were 260 379 vehicles registered with the licensing department in Malta and Gozo.

74% of these are private vehicles.

In the first quarter of 2002 (January-March), 3307 traffic accidents have been reported.

The great majority of these occurred in the Northern Harbour District where traffic congestion happens.
60 persons most injuries while another 2 experienced grievous individuals lost their life during this same quarter.

Transport accidents are definitely a preventable cause of morbidity and mortality.

This chapter attempts to analyse the mortality patterns due to traffic accidents over the period 1995-2001 by various classifications to identify target areas for intervention.
BY AGE GROUP AND GENDER OF THE INJURED PERSON As one can observe, transport accident deaths are v e ry low below the age of 15, after which these then peak abru p t l y.

Following the peak of the 15- 24 age group, the number of deaths decreases so as to achieve almost a plateau around 10 deaths per age group.

More o v e r, accident deaths are quite rare in females when compared to males.

Female deaths occur most commonly in the 15-24 age group and followed by the 45-54 group.
In males, deaths from transport accidents are commonest in the 15-24 age group.

The male m o rtality pattern then follows a similar trend to the overall pattern .

T r a n s p o r t A c c i d e n t s 59 BY CATEGORY OF THE MODE OF TRANSPORT AND GENDER While the graph above gives the impression that pedestrians are most at risk in traffic accidents, the a g g regate number of deaths amongst users of motorised transport is higher, both overall and in males.
In females, however, the number of pedestrian deaths exceeds that of motor transport users.

The next highest number of deaths in females occurs amongst passengers in cars, vans or trucks.

On the other hand, amongst male motor vehicle users, drivers tend to be most at risk, followed by motorcycle riders, regardless of whether driving or pillion riders.
One should note that even though drivers appear to be the second most susceptible groups in the male population, no female car, bus or truck drivers died in the period 1995-2001, but there were 2 fatalities involving female motorcycle riders.

60 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 BY CATEGORY OF INJURED PERSON AND AGE GROUPS One should appreciate that different categories show different mortality by age patterns.
Older pedestrians, p a rticularly beyond the age of 45 were more susceptible to transport accident deaths.

On the other hand, the young drivers are most susceptible and this risk decreases to disappear altogether beyond the age of 55.

Motorcycle deaths were almost exclusively limited to the 15-34 age group, with a slightly higher prevalence in the younger half.

Passengers have a mortality by age pattern similar to that of drivers, however the numbers are much lower.
Another point to note that while driver deaths were non-existent beyond the age of 45, passenger deaths only disappeared after an age of 64.

T r a n s p o r t A c c i d e n t s 61 Throughout the year the Environmental Health Unit of the Public Health Department conducts a coastal water surveillance programme.

This programme is intensified during the summer months i.e.
during the official bathing season (from the 3rd week of May up to the 3rd week of October), in order to monitor more closely the variation in microbiological quality of water.

A list of analyses performed on seawater samples is shown in Table 1.

Samples of seawater are collected on a weekly basis from 87 sampling points sited at the most popular bathing areas along the coastline of Malta, Gozo and Comino.
All sample are analysed at the Public Health Laboratory for Faecal coliform counts on a weekly basis, which every fortnight for Total coliform counts and Faecal Streptococci.

If any of the weekly samples following analysis results in Faecal coliform counts >1000/100mls of water, a repeat sample is taken the following day for confirmation of results.
If the same result is confirmed, then a health warning is issued through the media informing the general public that the particular area is temporarily closed for bathing until further notice.

A copy of this health warning is sent by email to all Ministries, Departments, Agencies and the respective Local Council for any action deemed necessary to be taken from their end.

The Department of Public Health also immediately puts up public information signs at the sites in question.
During such episodes, samples of seawater from the e ffected area are collected on a daily basis for microbiological parameters including faecal coliforms, total coliforms, faecal streptococci and salmonella species.

The health warning notice is not to be withdrawn until all samples results are within recommended levels for three consecutive days.

During last year’s bathing season 15 popular bays were monitored for enteroviruses.
10 litre samples were collected and sent to an accredited laboratory in the UK for analysis.

During last season 8 sandy beaches were also monitored for enteroviruses and no samples detected enteroviruses.

At the end of each bathing season i.e.


following 23 weeks; data analysis is carried out on all samples collected to classify each sampling point both with the classification requirements of the Barcelona Interim Criteria for the Mediterranean sea and also with the re q u i rements of the EU Bathing water Dire c t i v e requirements for microbiological parameters.
An annual report is issued by the Department of Public Health through which the public is informed about the general conditions of popular bathing areas during the particular season, in order to minimise risk-taking during the next season.
New initiatives taken during last year’s bathing season were the following: 1.A Public Automated Information System was installed at the Environmental Health Unit by which the public may have updated information on the quality of bathing water, plus information on non- bathing zones and other relevant inform a t i o n .

Health warnings issued by the Department are also made available on the same system immediately as these are issued.
2.Weekly site classification report is sent by email to a mailing list of over 60 entities.

These include Ministries, Government Departments, Agencies, Local Councils, Health Officials and to those who requested to the Environmental Health Unit that they would like to be informed.

3.The Environmental Health Unit web-page will make all this information available on the web, including the weekly reports and the annual reports.
62 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Parameters Guide Mandatory Minimum freq.
500 100 100 - - - - - - - 2 80 to 120 Absence 10000 2000 - 0 0 6 to 9 No abnormal change No film No odour No lasting foam No specific odour 1 (0) - Total coliforms /100ml Faecal coliforms /100ml Faecal streptococci /100ml Salmonella /l Enteroviruses PFU/10 l pH Colour Mineral oils mg/l Lauryl-sulfate mg/l Phenols mg/l Transparency m Dissolved O2 (% saturation) Tarry residues/flotsam/waste Ammonia mg/l Nitrogen mg/l Pesticides mg/l Heavy metals mg/l Cyanides mg/l Nitrates & phosphates mg/l Analyses conducted on seawater samples Source: Bathing Water Report 2001 – Public Health Inspectorate Fortnightly Fortnightly As indicated As indicated As indicated As indicated Fortnightly/ As indicated Fortnightly Fortnightly Fortnightly Fortnightly As indicated Fortnightly If eutrophication If eutrophication As indicated As indicated As indicated If eutrophication B a t h i n g W a t e r 63 Many objectives of the plan have been reached.
This does not mean that there is little yet to be done.

As a framework, this document is intended to act as a direction for the specific sectors to follow and build upon, encouraging further commitment and enticing those sectors that, as yet, may not have been given their due prominence.

This document endorsed by the Ministers of Health and Environment of the time is now being evaluated.
The Health Division also intends to revise the NEHAP to ensure that all the objectives and actions plans are updated, thereby creating a new framework for the next five years.

This revised version should be launched by the end of 2003.

The importance of revising the NEHAP is seen by the renewed interest in its implementation and revision offered by the World Health Organisation.
The WHO has taken a leading role in Environment and Health in all Member States, and in collaboration with the European Commission, has once again highlighted its importance and relevance to all accession states.

National Environmental Health Action Plan The National Environmental Health Action Plan (NEHAP) is a policy document that was drawn up in 1998 as a framework action plan for implementation right across all government departments and major economic industries.
The plan describes the basis for action i.e.

the groundwork on which the plan was built.

The actions demanded by the NEHAP were easy to achieve and were concerned primarily with the protection of public health through protection of the Environment, in which we live and work.
To ease matters, the actions were divided into three groups: G roup 1 actions which concerned the basic requirements for environmental health and aimed at p reventing or mitigating conditions whose environmental causes are well established and which could give rise to widespread and often acute health effects.

