Same pandemic yet different COVID-19 vaccination roll-out rates in two small European islands : a comparison between Cyprus and Malta

A mass vaccination strategy is estimated to be the long-term solution to control COVID-19. Different European countries have committed to vaccination strategies with variable population inoculation rates. We sought to investigate the extent to which the COVID-19 vaccination strategies, inoculation rate, and COVID-19 outcome differ between Cyprus and Malta. Data were obtained from the Ministry of Health websites and COVID-19 dashboards, while vaccination data were obtained from the European Centre for Disease Prevention and Control until mid-June, 2021. Comparative assessments were performed between the two countries using Microsoft® Excel for Mac, Version 16.54. Both islands took part in the European Union’s advanced purchase agreement and received their first batch of vaccines on 27 December 2020. The positivity rate and mortality between December and June differs between the two countries (average positivity rate Cyprus 1.34, Malta 3.37 p ≤ 0.01; average mortality Cyprus 7.29, Malta 9.68 p ≤ 0.01). Both the positivity rate and mortality for Cyprus declined due to strict public health measures and vaccination roll-out in early January (positivity rate by 95% and mortality by 58%). In contrast, for Malta, there was a sharp increase (64% p ≤ 0.01) with almost no public health restrictions in place and soaring cases during the Christmas and Carnival period until March, when lockdown measures were re-introduced. A distinctive difference between Cyprus and Malta in positivity rate (14 per 100,000 population; p ≤ 0.01) can also be observed between January and mid-April 2021. However, from April onwards it is evident that the positivity rate and mortality decline (positivity rate Cyprus by 82%, Malta by 95%; mortality Cyprus by 90%, Malta by 95%, p ≤ 0.01, respectively) in both countries as the vaccination roll-outs progressed, covering about 58.93% of the Maltese population, while Cyprus had fully inoculated about 38.03% of its population. The vaccine strategies and vaccination rates were similar for both countries; yet Malta had the fastest vaccine roll-out. Reluctancy to get vaccinated, significant differences in the vaccination appointment scheduling system, and the freedom of vaccination choice for the citizens in Cyprus may have contributed to a delayed vaccination roll-out. These potential contributing factors should be acknowledged and considered for future vaccination programs and potential COVID-19 boosters.peer-reviewe

A year of Covid-19 : experiences and lessons learnt by small European island states — Cyprus, Iceland and Malta

COVID-19 became a global pandemic within weeks, as every country including small states and islands experienced a surge in cases. Small islands are known to face several challenges in the quest to curb the viral spread, but with the absence of land boarders and small population size, these factors should have played to their advantage to minimize the spread. The aim of this article was to compare and contrast the COVID- 19 situation, restrictions, preparedness, management and the healthcare systems between the small population island states of Cyprus, Iceland and Malta. Methods: Data were obtained from Ministry of Health websites and COVID dashboards of the three respective Island states in Europe. Comparisons were made between the reported cases, deaths, excess deaths, years of life lost, swabbing rates, restrictive measures, vaccination roll-out and healthcare system structures. Results: Cyprus and Malta contained the COVID-19 spread better than Iceland during the first wave. However, a significantly higher viral spread and mortality rates were observed in Malta during the second waves. Similar healthcare preparedness and services, restrictions and relaxation measures were implemented across the three islands with some exceptions. Covid-19 vaccination has initiated across all Islands with Malta leading the vaccination roll-out. Conclusion: The small population size and island status proved to be an asset during the first wave of COVID-19, but different governance approaches led to a different COVID-19 outcomes, including high mortality rates during the transition phases and the subsequent waves.peer-reviewe

