Professor Joseph Galea MD(Melit) MD(Sheffield) FRCS(Edin) FRCS(CTh) FETCS, President, Association of Surgeons of Malta has shared his experience on COVID-19 in Malta.
The small island of Malta is only 60 miles away from Italy and all television providers on the island beam Italian TV channels into Maltese homes. Many of the Maltese grow up able to speak fluent Italian despite not always setting foot on the land of our boot-shaped neighbours, thus, it came as no surprise that the endless programmes and televised photo montages of army trucks carrying corpses of people killed by the new coronavirus and the reports of overwhelmed health systems in Northern Italy during the first week of March instilled terror in the Maltese population.
The Association of Surgeons of Malta, The Association of Anaesthetists of Malta, the Medical Association of Malta and other Maltese Medical Associations started pleading with the Government to close the flights to and from Northern Italy from the last week of February. The flights from Italy were banned on 10th March and those coming from Germany, Switzerland, France and Spain were halted on the following day. From 13th March, all incoming passengers from any country had to self-quarantine for 14 days from arrival. Self-quarantine had been voluntary from 5th March but became mandatory with a fine of a €1000 which was raised to €3000 on the 13th and 17th March respectively if the quarantined person was not found at home. A total ban of incoming flights and a closing of the ports and harbours except for freight took place on 21st March.
On 12th March, the Maltese Prime Minister Dr Robert Abela announced the closure of schools, child care centres, the University and day centres for the elderly. For the first time in possibly hundreds of years, the doors of the 365 churches which dot the island closed their doors to the faithful with local TV channels transmitting religious services instead. All political activities were cancelled. Later on in the day, the Prime Minister informed the public that gyms, bars and restaurants were to close for the public with immediate effect but they could offer take-aways and food delivery services. On the following day, the Minister for Health and Vice Prime Minister Mr Christopher Fearne FRCS(Edin), an ex paediatric surgeon, broadcasted the closure of non-essential retail such as clothes, appliances and electronics outlets and non-essential services such as hairdressers, nail salons, beauticians, and spas. He also banned all organised group gatherings. Any infringements were to be charged with a €3,000 penalty.
During this time, vulnerable people including persons over the age of 65 and people with chronic disease were strongly advised to stay at home and were given paid leave off work. The Government also released funds to help establishments and companies that lost business to be able to keep their workforce. This included paying €800 per month for workers who could not go to work because their workplace had closed or their work could not be done from home. Social distancing was promoted heavily and if more than three people not coming from the same household gathered together they would be fined €100 each.
Schools and educational institutions will remain closed until the end of the scholastic year with online teaching being used for continuity. The end of secondary schools (SEC) examination will not be held and the Malta examination body (MATSEC) will issue a certificate to successful students based on performance and mid-year mock exams. This certificate will be instrumental in deciding whether to allow students to progress for further education. Intermediate and Advanced Level exams will be held in September 2020.
In February, the Superintendent of Public Health Professor Charmaine Gauci and the Mater Dei Hospital administrators were preparing for the possible onslaught. On 7th March, a 12-year-old Italian girl presented with coronavirus infection symptoms and was found to be the first positive test for this infection in Malta. She had just returned to Malta with her parents from a holiday in Trentino, Italy. Later on in the day, her parents were found to be positive for coronavirus too. The three were admitted to the infectious diseases ward and kept in isolation. As the cases increased, the only acute hospital in Malta started to get ready to receive patients. People who could work from home were encouraged to do so to avoid contact as much as possible.
Starting from mid-February the hospital had 26 beds equipped with a ventilator. One could add another 24 anaesthetic machines that could cater for ventilating patients if need be. On the smaller island of Gozo, the local hospital had 6 ventilators. The Medical Director, Mr Walter Busuttil FRCS(Edin) who is also a cardiothoracic surgeon together with the CEO of the Mater Dei Hospital purchased 50 new ventilators and these were allocated to various parts of the hospital including one of the holding bays in the operating theatre, CCU and the cardiothoracic ward. The Gozo General Hospital too purchased 10 new ventilators. Currently, the islands have the possibility of 100 and 16 ventilated beds in Malta and Gozo respectively. The in hospital lecture rooms, the Medical Library and the staff canteen have been transformed into wards with beds.
In the meantime, doctors and nurses were trained on how to use personal protective equipment (PPE) and how to manage ventilators. The Mater Dei Hospital administration created a new emergency department so that possible COVID patients and known COVID patients would go through one emergency department and patients with acute non COVID related problems would be able to go through another emergency department on the other side of the hospital. All patients were however treated as possible COVID-19 positive and in fact, they are admitted to designated wards pending their COVID status. The beds in these wards are at least three meters away from each other. Once the results are negative, the patients are transferred to COVID-free wards until they are operated on or discharged. The COVID-19 positive patients are triaged and sent home to be quarantined if symptoms are light or admitted if symptoms are severe enough or the patient is vulnerable due to comorbid conditions. A private hospital was leased so that patients who could not be sent home for various reasons would be admitted there.
The COVID-19 positive patients who are sent home are monitored and contacted every day by primary health care workers to check on their condition. They are quarantined for the duration of their illness and for 2 weeks after a negative coronavirus test. They are fined €10,000 if they break their quarantine. Quarantine checks are very rigorous and the quarantined persons are checked upon several times a day.
The active operating theatres dropped from 24 in pre-COVID times to 6; two CEPOD theatres, two trauma theatres and two hotlist theatres. The CEPOD theatres are used for non COVID emergency surgical work, the trauma theatres are used by orthopaedic surgeons and the hotlist theatres are used for urgent cases such as semi-urgent vascular and cardiac cases and cancer-related surgery. Another theatre was designated as an emergency COVID theatre and if a patient is COVID positive he or she will be operated on in that theatre using the same staff from one of the CEPOD theatres.
The Superintendent of Public Health Professor Charmaine Gauci promoted extensive testing of the population with intense tracking of contacts of the COVID positive patients and rigorous quarantining. Up to 4th May, 81,994 tests per million population have been done and these numbers have only been surpassed by Iceland, Bahrain and the United Arab Emirates. Professor Gauci is very charismatic and she gives a daily news conference where she updates the public. She never stops telling people that social distancing, staying at home and avoiding gatherings even at home are the most important measures to avoid the spread of the disease.
The effects of all the measures taken bore fruit because to date we have never had a surge in cases (see Figure 1) and out of 480 patients only 4 have died and just 77 remain active. Only one of these 77 is in critical condition.
Figure 1. Daily New Positive Cases and Deaths during the Coronavirus Pandemic in Malta