These actions would yield immediate benefits easily recognisable by the public.
G roup 2 actions concerned the prevention and control of medium and long-term environmental health hazards and included long term effects from both chronic and shorter term exposures.

The benefits from such actions only appear after many years although when the actions lead to rapid and marked reductions of levels of pollution, their value would be rapidly appreciated by the public.

Group 3 actions concerned the promotion of human well being and mental health rather then the the p revention of disease.
Perceptions of environment as unpleasant imposes stress on the affected population and since different factors may be perceived as unpleasant by different groups of people, considerable expense could be entailed in attempting to satisfy everybody.

Thus, here more than with the other groups of actions, priority setting was important and involved consideration of public p e rception, public education and information if funds were to be invested appropriately.
64 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 PROGRESS IN THE PHARMACEUTICAL FIELD The progress of change in the pharmaceutical field has involved not only a wide spectrum of drugs being made available but also the ways in which these are developed, presented, ensured to be safe and of good quality and protected by law.
Developments in Western economy and in living standards, the creation of social security systems, national health services and schemes for reimbursement of the costs of drugs all influenced the increase in demand for health services and for medicines.

The pressure exerted by pharmaceutical manufacturers seeking to ensure a constant expansion of their market was also a significant driving force.

Today, the use of pharmaceuticals is an integral part of the health care system.
This leads to a corresponding i n c rease in drug expenditure and an incre a s e d awareness that drug resources are limited and finite in all countries.

The persistent problems encountered are complex and go beyond simple financial constraints.

The attitudes and behaviour of govern m e n t s , p rescribers, dispensers, consumers and the dru g industry also contribute.
New global trade agreements and a country’s structural and economic reform can all disrupt the ultimate goal of achieving equity in health care.

While the European Union has achieved a single market for the registration of pharmaceuticals within member states, there is no uniformity with regards to policy on pricing and reimbursement of medicines.

All countries have systems for pricing and reimbursement but the methods for implementation differ from one country to another.
Major issues effecting the pharmaceutical field in Malta include: changes in life expectancy resulting in increasing demand for drugs, the sustainability of the current reimbursement system, irrational prescribing, the managed entry of new drugs within the National Health Services and increasing patient demands and expectations.

The share of the GDP spent on health was 8.81% and 8.92% for 2000 and 2001 respectively, and being very close to the EU average of 8.68% in 2000 P h a rmaceutical Policy in Malta.
of Health expenditure Information, 2002).

( D e p a rtment G o v e rnment on pharm a c e u t i c a l s expressed as a percentage of the total government expenditure was 23.6% and 20.2% for the years 2000 and 2001 respectively (Budgetary Estimates for the Ministry of Health).

Malta’s current candidate status for accession into the European Union influences the local pharmaceutical scenario in that Malta is introducing a regulatory system for medicines.
Also new legislation, T h e Medicines Act was adopted earlier this year.

DEVELOPMENT OF NATIONAL DRUG POLICIES - THE PERSPECTIVE OF THE WORLD HEALTH ORGANISATION The World Health Organisation (WHO) recommends the formulation and implementation of a National Drug Policy (NDP) as an essential part of the National Health Policy to tackle the interdependent problems specific to the pharmaceutical field.
The NDP is a commitment to a goal and provides a guide for action with the systematic involvement of all intere s t e d stakeholders.

The general objectives of a NDP are to ensure access, quality and rational use of medicines.

The main components of the NDP include selection of essential drugs, affordability, drug financing, supply systems, drug regulation and rational drug use.

Drug selection is a crucial step in ensuring access to essential drugs on a national level.
Affordable prices are an important prerequisite for ensuring access to essential d rugs in both the public and private sectors.

Governments must be committed to ensure access of all drugs through strategies such as reducing or abolishing import duties on essential drugs, control of drug tariffs and profit margins and by introducing a pricing policy.
For single-source products the WHO recommends the wide publication of price information and by allowing substitution within the groups of single-source drugs that are considered therapeutically equivalent.

Drug financing is a major issue for any policymaker and politician and governments must be committed to competition through M e d i c i n e s 65 introduce measures to improve efficiency and reduce waste.
The responsibility for the supply system and how it is stru c t u red will influence the accessibility of essential drugs.

The rational use of drugs means that patients receive medicines appropriate to their clinical needs, in the correct doses for the correct time period and at the lowest possible cost to them and the community.

WHO also recommends regulatory and managerial strategies to promote rational drug use such as through the availability of independent, unbiased drug information.
PHARMACEUTICAL POLICY IN MALTA The Medicines Policy and Audit Unit within the Health Division is responsible for the formulation and implementation of the NDP for Malta.

Two seminars were held during the last week of August 2002 in collaboration with two visiting experts from the World Health Organisation.

These were aimed at introducing the concept of a NDP, to establish the current picture and to start the discussion at a national level with the various stakeholders involved.
An action plan is being formulated and the various stakeholders’ perspectives are being included to achieve a balance.

The public is a major stakeholder in this policy.

Medicines are available through the public sector to patients who fulfil entitlement criteria and through the private sector whereby patients pay the full price of medicines with no existent co-payment schemes or user charges.
Within the public sector The Form u l a ry of the Government Health Services is being revised and was recently launched on the Intranet of the Health Division.

Its aim is to provide information on the drugs available within the Government Health Services and to support rational prescribing and use of medicines.

The relevant medicine protocols and therapeutic guidelines are included in this revised formulary.
The procurement of drugs in the public sector is through competitive bulk procurement from a central unit, the Government Pharmaceutical Services.

Medicines are provided free of charge at the point of use through stock procured through the tender process to specific categories of patients.

The use of generic drugs is encouraged within the Government Health Services with generic substitution being done automatically at the point of dispensing.
In the local private sector, the prices of medicines are calculated through a fixed margin based on the invoice price.

This system falls under the responsibility of the Ministry for Economic Services.

Although the WHO recommends generic substitution and generic prescribing as the means to improve price competition, generic substitution is not considered normal practice within the private sector in Malta.
ROLE OF THE PUBLIC IN DECISIONS REGARDING PHARMACEUTICAL ISSUES IN MALTA The main aim of educating the public is to empower patients to participate in the management of their disease including the choice of treatment and products used, thus achieving maximum clinical benefit at an affordable cost.

The level of involvement of the Maltese public in pharmaceutical policies needs to be studied more closely.
One major issue in this regard is the system for reimbursement for medicines including the possibility of the introduction of any co-payment schemes.

the process of decision-making in In one study 100 patients entitled to free medicines f rom the government dispensaries were randomly selected and interviewed.

Amongst other areas tackled, patients were asked about the introduction of a co- payment system for pharmaceuticals.
66% of patients stated that they are not willing to pay a fee whilst patients who knew how expensive their medicines were (since they had to buy these in the past) were m o re inclined to pay a small co-payment fee in preference to paying the full price of the medicines.

FUTURE CHALLENGES The way forward will be the prioritisation of areas of the National Drug Policy considered important within the local pharmaceutical setting.
The stakeholders 66 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 involved may have different interests but a balance must be found to develop a document that reflects as closely as possible local needs.

There is also the need for commitment from all those involved, including the government, in the best interest of all.
One of the main challenges for policymakers is to ensure that the interests of patients and the public are integrated in a holistic way and are not focused only on the expectations of specific patients and patient groups.

References: Budgetary Estimates published for years 2000 and 2001.

Cassar Buontempo E., Patients’ Expectations of the Pharmaceutical Services provided at Dispensaries of the G o v e rnment Health Services, Institute of Health Care , University of Malta, 2001.
Department of Health Information, Health Expenditure Data 2002.