Re-engineering the Cypriot general healthcare system for syndemics

To date in Cyprus, there is no dedicated “Quality Improvement” body or Public Health authority. The long-awaited general healthcare system (known as GeSy or GHS) has been completed, mid-stream of the COVID-19 pandemic. A recently proposed resilience plan in response to the lessons learnt from the pandemic was put forward by the Government of the Republic of Cyprus to strengthen the capacity of the GHS and support public health defense. The negotiator of GeSy and Health Minister 2015–2018 also provided his view that the health system needs a holistic transformation of service provision. Recognizing failures and thinking from a syndemogenesis perspective how the envisioned patient-centric healthcare delivery can be achieved, we propose that the public health response could also be linked to a politico-economic one in shielding GeSy. We make such case for a syndemic strategy (simultaneous management of COVID-19 and pre-existing epidemics on the island) and the development of the five-district model where each main district hospital is to complement the activities of the GHS through developing: 1. A training Center for training and sharing of best practices for COVID-19 and other public emergencies. 2. A public health body. 3. A quality improvement institute. 4. A commissioning center on planning and streamlining healthcare services. 5. A clinical trial platform. The rationale is based on the management literature and use of existing resources and capabilities for transforming the GeSy and generating value

Estimating Years of Life Lost due to COVID-19 over the first two years of the pandemic in Cyprus: comparisons across areas, age, and sex

Knowledge about the extent of the COVID-19 mortality burden is important to inform policy-making decisions. To gain greater insights into the population health impact of COVID-19 mortality, Years of Life Lost (YLL) can be estimated. We aimed to determine YLL linked to COVID-19 over the first two years (March 2020–March 2022) of the pandemic in Cyprus, by areas, and by age and sex. COVID-19 YLL was estimated by multiplying COVID-19 mortality counts by age-conditional life expectancy from the 2019 Global Burden of Disease life table. COVID-19 accounted for 16,704 YLL over the first two years of the pandemic—approximately 18.5 years lost per individual who died due to COVID-19 and 1881 YLL per 100,000 population. YLL per 100,000 was higher among males compared to females (2485 versus 1303 per 100,000) and higher among older than younger individuals. COVID-19 deaths and YLL per 100,000 were higher in high population-dense areas of Cyprus, such as Limassol. Continued evaluations of COVID-19 YLL are needed to inform on the proportionate population impact of COVID-19, over time and across areas of Cyprus

Identification of hypertensive subjects who are predisposed to develop atrial fibrillation and correlate the latter with parameters from the surface electrocardiogram, the 24-h ambulatory blood pressure, the 24-h holter monitoring, the echocardiographic study and laboratory measurements

