Abstract
Malta is situated in the central Mediterranean region and is a southern European nation in the form of three islands. Though age-standardized mortality rates are published in reports by the WHO, there seems to be a limitation of epidemiological research in the area of alcoholic liver disease in the region of Malta, which we can very well categorize as an unmet medical need. There has been a slow increase in standardized mortality rate due to cirrhosis from 1998 to 2003, but it is still low as compared to other EU nations. Besides, Malta stood at a lower rank at #51 in mortality statistics due to cirrhosis. However, a shocking result of European School Survey Project showed alcohol use among adolescent teenagers in Malta remained high at 86% as compared to an EU average of 79%. Although, Malta had a low rate of drinking in comparison to EU, it seems to be a thing of the past now. With more number of individuals taking to drinking, incidence of diseases like alcoholic liver disease also will be on a rise. To conclude based upon limited data available, in general the scenario in Malta is not as bad as the EU, but more research is required on this.
According to WHO report of 2010, Malta has a total population of over 405,000 with annual growth rate of 0.6%. A total of 96% of its population lives in the urban areas and the literacy rate is 87.9%. The population lies in the high income group. As per the report, the last recorded alcohol consumption by type of alcoholic beverage was in 2005, in the above 15 years age group. A total of 34% citizens consume beer, 35% consume spirits, and 28% of them consume wine made from grapes, while only 3% consume some other types of alcohol. The robust estimate of a five-year change in adults of the age group 15+ years has shown a decrease in alcohol consumption from 2001 to 2005. While the adult (15+) per capita consumption is 12.2 L of pure alcohol for the whole European region, it is only 4.3 L of pure alcohol for Malta on an average from the year 2003 -2005. However, there is significant morbidity associated with the use of alcohol. Alcohol use disorders in the 15 to 64 year age group are 3,325.5 in males and 882.3 in females per 100,000 population (World Health Organisation, 2010).
A hepatitis study in the EU compared hepatitis treatment and policies across Europe. It looked at areas such as prevention, screening, treatment access, national strategy, patient participation and outcomes. Malta scored very poor at 20th position among 30 EU countries. It scored well on prevention and monitoring, but did not do well on outcomes and national strategy (Times of Malta, 2012).
According to European Commission’s Information and Data Interface, there was a substantial decline in cirrhosis mortality among men in south European countries, including Malta. The mortality rate was round 10 to 13 per 100,000 men in the early 1980s which dropped to around 5 per 100,000 in 2000-02. Mortality rates among women were lower with lowest prevalence below 2 per 100,000 in Malta (Health in Europe: Information and Data Interface).
The age-adjusted mortality rate from cirrhosis in Malta per 100,000 men for all ages and for those who are 35-64 from various European countries in 1980-82, 1990-92 and 2000-02, and corresponding change in rates are given in the table below: (Health in Europe: Information and Data Interface)
Malta stands at # 51 in the mortality statistics for fibrosis and cirrhosis of liver where US stands at # 2 (NationMaster).
According to Health in Malta Factsheet, the mortality from liver cirrhosis is low at a standardized mortality rate of 6.1 per 100 000 population in 1998 as compared to 14.4 in the EU on average (1996) (Health in Malta, 2001).
In Malta, over 1/5th of the population (21.1%) consumes alcohol every week with regular consumption in 30% of them in the 30-59 year age group (National Commission for Abuse of Drugs, Alcohol, and other Dependencies, 2001).
In 2003, ESPAD study reported 33.3% of younger individuals of age 15 to 16 years, who had a lifetime use of alcohol 40 times or more. The same study showed citizens who reported binge drinking thrice or more in the last 30 days was 24.2% (European school survey, 2003).
The 2007 ESPAD findings published in March 2009 investigated illicit drug use among teenagers in 35 european countries one of which was Malta. The overall findings of the 1995, 1999 and 2003 ESPAD surveys were generally confirmed by these findings. Malta recorded 57% of its citizens with a habit of binge drinking (Alcohol Concern, 2009).
According to data by WHO published in 2001 by Nina Rehn, Malta had 5.1 litres/ person/ year alcohol consumption in the late 1990s. Malta was grouped under “Middle level of Consumption” nation. More than five litres/person/ year defined the middle level of consumption. Standardized death rate due to alcohol consumption was at a low of 25.98 per 100000 population. According to the report, in Malta both alcohol consumption and mortality indicators are either decreasing or stable (Rehn 2001).
According to Health Interview Survey, 2005, alcohol consumption is an important health related issue that requires attention. Alcohol is still a predominant popular choice among men with a rising popularity in women in Malta. Besides, it is seen that daily consumption of alcohol is most popular with those with a primary level of education and those who are elderly. This is associated with recommended small daily intake of wine for good health. Weekly consumption is highest with those with a tertiary level of education. This is resulting in many ailments such as cirrhosis of liver (Ministry of Health, 2008).