M e d i c i n e s 67 BACKGROUND In the early 1990’s a need was felt to develop Malta’s hospital services further in order to keep up with new developments and an ever- i n c reasing demand on public health re s o u rces.

Various options were considered including a partnership with the private sector to construct a new hospital.
Eventually a decision was taken to build a new 430-bed specialist hospital in collaboration with the Monte Ta b o r Foundation of the San Raffaele Hospital of Milan.

This hospital was to complement our present St Luke’s Hospital, which was to decrease its bed complement by half.

Construction commenced in 1994.


Following successive changes in government in 1996 and 1998, the project was completely re-dimensioned in the form of a new 825-bed acute general and teaching hospital incorporating all specialities and most supra- specialities.

This hospital, recently given the name of Mater Dei, will eventually completely replace St Luke’s Hospital.

The hospital is due to open in 2005.


Most blocks of the hospital have been completed and work on the internal services and infrastructure has commenced in earnest.

The delivery of medical equipment and furniture will commence in the third quarter of 2003.

DEVELOPING A WHOLE HOSPITAL SYSTEM FOR MALTA Given the trends and rapid developments in this sector there is a clear need to ensure hospital services are best configured to meet the changing needs of patients as they progress through their care.
Thus Mater Dei Hospital has been modelled upon a whole system service model to meet these needs.

This service model is represented schematically below.

The benefits of this system include: • Emergency admissions are fast tracked with quick access to diagnostic and treatment facilities.

• Patients attending hospital on an ambulatory basis have access to dedicated treatment facilities.
• Specialty beds can be organised and run without disruption from emergency admissions and without blocking of beds by long stay patients.

• Patients will have access to dedicated facilities as they move into their post acute phase.

These facilities will support the rehabilitation and effective discharge of the patient.
68 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 OBJECTIVES FOR THE DEVELOPMENT OF MATER DEI HOSPITAL The main objectives for the development of Mater Dei Hospital are: • Develop state of the art secondary and tertiary acute medical services at Mater Dei Hospital for the next half century.

• Address and cater for the medical and health needs of the Maltese population.

• Strengthen and consolidate the role of primary/ community health services.
In order to meet these objectives a number of underlying principles have been developed to inform the planning of the new hospital: MATER DEI PLANNING PRINCIPLES • All emergency services will be located at Mater Dei • Establish Mater Dei Hospital as a research centre of Hospital.

excellence.

• Provide the facilities to function as a fully fledged teaching hospital, incorporating the Medical School, Institute of Health Care and other related academic activities.
• The primary focus of the new hospital will be to care for patients during their acute phase, ideally with a discrete post acute unit on site.

• Sizing of ambulatory facilities will be appropriate to handle increases in this type of patient activity.

• Establish concurrently a centre of excellence for rehabilitative and other non-acute services, either at St Luke’s or at Mater Dei Hospital.
• Teaching and Research space will be made available embedded in Mater Dei Hospital as well as the Medical School and Institute of Health Care.

N e w H o s p i t a l 69 • Services and specialities should be best aggregated to meet the clinical and holistic needs of patients.

• Provision should be made at the hospital for facilities and services to care for patients during an acute phase of mental illness.
70 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 These principles have been taken to inform the configuration and organisation of the Mater Dei Hospital.

The key elements of the organisation are set out in the figure below.

N e w H o s p i t a l 71 NEW DEVELOPMENTS IN HOSPITAL CARE Developments in hospital care and supporting medical technologies continue apace.

It was important that plans for the new hospital took ino account these developments.
These have been considered, analysed and quantified for the planning of future hospital services in Malta and are set out below: KEY ELEMENTS OF MATER DEI HOSPITAL FUTURE DEVELOPMENTS IN HOSPITAL CARE • Increase in Ambulatory Care: Developments in new technologies and less invasive techniques have led to an increasing number of hospital procedures which can be undertaken on a day case basis rather than requiring inpatient stay.
• E m e rgency Care : The re q u i rement for quick assessment, diagnosis and treatment for emergencies has led to the development of discrete parts of the acute hospital to be designated for emerg e n c y admissions.

• Post Acute Care: It is increasingly recognised that once patients have passed through their acute phase they no longer require acute care but are more appropriately cared for in a rehabilitative post acute environment.
• I m p roved Diagnostics: accurate diagnostics in association with new techniques have had a significant impact on the organisation and delivery of patient care.

Faster more • P e rf o rmance Impro v e m e n t : Managing increases in acute hospital activity has acted as an incentive to focus on performance improvement measures such as admissions on same day as surgical procedures, improved scheduling of outpatient consultations and increased utilisation of operating theatres.
• Accident and Emergency: Attendances at Accident and Emergency departments vary greatly in terms of their level of acuity from patients with major trauma t h rough to those with minor complaints more appropriate for primary care.

Configuration of the A&E Department will to reflect this with discrete areas set aside for the primary care attendance and fast tracking for the trauma/emergency patient.
THE HOSPITAL SYSTEM IN THE WIDER HEALTH ENVIRONMENT Mater Dei Hospital has been planned as part of the wider health environment.

The degree to which other parts of the health environment are developed will have a significant impact on the role and size of the acute hospital.

For example, the degree to which patients are managed by primary care professionals in community-based facilities will affect the numbers of referrals to and facilities required at the acute hospital.
in the absence of In Malta there appears to be consensus amongst policy makers and practising clinicians that many activities currently taking place in an acute hospital environment could, with appropriate development of primary and community care, take place in community facilities.

These activities range from inappropriate attendances at the A&E department to the care of the convalescent furt h e r patient.
However development in primary care services, it was prudent to plan the new hospital on the basis of existing service arrangements rather than those which might, or might not be in place in the future.

Nonetheless it is vital that hospital facilities are planned to enable new working partnerships to develop between the hospital and wider clinical networks.
In practice this is likely to include the development of robust inform a t i o n technology links between the hospital and primary and community care in order to provide a seamless continuum of care.

The development of Mater Dei Hospital should therefore be seen as a catalyst in developing the whole health system for Malta.
The principles that underpin the plans for Mater Dei Hospital are soundly based and provide the basis for extending development into p r i m a ry and community care without having to radically rethink the role or scale of the hospital.

72 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Tourism has been one of the major industries in Malta for a number of years.

In fact, well over a million tourists visit Malta each year, that is, almost three times the resident population of the country.
Consequently, this proportionally huge influx of tourists exerts an effect even in the health care sector.

One can notice that while overall tourism follows a fairly normal distribution through the year, elderly tourists tend to visit Malta mostly in Spring and Autumn resulting in a bimodal d i s t r i b u t i o n .

The figure above shows the number of tourists a rriving in Malta in 2001, classified by month.
The various figures have been further split at the age of 65 since the major contributors t o w a rds morbidity and mortality in the non- resident population are thought to be elderly t o u r i s t s .

The figure on the following page shows the distribution of admissions to St Luke’s Hospital of non-residents.

These may include not only tourists but also illegal immigrants, students, people recovered at sea etc.
However, the elderly non-residents tend to be almost exclusively tourists and therefore the ‘non-tourists’ may be inflating figures for the younger age group.

This is T o u r i s t H e a l t h 73 also true of the figure below that shows the distribution of mortality among non-residents.

In both cases, one must keep in mind that the numbers are much smaller and therefore interpretations of the graphs may be slightly more difficult and prone to influence due to extraordinary events.
One can notice that non-resident admissions to St. Luke’s do not follow any particular pattern, regardless of tourist arrivals.

This implies that a higher proportion tends to be admitted during the winter months (Jan & Dec in particular) rather than in other months.

Elderly admissions appear to decrease in August and October, but not in September.