BACKGROUND: The purpose of the present study was to identify hypertensive subjects who are predisposed to develop atrial fibrillation (AF) and correlate the latter with parameters from the surface electrocardiogram (ECG), the 24-h ambulatory blood pressure (BP), the 24-h holter monitoring, the echocardiogrphic study and laboratory measurements.METHODS: To investigate the hypothesis, from the general population of hypertensive subjects in sinus rhythm presenting in the Outpatient Clinic, we recruited 50 subjects with a documented episode of paroxysmal AF (PAF group, age 63±9 y) and 50 subjects with no history of AF (non AF group, age 49±8 y). All study participants underwent 24-h ambulatory BP and Holter monitoring, 12-lead ECG for Pdisp assessment, a complete transthoracic echocardiographic study, routine biochemical profile assessment and finally, determination of 1) hs-CRP and endothelin-1, as markers of subclinical inflammation as well as 2) the level of natriuretic peptides (BNP and ANP).RESULTS: Hypertensive subjects with PAF compared to those without AF were older by 14 years (p <0.0001). The paroxysmal AF group in comparison with the non PAF group exhibited a lower office and 24-h diastolic BP and, consequently, a higher office and average 24-h pulse pressure. With respect to their medical treatment, AF subjects were treated in a higher proportion with statins, renin-angiotensin-aldosterone system inhibitors, diuretics and calcium channel blockers. The echocardiographic measurements revealed a higher LA diameter index in the AF group and a higher LVMI. The AF group compared to the non AF group with regard to the indexes of diastolic performance exhibited a prolonged isovolumetric relaxation time and a lower fractional shortening and ejection. In terms of ECG-derived indexes regarding P wave variability, the AF group compared to the group without AF exhibited a shorter Pmin (by 13 ms, p ≤0.01) and a greater Pdisp (by 22 ms, p <0.0001). Another important finding of this study concerned the inflammatory markers. The AF group had higher mean log10(hs-CRP) values (by 0.55 mm/l, p < 0.001) that remained significant even after adjustment for age, 24-h DBP and baseline medical treatment. Finally, both of natriuritic peptide levels, BNP and ANP were higher in the subjects with AF compared with the group without AF.CONCLUSIONS: The present study, apart from confirming that hypertensive subjects with a history of paroxysmal AF are characterized by elevated CRP levels and greater values of Pdisp, demonstrated for the first time the association between Pdisp and CRP values. This findings support the notion that low grade inflammation is implicated in the electrophysiological remodeling of the atria in the setting of paroxysmal AF in hypertension. Moreover, natriuretic peptide levels (BNP and ANP) could be a significant and reliable index for the detection of patients prone to the development of PAF among essential hypertensive patients in sinus rhythm.ΣΚΟΠΟΣ: Σκοπός της παρούσας μελέτης ήταν η ανίχνευση υπερτασικών ασθενών με επιρρέπεια για ανάπτυξη κολπικής μαρμαρυγής (ΚΜ) σε συσχέτιση με παραμέτρους από το ΗΚΓ, το υπερηχοκαρδιογράφημα, την 24ωρη ΗΚΓ καταγραφή ρυθμού, την 24ωρη καταγραφή αρτηριακής πίεσης (ΑΠ) και βιοχημικές παραμέτρους.ΜΕΘΟΔΟΙ: Μελετήθηκαν 50 υπερτασικοί ασθενείς με τεκμηριωμένο επεισόδιο παροξυσμικής κολπικής μαρμαρυγής και 50 υπερτασικοί ασθενείς χωρίς κολπική μαρμαρυγή. Όλοι οι ασθενείς υποβλήθηκαν σε 24ωρη καταγραφή της ΑΠ, σε 24ωρη καταγραφής ρυθμού και ΗΚΓ ηρεμίας 12 απαγωγών από το οποίο υπολογίστηκε η διασπορά του επάρματος p, σε διαθωρακικό υπερηχοκαρδιογραφικό έλεγχο και βιοχημικό έλεγχο ρουτίνας. Τέλος σε πρωινό δείγμα φλεβικού αίματος προσδιορίστηκαν η ενδοθηλίνη και η hs-CRP ως δείκτες υποκλινικής φλεγμονής, καθώς επίσης και τα νατριουρητικά πεπτίδια (ANP και BNP). ΑΠΟΤΕΛΕΣΜΑΤΑ: Οι υπερτασικοί ασθενείς με ΠΚΜ σε σχέση με αυτούς χωρίς ΚΜ είχαν μεγαλύτερο μέσο όρο ηλικίας κατά 14 έτη (63±9, 49±8 έτη, p<0.0001). Επιπλέον, η ομάδα των υπερτασικών με ΠΚΜ παρουσίασε χαμηλότερη διαστολική πίεση ιατρείου όπως επίσης και χαμηλότερες τιμές 24ωρης διαστολικής αρτηριακής πίεσης συγκριτικά με την ομάδα υπερτασικών χωρίς ΚΜ και συνεπώς υψηλότερη πίεση παλμού ιατρείου και 24ωρη μέση πίεση παλμού. Οι ασθενείς της ομάδας με ΑΥ και ΠΚΜ θεραπεύονταν συχνότερα με στατίνες έναντι της ομάδας χωρίς ΚΜ, αναστολείς του συστήματος ρενίνης αλδοστερόνης, διουρητικά και ανταγωνιστές διαύλων ασβεστίου. Η υπερηχοκαρδιογραφική μελέτη έδειξε ένα υψηλότερο δείκτη διαμέτρου του αριστερού κόλπου καθώς επίσης και υψηλότερο δείκτη μάζας της αριστερής κοιλίας στους υπερτασικούς ασθενείς με ΚΜ. Η ίδια ομάδα παρουσίασε επίσης συγκριτικά με την ομάδα υπερτασικών χωρίς ΚΜ ένα παρατεταμένο χρόνο ισοογκοκικής χάλασης καθώς επίσης και χαμηλότερο κλάσμα βράχυνσης και εξώθησης. Ένα από τα κυριότερα ευρήματα της παρούσας εργασίας είναι ότι στην ηλεκτροκαρδιογραφική μελέτη του επάρματος p οι υπερτασικοί ασθενείς με ΚΜ παρουσίασαν ένα μικρότερο σε διάρκεια Pmin (13 ms, p≤0.01) και μεγαλύτερη διάρκεια της διασποράς του επάρματος p (Pdisp) (22ms, p<0.0001) σε σχέση με την ομάδα χωρίς ΚΜ. Οι ασθενείς με ΑΥ και ΠΚΜ παρουσίασαν υψηλότερες τιμές της log-hs-CRP (0.55 mg/l, p<0.0001) οι οποίες παρέμεναν στατιστικά σημαντικές και μετά από έλεγχο για άλλους συγχυτικούς παράγοντες. Τέλος, στην ομάδα ασθενών με παροξυσμική ΚΜ τα επίπεδα των BNP αλλά και αυτά των ANP ήταν σημαντικά αυξημένα έναντι της ομάδας των υπερτασικών χωρίς ΚΜ.ΣΥΜΠΕΡΑΣΜΑΤΑ: Η παρούσα μελέτη εκτός από την επιβεβαίωση ότι οι υπερτασικοί ασθενείς με ιστορικό παροξυσμικής κολπικής μαρμαρυγής παρουσιάζουν αυξημένα επίπεδα της hs-CRP και υψηλότερες τιμές του Pdisp, έδειξε για πρώτη φορά ότι σε υπερτασικούς ασθενείς τα επίπεδα της hs-CRP και η διασπορά του επάρματος p στο ΗΚΓ συσχετίζονται στενά μεταξύ τους και με τη ΚΜ. Το εύρημα αυτό περιγράφεται για πρώτη φορά αναδεικνύοντας το σημαντικό ρόλο της συστηματικής φλεγμονής στην ηλεκτροφυσιολογική κολπική αναδιαμόρφωση. Τέλος, τα επίπεδα των νατριουρητικών πεπτιδίων (ANP και BNP) είναι αυξημένα σε υπερτασικούς ασθενείς με επιρρέπεια ανάπτυξης κολπικής μαρμαρυγής