According to a report of WHO, Europe titled “Highlights of Health” in Malta, 2005, the mortality from liver cirrhosis is low at a standardized mortality rate of 7.3 per 100 000 population in 2003 as compared to 12.6 in the EU on average (2002). Chronic liver disease and cirrhosis account for just 1.1% of total deaths in the country (Health in Malta, 2005).
When this data is compared to earlier data published in 2001, there has been an increased in the standardized mortality rate of 6.1% in 1998 to 7.3% in 2003.
According to the European School Survey Project published 2011, alcohol use among adolescent teenagers in Malta remained high at 86% as compared to an EU average of 79 %. However, Malta’s result was down by one per cent as compared to EU over a similar survey conducted four years ago. Drunkenness among adolescent teenagers in Malta over a span of 30 days before the survey was 20% while that of the EU was 17% (Times of Malta, 2012).
Recorded per capita alcohol consumption in Malta in 1999 was 5.2 l of pure alcohol which dropped down to 4.9 in the year 2003.
As per WHO report published 2010, standardised total death rate for chronic liver disease and cirrhosis per 100,000 in Malta was 10.17 in 1970 and 6.41 in 2005. Data after that was not available. Similarly, standardised death rate for chronic liver disease and cirrhosis per 100,000 in Malta for all ages, men and women total deaths is 9.65 for men and 2.84 for women. The lowest number of deaths from cirrhosis occurred in Malta (WHO Regional Office for Europe, 2010).
According to a report compiled by the WHO on alcohol consumption within the EU, Malta’s alcohol consumption is at 8.1L/ capita, which is the lowest in all the EU nations. However, even in the region with the relatively lowest burden, the southern European region where Malta lies, about 9.2 % and 6.5 % of all deaths in men and women, respectively, are attributed to alcohol consumption. Malta has a Mediterranean drinking pattern characterized by daily intake of wine with meals, but the consumption is not traditionally high (MaltaToday, 2012).
According to WHO Regional office for Europe, 2001 report, in all European countries including Malta, men have much higher rates of alcohol-related diseases of the liver than women, denoting their greater consumption rate as compared to women. Cirrhosis is the most frequently related disease of the liver and an indicator of alcohol abuse. Research shows that cirrhosis of liver is a reasonably reliable indicator of alcohol abuse and that the amount of cirrhosis usually varies with the level of alcohol consumption, although often with a time lag . Highest death rates due to alcoholic liver disease are not seen in Malta. (WHO Regional Office for Europe 2001).
According to WorldlifeExpectancy website, Malta ranks at # 171 in the world ranking for deaths due to liver diseases, which is a good indicator. In the same rating, UK lies at #96 position (World Life Expectancy).
According to National Report, 2003, in general, Maltese population do not appear to have a alcohol related addiction or a drinking problem. Therefore, the mortality rate from chronic alcoholic liver disease or cirrhosis is comparatively lower than other European nations. (National Report, 2003, p. 59).
http://www.euro.who.int/__data/assets/pdf_file/0017/103562/E88742.pdf
Risk factors for development of Alcoholic Liver Disease
Alcohol consumption leads to ill health and has social consequences. Not only volume of consumed alcohol, but the drinking pattern has an effect on the liver. According to Alcohol Concern’s Information and Statistical Digest Factsheet published in 2009, 57% of Maltese population indulges itself in Binge drinking which is on a higher side. Binge drinking is defines as consuming five or more drinks on one occasion (Alcohol Concern, 2009).
Studies on alcohol consumption are usually focused on teenagers because this age group is widely been viewed as being at high risk from problems associated with these substances. Besides, adolescents and teenagers worldwide typically have positive views on drinking, which they take it to be a hallmark of sociability, having a good time in general, and adulthood (Davies, 1972; Plant, 1985; Plant 1992). All these factors lead to development of damage to the liver and its function. However, ALD is not acute and sudden but it is a chronic condition which develops after years of drinking too much of alcohol. The liver develops swelling and inflammation and over years it develops scarring and finally cirrhosis. Cirrhosis is the final stage of the condition (Alcoholic Liver Disease, Medline plus, 2010).
Research Limitations
The data on Alcoholic Liver Disease (ALD) was attempted to obtain from internet searches and using databases such as PubMed and PubMed central (PMC). The keywords used were Malta, Maltese, alcoholic liver disease, ALD, Cirrhosis, Liver disease, and alcohol consumption. Keywords like southern European and central Mediterranean were also used considering Malta lies in the central Mediterranean region and in south of Europe. It can be concluded that data on the prevalence and incidence of alcoholic liver disease is quite limited. It appears that the area has been completely neglected while even conducting studies locally in Europe. Very few studies even on the topic of “alcohol consumption” are carried out. There is no data available on morbidity due to alcoholic liver disease or cirrhosis. The limited data available hinders the outcome of the research. An important finding was the rising incidence of binge drinking in Malta which is alarming. In spite of this finding, data on liver diseases especially alcoholic liver disease is limited. May be the smaller size of the nation has put a limit on the research carried out. It is important to carry out more research related to alcohol consumption and consequent disease of the liver.
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