Even so, in the case of morbidity, elderly patients account for 24.1% of all non-resident admissions, while accounting for 12.9% of tourist arrivals.
While there is a higher proportion of elderly non-residents utilizing our health services, one cannot 74 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 imply that elderly tourists are the major consumers of health care in the non-resident population.

This is not the case with mortality, however, as shown in the bottom left figure.
This figure (bottom left) shows that elderly tourists are susceptible to the seasonal pattern s experienced by the resident population, with m o rtality being higher in the winter months.

Another peak of the overall mort a l i t y, larg e l y attributable to the younger population, occurs in J u l y.

The following two tables show the main reasons for admission and the main causes of death in the non- resident population in 2001, respectively.
The table below shows the number of admissions to St. Luke’s Hospital for each diagnosis.

These include only those with a reported diagnosis.

Main Discharge Diagnosis No.
of Admissions CHEST PAIN, UNSPECIFIED SINGLE SPONTANEOUS DELIVERY, UNSPECIFIED CHEST INFECTION, UNSPECIFIED NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED UNSPECIFIED INJURY OF HEAD ASTHMA, UNSPECIFIED DYSPNOEA ABDOMINAL PAIN, UNSPECIFIED STROKE, NOT SPECIFIED AS HAEMORRHAGE OR INFARCTION SYNCOPE AND COLLAPSE PAIN LOCALIZED TO UPPER ABDOMEN ACUTE MYOCARDIAL INFARCTION, UNSPECIFIED COMA, UNSPECIFIED CHRONIC ISCHAEMIC HEART DISEASE, UNSPECIFIED CONVULSIONS, UNSPECIFIED HEADACHE CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED POISONING BY UNSPEC DRUGS, MEDICINES & BIOLOGICAL SUBS.
OF UNDET INTENT SPECIAL SCREENING EXAMINATION FOR CARDIOVASCULAR DISORDERS UNSTABLE ANGINA OTHER DIAGNOSES Main discharge diagnoses in the non-resident population in 2001 40 35 26 25 24 20 19 18 14 12 11 11 11 10 10 10 10 10 10 9 303 T o u r i s t H e a l t h 75 The table below shows the number of deaths by major age group for each cause of death.
Cause of Death < 65yrs ‡ 65yrs Total Cerebrovascular diseases Other heart diseases Pneumonia External causes of morbidity and mortality Ischaemic heart diseases Neoplasms Other acute lower respiratory infections Chronic lower respiratory diseases Gastric and duodenal ulcer Diseases of the liver Other causes 4 0 1 3 13 0 1 0 0 0 0 Main causes of death in the non-resident population in 2001 5 5 3 1 20 3 2 3 2 1 5 9 5 4 4 33 3 3 3 2 1 5 76 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 The incidence of osteoporosis is assuming significant importance due to the increasing number of elderly people in the population.
Osteoporosis affects some 75 million persons in the USA, Europe and Japan.

In 1990 an estimated 1.7 million hip fractures occurre d worldwide.

At this rate, by the year 2050, this figure would have increased up to 6.3 million hip fractures.

In the USA alone, osteoporotic fractures account for health costs of around 5 billion dollars annually (World Congress on the Menopause, Copenhagen, Denmark, 1996).
However, the Maltese fractures rate only approaches 1/2 to 1/3 that found in Northern European countries, as illustrated in the table below.

Women are at greater risk for fracture due to post- menopausal osteoporosis.

In our study there were almost twice (1.9) as many fractures in females than in males.

More recent data (1999-2001) from St Luke’s Hospital alone further emphasise the predominance of females in the gender ratio for fracture hip (3.8:1).
Osteoporosis is the decreased amount of osseous tissue per unit volume of bone.

This leads to progressive Fracture of the forearm was the most frequent fracture encountered in the outpatient clinic.
Fractured forearm in the females predominated the sex ratio but to a Country Females Norway (Oslo) 1985 Denmark (Funen) 1983 Sweden (Stockholm) 1985 United Kingdom (Oxford) 1985 Finland 1985 Spain (Barcelona) 1989 Malta 1987-1990 Israel (Jerusalem) 1970 Yugoslavia 1979 715.0 595.0 551.1 495.4 487.4 289.3 268.3 206.9 105.7 Males 298.4 211.4 254.0 160.6 175.5 137.8 136.3 114.5 90.1 Incidence of Fractured Hip in men and women over 50 years (per 100 000) F:M ratio 2.39 2.81 2.10 3.08 2.78 2.10 1.96 1.81 1.20 weakening of the skeletal system until a threshold is reached when fractures occur.
The three classical sites affected are the hip, forearm and spine.

Osteoporotic fractures exact an appreciable toll in human terms of morbidity and mortality.

much lesser extent when compared to the ratios of Northern European countries.

Again this suggests that certain Mediterranean variables attenuate the effect of post-menopausal osteoporosis (see table on the next page).

A study in the Maltese Islands has been undertaken to assess the size of the problem of osteoporo s i s .
Fractured hip was the commonest fracture for which patients were hospitalised.

The incidences are similar to those found in other Mediterranean countries.
O s t e o p o r o s i s 77 Country Females Males F:M ratio Sweden (Malmo) 1985 Norway (Oslo) 1983 United Kingdom (Newcastle) 1982 Denmark (Hillerod) 1985 Sweden (Stockholm) 1982 Sweden (Malmo) 1960 United Kingdom (Oxford) 1986 Malta 860.0 775.0 740.0 644.0 641.0 570.0 480.0 368.0 158.0 98.9 160.0 142.0 137.0 80.0 80.0 100.1 5.4 7.8 4.6 4.5 4.6 7.1 6.0 3.6 Incidence of fractures of the distal forearm for males and females over 50 years of age (per 100 000) The low latitude of the Maltese Islands offers long hours of sunshine.
At the peak of the Maltese summer the number of sunshine hours may be as high as 12 hours d a i l y. Nordic summers only offer 5 hours of sunshine e v e ry d a y. Sunlight catalyses the metabolism of derm a l vitamin D which in turn increases calcium absorption f rom the intestine.

Some of this mineral is deposited in bone and in the process elevates the peak bone mass.

T h e re is high calcium content in the Maltese diet.
This p a rtly stems from the fact that water in Malta is supersaturated with this mineral.

Rainwater seeping t h rough the Maltese calcium-rich rock form a t i o n dissolves large amounts of calcium salts.

This water is used for drinking purposes, hydration of desiccated food (flour) and for agricultural irrigation.

The gre a t majority of the Maltese people ingests diary pro d u c t s rich in calcium, in rather large amounts (113.8 k g / c a p i t a / y e a r ) .
lifelong augmented process of calcium The incorporation into bone may contribute to the low incidence of osteoporotic fractures.

Possibly the application of to most M e d i t e rranean countries may further reduce the incidence of osteoporotic fracture s .
this variable common O s t e o p o rosis was previously called the ’silent disease’ as it could only be detected by X-rays when 35% of the bone content would already have been lost Nowadays bone density can be measured to a high degree of accuracy with bone densitometers.

Treatment in the form of certain hormonal and non- h o rmonal preparations exist for both the prevention and t reatment of osteoporosis.
The most common tre a t m e n t in Maltese women is hormone replacement therapy that besides maintaining and improving bone mass also has a beneficial effect on muscle bulk and the circ u l a t o ry system.

Other factors that may have an impact on falls and there f o re fractures, such as reflexes, vision and balance, have been noted to improve with HRT.

Most other treatments concentrate on improving bone mass.
Public health measures are of immense importance in the attenuation of osteoporosis and its sequelae.

Peak bone mass may be improved upon by the widespre a d education of the public in general as re g a rds the i m p o rtance of good nutrition and avoidance of a s e d e n t a ry way of life.