Association between retinal microcirculation and aortic stiffness in hypertensive patients

Background: The fundoscopic examination of hypertensive patients, an established hypertension-related target organ damage, tends to be underutilized in clinical practice. We sought to investigate the relationship between retinal alterations and aortic stiffness, an independent predictor of cardiovascular morbidity and mortality. Methods: Our population consisted of 197 consecutive essential hypertensive patients (age 60 +/- 13 years, 115 females) without overt cardiovascular disease. All subjects underwent fundoscopy examination and were distributed to four groups according to Scheie’s grading system. Aortic stiffness was evaluated by carotidfemoral pulse wave velocity with a validated device (Complior). Results: The four groups (Scheie’s grades 0-3: including 24, 75, 74, 24 patients respectively) did not differ with regard to age, gender and their metabolic profile. Patients with higher Scheie’s category had higher values of pulse wave velocity (8.2 +/- 1.5, 8.9 +/- 1.7, 9.3 +/- 1.8, 9.8 +/- 2.1 m/s respectively, p=0.001). Multivariable regression analysis showed that age, fundus classification and systolic arterial pressure were independent determinants of pulse wave velocity. Conclusion: Hypertensive subjects exhibit a progressive stiffening of the aorta in parallel with the progression of retinal alterations according to Scheie’s scale. Further studies are needed to clarify involved pathophysiological mechanisms and explore possible causal relationships. (C) 2010 Elsevier Ireland Ltd. All rights reserved