Bone mass may be furt h e r c o n s e rved by the avoidance of cigarette smoking and excessive alcohol ingestion.
Adequate vitamin D (400- 800iu/day) (500-1000mg/day) calcium supplementation for the elderly has been advised by the Food and Drug Administration.

A more elderly-friendly e n v i ronment may avoid falls leading to fracture .

I m p roving vision, balance and hearing together with the judicious use/avoidance of sedative and tranquillising d rugs may also prevent falls in the elderly and consequently avoid fracture .
and 78 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 References World Congress of the Menopause, Copenhagen, Denmark 1996.

Muscat Baron Y, Brincat M, Muscat Baron A, Galea R. The epidemiology of postmenopausal osteoporosis in a M e d i t e rranean country.

Calcified Tissue Intern a t i o n a l 1996;54:365-369 Diez A, Puig J, Martinez M, Diez JL, Aubria J, Vivancos J.

Epidemiology of femur associated with o s t e o p o rosis in Barcelona, Spain.
Calcified Tiss Int 1989;44:389-392 fracture of Boyce WJ and Vessey MP.

The rising incidence of fracture of the proximal femur.

Lancet 1985,150-151 Levine S, Myer M, Jacob M, Gerdin G, Naer E, Steinberg R. Incidence of fracture of the proximal end of femur in Jerusalem.

A study of ethnic factors, Jerusalem, Israel.

Journal of Bone and Joint Surgery 1970;52a:1193-1202.

Schmalholz A.

Epidemiology of distal radius fracture.

Acta.

Orthop.
Acta.

Orthop.

1985 Winner S, Morgan C, Evan J. Perimenopausal risk of falling and fractures.

BMJ 1989;298:1486-8 incidence of distal fore a rm Annual Statistical Review.

Central Office of Statistics – Malta.

1987;1:1-2.

Malta Dairy Products report 1989. International Congress of the Menopause.

2002, Berlin, Germany.

Sobel S. Osteoporosis: Regulatory View.

Public Health Report 1987;Suppl:1136-9.


O s t e o p o r o s i s 79 Globally predominant among dental problems are two highly prevalent chronic diseases: dental caries a n d periodontal (gum) disease.

They are together re s p o n s i b l e for an enormous amount of pain and suffering which leads to the loss of millions of teeth annually.

The social and psychological toll also includes discomfort, anxiety, e m b a rrassment and dietary restriction.
However it is v e ry rare for a person to go through life without experiencing some form of dental disease even if mild.

Dental problems have always been present in Malta.

E v e rybody is familiar with tooth decay (dental caries) but not everyone is aware of the problems of periodontal disease that is a significant problem in Malta.

Over the years dental services provision has increased and been made more accessible in both hospitals and community health centers.
Dental care is provided within the national health system provided by the Government to all citizens on the basis of equity.

There is ease of access to all irrespective of means in respect of all urgent dental care as well as diagnostic and preventive care and oral surgery.

Those who qualify on a means test (low-income groups), hospitalized patients, the police and armed forces and religious orders are eligible for free restorative care.
In addition children below the age of 16 attending private, state and church schools including kindergarten are offered free comprehensive dental care.

Over 80% of school children are screened annually.

P r i m a ry dental care is delivered through eight Govern m e n t Health Centers.

Secondary and tert i a ry dental care is p rovided at the general hospitals and School Dental Clinic.
Since August 2001 dental screening sessions are being c a rried out at the Child Development Assessment Unit (CDAU) in order to assess the dental condition of childre n with special needs.

Special cases are re f e rred to the Pediatric Dentist at the School Dental Clinic.

DENTAL DISEASES Dental Caries The amount of tooth decay in a population is gauged by the average count of decayed, missing and filled teeth (DMFT).
DMFT is an index that is used internationally to measure the decayed (D), missing (M) and filled (F) teeth in the permanent dentition whereas dmft is used in the deciduous dentition ( p e rmanent dentition = adult teeth; deciduous dentition = baby teeth).

Results of studies carried out by the University of Malta and the Dental Division (1995) show low p revalence of caries by WHO standards - a DMFT of 1.6 in 12 year olds.

However the treatment ratio is also v e ry low and untreated decay is prevalent.
In the 35- 44 year old group dental caries is at a moderate level.

In 1986, however extracted teeth comprised more than 50% of the DMFT index which was the reason for the relatively high number of adults re q u i r i n g d e n t u res.

80 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 One must add that the distribution of caries is uneven in all age groups including the 3- 4 year olds where rampant or severe caries was seen in 12% of children who had 63% of all the caries seen.
This is seen in young children who frequently snack on sugary food and drinks in preference to regular meals.

These pose a problem for the hospital dental service, as most would require general anesthesia.

Parents have to become aware that the problem starts before school age and should seek advice from dentists and hygienists in the primary care.

Caries levels in Gozo were much lower than in Malta - thus preventive measures required for Malta may not necessarily be applicable to Gozo.
It has been wildly recognized that fluoride has played an important role in the prevention of dental caries.

The availability of fluoride in the water supplies is the most efficient mode of pre v e n t i n g dental caries.

Over the past decades Malta has seen changes in the water supply system, from one pure l y dependant on underg round water, to one which is heavily dependant on desalinated sea water fro m reverse osmosis plants.
This has led to a decline in the levels of fluoride naturally present in our drinking water and this may have had an impact on oral health.

Gozo, on the other hand does not receive any desalinated water and average fluoride levels of around 1.0ppm have been maintained for a number of years.

D e n t a l P u b l i c H e a l t h 81 Periodontal Disease Periodontal disease is the disease of tissues supporting the teeth.
The disease pro g resses slowly from an inflammation of the gums (gingivitis) and proceeds to destroy the attachment of each tooth together with the surrounding bone (periodontitis).

than 95% of Data on levels of periodontal disease are less recent, though there is a high prevalence of poor oral hygiene.

Poor oral hygiene, gingivitis and calculus are found in m o re the children and adults.
Nevertheless complex dental care to salvage teeth affected by severe periodontitis was only required in 2% of 35-44 year old Maltese.

Although the situation is improving this remains a problem.

Other The prevalence of oral mucosal lesions is low and the presence of oral malignant tumors appears to be rare.

Abnormal dietary habits, including the frequent intake of acidic beverages can lead to excessive tooth surface loss.

Local data is however not available.
NATIONAL TARGETS FOR DENTAL HEALTH The National Goals for Oral health by the year 2000 were the following: In respect of Dental Caries 60% of 5-6 year olds caries free 2.0 DMFT at 12 years of age FT per person 1.6 at 12 years of age In respect of Periodontal Disease All 12 year olds with at least 4 healthy sextants* 90% of 18 year olds with a t least 3 healthy sextants 75% of 35-44 year olds with at least three healthy sextants 5% of 65 year olds with one or more sextants with deep pockets *For purposes of screening the mouth is divided into six areas / sextants In respect of Tooth loss 60% of 18 year olds with no missing teeth 35% of 65 year old are edentulous CURRENT AND FUTURE ACTION During the scholastic year 2001/2002 the dental department carried out a survey to establish the DMFT in 12-year-olds in order to evaluate whether the targets for caries and tooth loss have been achieved.
The results are still being analysed.

in the primary dentition Caries experience is c o n s i d e red to be a risk factor for caries in the permanent dentition.

In fact there is a move to restore carious deciduous dentition were feasible.

There is a low perceived need to treat dental caries in the deciduous dentition.
This applies both to the dental profession as much as to the patients and their parents There is an ongoing dental health promotion campaign aimed at • reducing consumption of soft drinks and fruit juices, • limiting consumption of sugar containing foods, • improving oral hygiene, and • having regular dental check ups.

Following discussions with Malta Dairy Pro d u c t s flavoured milk has had no fermentable sugars added since 1995.
During 2002/2003 the department will be conducting further research to establish whether all the goals for the year 2000 particularly in respect of periodontal disease have been met.

The findings of the above mentioned research will enable the division to review and update our national targets.

Meanwhile the dental department will continue to monitor and evaluate its promotion campaigns in order to assess the impact on oral health.
82 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 Maltese persons with disability enjoy a wide range of services that have developed over the last fifty years.

Most of these services were designed to give support to disabled persons and include a non-contributory pension, subsidies in the purchase of disability related equipment, educational, vocational day and residential services.

The past two decades have seen a move towards the assertion of the rights of disabled persons.
The setting up of the National Commission Persons with Disability in 1987 brought the struggle for rights to the forefront of the political agenda.

From its inception, the Commission worked on the lines of the social model of disability, which sees disability as being created by a society that has little or no regard for people with physical, sensory and/or intellectual i m p a i rments and fro m participating in the mainstream of social activities.
thus excludes them disabled boys than girls in any given population means that the percentage of boys who are included is probably higher than the percentage of girls.

This does not mean that inclusive education in Malta does not have room for improvement.

Facilitators and support teachers need to be better trained in order to be able to cater for the individual needs of the children in their charge.
The Individual Educational Planning system also needs to be improved in order to ensure that it is better monitored and reviewed.

Finally, special schools need to be developed in order to serve as resource centres for mainstream schools that cater for disabled students.

EMPLOYMENT AND ADULT LIFE Inclusion in the world of work is proving to be more challenging for disabled persons in Malta.
While exact figures of the participation of disabled persons in the Disabled Students Included in State Mainstream Schools School All schools Primary Secondary Total Students Students With Disability 42,000 25,000 17,000 789 718 71 % 1.9 2.9 0.4 EDUCATION Since 1987, a number of significant milestones have been reached.

These include the adoption of an inclusive education policy by the Ministry of Education.
To d a y, around 800 disabled students attend mainstream schools, with the support of facilitators and peripatetic support teachers where this is necessary.

On the other hand, around 200 students attend special schools.

This means that whilst 2% of disabled children attend mainstream schools less than 0.5% attend special schools.

These figures compare well with those found in other European countries.
work force are not yet available, it is clear that they face considerable obstacles in their attempts to secure employment.

Lack of qualifications, low expectations and negative attitudes from employers all serve to c reate obstacles.

The disability pension is also, ironically, an obstacle since it provides a sense of security that is lost once a person starts working and needs to earn his or her keep.
Disabled women may also find it harder than men to find work because they tend to be more overprotected by their parents and carers.

While separate figures for girls and boys are not currently available, the fact that there tends to be more Although it is not easy for disabled persons to find and maintain jobs, there is a considerable number who D i s a b i l i t y 83 achieve success in this area.

Disabled people can in fact make use of a range of specially designed services.
The Employment and Training Corporation (ETC) maintains a register of disabled persons seeking work, actively looks for jobs for persons on the register and provides incentive schemes for employers to take on disabled employees.

Moreover, it buys the services of non-government organisations to train people with intellectual disability or with mental health difficulties.

The ETC needs to continue improving its services, especially by providing a service that offers vocational assessment, in the workplace.
job matching and support Severity of disability is another factor that can hinder employment chances.

This is especially true for persons with intellectual disability who are more likely to use day services than go to work.

These services have traditionally been seen as a place of respite for both disabled persons, who thus do not have to stay at home all day, and their carers, who do not have to care for their disabled family members all day.
More re c e n t l y, day services have been developing into community-based services that are more person centred and focus on meaningful activities.
Places of Residence of Disabled Persons Parents Spouse Son/daughter Siblings Residence On their own With close relative With other relative With a legal guardian In government institution In church institution Other/unspecified INDEPENDENT LIVING The National Disability Survey shows that among those who are registered as a person with disability, 6.5% live on their own.

Disabled persons tend to live with their families for as long as possible.
Once the family structure cannot give them the support they need, they tend to be institutionalised.

This means that very few disabled people enjoy a truly independent life in which they can take their own decisions.

While there are two community houses for persons with mild intellectual disability, supporting 25 persons between them, there is clearly a need for more services in this area.

The Supported Living Division, which was set up in September 2001, is now addressing these issues.
It is currently working on two aspects of the independent community for persons with severe intellecutal disability and challenging behaviour, and personal assitance schemes for persons with physical and/or sensory impairments.

supported living: living in Persons 413 1638 1542 56 27 1901 250 44 14 455 % 6.5 25.8 24.3 0.9 0.4 30.0 3.9 0.7 0.2 7.2 84 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 LEGISLATION The struggle for the rights of persons with disability underpins all the work in this area.
In Malta, the rights of disabled persons are enshrined in the Equal Opportunities (Persons with Disability) Act 2000.

This act makes it illegal to discriminate against a person on the grounds of their disability in areas such as education, employment, the provision of goods and services and insurance.

The act compares well with similar legislation in European countries since it is very comprehensive and covers all areas of life.
Through the Equal Opportunities Compliance Unit, the Commission monitors the implementation of this act and deals with complaints lodged by persons with disability.
Complaints lodged between 2000 to 2002 can be categorised as follows: Complaints Lodged with the Equal Opportunities Compliance Unit Type of Complaint Work Education Access Provision of goods and services Insurance Housing Total Total 22 15 86 28 2 2 155 Percentage 14 10 55 18 1 1 100 References The Union of the Physically Impaired Against Segregation and The Disability Alliance: Fundamental 2 Principles of Disability, London, Union of the Physically Impaired Against Segregation, 1976.
E u ropean Agency for Development in Special Needs Education: Provision for Pupils with Special Educational Needs - Trends in 14 European Countries.

E u ropean Commission, 1998.

National Commission Persons with Disability: N a t i o n a l Disability Survey.

NCPD, 1999 Council of Europe: Legislation to Counter Discrimination Against Persons with Disabilities.

Council of Europe: 2000.

National Commission Persons with Disability: I l - L i g i Opportunitajiet Indaq (Persuni b’Dizabilità) - It-Tieni Sena.
NCPD: 2002.

D i s a b i l i t y 85 I N T R O D U C T I O N Population ageing is posing unique challenges to our s o c i e t y.

The significant increase in life expectancy unavoidably implies a heightened demand for the existing support services as well as increasing pre s s u re for a l t e rnative approaches for their care.

Although the older persons and persons with special needs have many needs, which are shared by the rest of the population, they do have certain problems, which are specific.
C o n s e q u e n t l y, one has to modify and find altern a t i v e a p p roaches to the delivery of social and community s e rvices as well as medical care.

The issue is becoming more complicated when one considers that the traditional role of the Maltese family in the provision of care and support to their older re l a t i v e s is diminishing as a direct result of the economic, social and cultural changes that are affecting our society.
As a result, the family alone, without the support of specialized p rogrammes and services sponsored by government, can no longer meet the needs of the frail older persons and those with special needs, hence, the increasing demands for additional services from the formal sector.
DESCRIPTION OF THE SECTOR In Malta, care for the older persons and persons with special needs has dramatically developed from the traditionally depersonalised ’problem-oriented’ a p p roach, to the present day community oriented personalised approach covering the totality of the i n d i v i d u a l ’s well-being while reflecting the centrality of the human person and the human family.
Curre n t strategies provide various schemes from which the elderly and persons with special needs benefit either in cash or in services.

Pension schemes, free medical care , community programmes, home help service and residential care constitute the core of the strategy that s a f e g u a rds the general well-being of our elderly and people with special needs.
The concept of income security for these people in Malta a c q u i red new dimensions with the setting up of a d e p a rtment specifically responsible for their welfare.
The role of this department may be considered as c o m p l e m e n t a ry to that of the Department of Social Security for whereas the latter is responsible for the assessment and issue of financial entitlements, the D e p a rtment of the Elderly and Community Services is e n t rusted with the formulation, implementation and administration of a range of support services designed to cater for the individual needs of the elderly as well as those persons having special needs.
These services are heavily subsidized by the state so that beneficiaries only pay nominal fees or very low rates computed as a p ro p o rtion of their income for the services that they get.

In fact this department is contributing substantially t o w a rds the income security of the elderly and persons with special needs.

Elderly and persons with special needs are covered by an extensive system of social security provision.
Every Maltese citizen is entitled to either a contributory pension or a non-contributory or a means-tested pension.

These together with all other social benefit and allowances are included in the Social Security Act (1987).
Community s e rvices such as Home Care/Help Scheme, Te l e c a re , Handyman Service, Meals on Wheels, Incontinence S e rvice, Community Nursing Services and Day Care C e n t res are all forms of welfare services which pro v i d e income-in-kind for the elderly and those persons with special needs.
In this re g a rd it must be emphasized that with the projected large number of elderly, pro v i d i n g s e rvices according to need but sharing costs according to means, is not only socially desirable but also economically inevitable.

At a time when the social partners are debating the welfare gap, with emphasis being made primarily of pensions, it is essential to bear in mind the non-pension element of the social welfare package.
IDENTIFIED TRENDS IN THE SECTOR D e m o g r a p h y The Maltese population has been estimated to be 391,000 with an average population growth rate of 0.65%.

Of these 12.4% are over the age of 65 years.

It is a l a rming to note that the Maltese population may be c o n s i d e red as an aged population and the number of older persons in the Maltese islands is expected to continue to increase sharply over the next decade.
86 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 The projected population increases are illustrated below: 60 - 64 65 - 69 70 - 74 75+ SubTotal Grand Total 1999 2005 2025 Male 8,400 6,700 5,300 7,400 27,800 Female 9,600 8,600 7,000 11,500 36,700 Male 9,800 7,600 5,800 8,300 31,500 Female 10,400 8,800 7,900 13,600 40,700 Male 12,000 12,200 9,900 14,500 48,600 Female 11,800 12,900 11,100 21,200 57,000 6 4,5 0 0 7 2,2 0 0 1 0 5,6 0 0 The above scenario illustrates the rapid and sharp increase in the population aged 60 years and over.
Provision of Serv i c e s The provision of services to older people and persons with special needs can be divided into two categories: 1 .L o n g - t e rm Residential Care Pro v i s i o n .

•Community based re s i d e n c e s •S t .

Vincent de Paule Residence 2 .Community Support serv i c e s L o n g - t e rm Residential Care Pro v i s i o n L o n g - t e rm care in Malta is provided by the State ( G o v e rnment), the Roman Catholic Church and the Private Sector.
Of these three, Government and Churc h - run institutions are the most established, with the private sector joining in this field of care during the last decade.

(Fig.1) The entry of the private sector has b rought about a major change in the outlook of serv i c e p rovision in that the private sector started intro d u c i n g newer concepts in health care management so as to attract older persons to reside at their residential homes.

geographical area.
geographical area.

Residents are re q u i red to contribute 60% of their total income provided that such an amount does not exceed Lm 6 per day and provided that resident is not left with less than Lm550 per annum at his/her disposal.

St. Vincent de Paul Residence St Vincent de Paule Residence, which houses aro u n d 1050 residents, is the largest residential complex for older adults in Malta.
Only 30% of the residents may be classified as independent whereas the remaining 70% manifest varying degrees of dependence.

This residential complex had a total staff complement of 935 employees at the end of April 2001 of which 13 are medical doctors, 291 are qualified nurses and 373 are other categories of care-workers.

The scope of this service is to provide care, safeguard and promote the welfare of older adults resident as well as persons with special needs in this long-term care stay complex.
A respite care service is also provided.

Community Residential Homes The aim behind the nine community residential homes is to provide residential accommodation to persons who a re over the age of 60 years and persons with special needs.
The primary aim of these homes is to enable those older persons who are not able to continue living at their own home to at least remain within their own Community Serv i c e s Various services are provided or supported by the state in an attempt to keep the older person and persons with special needs to remain living within their community for as long as is feasibly possible.
The services include the Home Help scheme, Te l e c a re service, meals-on- wheels service, the handyman service, an incontinence E l d e r l y 87 s e rvice and other forms of rebates or subsidies such as telephone rebates to help ease off the burden from these persons.

One of the major difficulties being e n c o u n t e red is that these services are becoming very expensive to maintain and one needs to integrate the s e rvices better since the delivery of service is at times f r a g m e n t e d .
DESCRIPTION OF THE MAIN GOVERNMENT POLICIES RELATED TO THE SECTOR The Vienna Plan of Action in 1982 ’solemnly recognized that quality of life is no less important than longevity, and that the ageing should there f o re, as far as possible, be enabled to enjoy in their own families and communities a life of fulfilment, health, security and contentment, appreciated as an integral part of society’.
This statement has to be kept in mind and given the utmost consideration by all those involved directly or i n d i rectly with the implementation of services for the elderly including persons with special needs.

Living longer can offer unprecedented opportunities for personal and socially fulfilling lives.

However, it also p resents individual and societal challenges related to quality of include independence, social interaction, social integration, health care and community involvement.
In order to respond to these challenges, countries have to develop sound and aff o rdable policies that perceive ageing as a natural process, which continues throughout the life s p a n .

later years.

These life in This is the scenario that triggered the need to set up a S e c retariat for the Care of the Elderly, within the M i n i s t ry for Social Policy.
Since its very inception in 1987, it has always looked upon the elderly as those persons who had contributed to their country thro u g h various commitments: either through work or family rearing.
Govern m e n t ’s policy aims at safeguarding a respectable living standard for all; at pro v i d i n g s a t i s f a c t o ry care and attention to those who need it; s u p p o rting all private and voluntary initiatives that aim at promoting the true welfare of the elderly as well as those of persons with special needs and, last but not the least, encouraging this sector of the population to continue participating in the economic and social life, thus avoiding social exclusion and marg i n a l i s a t i o n .
It is precisely within this context that the Secre t a r i a t continually endeavours to complement longevity of life with quality by pro v i d i n g : • The necessary support in the community with the scope of helping the elderly to remain in their own homes for as long as possible, mainly through the following services: home help, handyman, telecare , meals-on wheels and the Day Centre s .
• Respite to the informal caregivers to temporarily relieve them of the often strenuous task of caring for frail or dependant elderly relatives or friends.

• Specialised geriatric rehabilitative care that helps maximise an elderly person’s level of independence.

• Residential care for frail elderly who despite community services still find it difficult to continue living in their own homes.
• A long-term nursing complex that houses elderly persons and persons with special needs having d i ff e rent levels of dependence.

• Training Opportunities for persons who work or intend to work in the field of ageing and disability, thus securing an increase in the availability of skilled human re s o u rce that should in turn reflect itself in m o re effective service delivery.

• P romote Active Ageing.

Elderly persons are encouraged to take an active part in their own aff a i r s and support schemes.
An important medium that empowers the elderly to have a say in matters, which d i rectly or indirectly affect their interests, is the National Council of the Elderly.

We also believe that education is an effective means of empowerment and thus the University of the Third Age within the Institute of Gero n t o l o g y, University of Malta was set up in 1993.

This creates the right medium for the p romotion of knowledge and the exchange of various views among peers.
88 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 EXISTING GOVERNMENT INVESTMENT PROGRAMMES AND INVESTMENT SUPPORT PROGRAMMES FOR THE SECTOR The following programmes and initiatives are curre n t l y u n d e rw a y : • Refurbishment and modernization of various wards at S t .

Vincent de Paul Residence • The introduction of examples of good practices and s t a n d a rdization of pro c e d u res at St.Vincent d e Paul R e s i d e n c e • The introduction of a Waste Management Plan for S t .
Vincent de Paule Residence and the other community homes.

• The construction and refurbishment of Day Care C e n t res for the Older Persons and persons with special needs in the various towns and villages of Malta and Gozo.

• The integration of community support serv i c e s .

• The introduction of the Residential Care Act.

• Public-Private Partnership initiatives in the pro v i s i o n of community residential care for older persons and persons with special needs.
• The integration of persons with special needs and p rovide those re s o u rces, services, training and other f o rm of support that enable persons with disability and their families to form an integral part of society (the community).

• The construction and development of small residential homes for persons with disability.
• Training and education services to help persons with special needs to integrate themselves fully in the c o m m u n i t y. E l d e r l y 89 INTRODUCTION Everyone everywhere seems to be in the process of carrying out “reform” and the health sector in Malta is no exception.

Reform can be difficult to define although it is generally easy to recognise when it happens.
Reform in the health sector has been defined as “changing health policies and the institutions through which these are implemented” This indicates that a change in policy alone is not enough, unless the appropriate administrative structures and systems to implement that same policy follow.

Using the above definition, the Maltese health sector can be described as being in transition.
An evaluation of the health care system carried out in 1998 found that most of the changes that had taken place in the 1990s were small and incremental in nature.

The new century witnessed the ambitious launch of a set of far reaching changes that are easily classified as radical reforms.

DRIVERS FOR REFORM The main drivers for reform can be categorised into internal and external factors.

The internal pressures for reform arise directly from within the system.
Some of the major instigators include: • Rapid development of costly, innovative medicines and technology • Demands from health care workers for superior working conditions • Construction and commissioning of the new Mater Dei Hospital at Tal-Qroqq These primarily exert pre s s u res on health care expenditure, forcing it upwards.

The health sector however does not exist in a vacuum and external drivers for reform have been just as important in recent years.
• Malta’s accession to the European Union • National economic policy to curb growth of public sector expenditure • An increasingly informed population with higher expectations.

These drivers are exerting their pressures on the health sector in different directions and the resultant change will ultimately depend upon the greatest strength of the drivers for change singly or in combination.
POLICY REFORM Policies exist at different levels throughout the health s e c t o r. Legislation is the strongest type of policy statement.

A brief look at the legislation pertaining to the heath sector shows that most of this body of legislation is being re-written.

There f o re the very foundations of the policy and regulatory aspects of health and health care in Malta are in effect being redesigned.
Old Legislation New Legislation Food Drugs and Drinking Water Act Medical and Kindred Professions Ordinance Prevention of Disease Ordinance and other regulations affecting public health Tobacco Smoking Control Act Department of Health Constitution Ordinance Food Safety Act a) Health Care Professions Act b) Medicines Act Public Health Act Amendment to Act allowing for stronger and wider regulation a) Health Care Professions Act b) Health Services Act 90 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2 PUBLIC HEALTH POLICY The new legislation generally gives greater re g u l a t o ry powers so as to ensure the highest possible level of is health protection for the population.
This exemplified in Food Safety, Quality Safety and E fficacy of Medicines, Radiation Protection, Quality of Bathing Water and Tobacco Control amongst others.

The Public Health authorities will be working v e ry closely with other sectors such as veterinary s e rvices and consumer protection in order to pursue the most effective regulation possible.

Euro p e a n Union legislation has served as the model upon which minimum standards have been set in line with the national political dire c t i o n .
Legislation governing regulation of health care p rofessions has also been re-drafted.

The new legislation aims to streamline the regulations of health c a re professions whilst safeguarding and pro t e c t i n g the public through mechanisms such as compulsory lay re p resentation on the re g u l a t o ry bodies as well as the introduction of specialist re g i s t e r s .

HEALTH CARE POLICY Since the early 1990s, Government has pursued the goal of decentralisation of health care provision.
This policy forms part of the National Health Policy document - Health Vision 2000, which was published in 1995.

The ultimate aim is to move from an integrated model of health care provision to a contractual model for our health care system.

This follows the major trends in European Health Care R e f o rm in the 1980s and 1990s.
Effectively this would mean that the Ministry of Health would for org a n i s i n g relinquish direct responsibility hospitals and primary care and would concentrate on p u rchasing or commissioning services from pro v i d e r s and monitoring the clinical and service standards as well as the corporate accountability.

In this manner a system of checks and balances would be intro d u c e d into the health care system.

This policy change re q u i res new legislation.


It is envisaged that the Department of Health Constitution O rdinance would be replaced by a new Health S e rvices Act that would set out the re q u i re d parameters for a contractual type of health care system to operate on a sound basis.

In the meantime, the Prime Minister announced the new policy direction for health care in July 2001, clearly setting out the road ahead.
INSTITUTIONAL REFORM The current package of re f o rms in health care re q u i re s the setting up of appropriate institutions that can implement the new policies.

In some instances, re g u l a t o ry or enforcement bodies already exist and m e rely need strengthening.

This is the case with Food Safety and re g u l a t o ry bodies for health care p rofessionals.

In other areas, the creation of new re g u l a t o ry functions is necessary.
This is true for the regulation of manufacture, importation, licensing and wholesale dealing of medicines.

In general, where v e r possible, the thrust has been to utilise re s o u rces that a l ready exist, and to create the minimalist necessary s t ru c t u res that will be capable of meeting Malta’s re g u l a t o ry re q u i re m e n t s .

In health care provision, decentralisation was p receded by grass roots re f o rm in order to set up the n e c e s s a ry management systems.
This process is well u n d e rway for smaller hospitals but still re q u i res much work at the main acute hospital.

The constru c t i o n and commissioning of the Mater Dei Hospital must s e rve as an impetus to implement the much desire d management re f o rms in the hospital sector.

In p r i m a ry care, much remains to be done.

The policy is still not clearly enunciated and d i rection decentralisation is not expected to take place for some time in this sector.
The Health Division needs to undergo the necessary t r a n s f o rmation in order to meet its incre a s i n g demands as a guardian for public health as well as an e ffective regulator for private and public health care .

C h a n g e & R e f o r m 91 Institutional re f o rm is proceeding at a slower pace than policy re f o rm.
Effective institution building relies upon the following key re s o u rc e s : • Skilled and trained human re s o u rc e s • A p p ropriate information systems • Sustainable funding CRITICAL SUCCESS FACTORS In order to maintain a steady pace for re f o rm , attention to the following factors is also critical.
• Key stakeholders must be brought on board • Skilled human re s o u rces must be retained • Fledgling institutions must be transpare n t , accountable and customer friendly CONCLUSION The health sector in Malta is currently underg o i n g major re f o rm on various fronts.

This has meant a huge challenge for the Office of Review within the M i n i s t ry of Health with its responsibility for s p e a rheading, facilitating and coordinating re f o rm .
Any re f o rm ultimately needs to translate into eff e c t i v e health protection and better service delivery.

The agenda is daunting and time frames are short.

The s h o rt time frames have necessitated a sense of urg e n c y that is uncharacteristic of our culture.

However the drivers, notably EU accession and Mater Dei Hospital, a re strong and real.

With determination and perseverance, change will pre v a i l !

92 P u b l i c H e a l t h R e p o r t M a l t a 2 0 0 2