Celiac Disease in Malta

Thomas M Attard MD FAAP FACG

The Picture of Celiac Disease in Malta

• The national picture of Celiac Disease in Malta

• The composition of the Malta Celiac National Task Force

• The diagnostic guidelines in Malta

• Training and dissemination in Malta

The national picture - Rough Epidemiology

• Extrapolation based on international prevalence estimates 1:133*; 412,970**, 3,105 cases in the Maltese Islands

• Estimate based on individuals on Gluten Free Diet benefits through Dept. of Health: 786 individuals Dx with CD

• Frequency of celiac association membership (250) compared with Europe data: 1:2377***; 1:1651

* Fasano, et al, Arch of Intern Med, Volume 163: 286-292, 200

** NSO Malta, 2010

*** A. Catassi, A. Fasano . Curr Gastroenterol Rep 2002;4:238‑243.

Distribution of Celiac Disease by Region of the Maltese Islands

Northern 14%

Western14%

South Eastern15%

Southern Harbor 20%

Northern Harbor29%

Gozo and Comino

8%

Gozo and Comino

4%

Northern 42%

Western15%

South Eastern15%

Southern Harbor

4%

Northern Harbor20%

Population Distribution by Region of Malta

(Source: NSO Office 2010)

Celiac Patient Distribution by Region of Malta

(Source: Free Drugs Entitlement Office 2010)

Regional Differences in the Distribution of Celiac Disease in Malta

• Significant underrepresentation of celiac disease in the Harbour Area of Malta and a relative underrepresentation in the Gozo – Comino Area

• There are many potential reasons for these observations

Reasons for observed inequity in the distribution of Celiac Cases by region

• True difference in the incidence based on environmental and genetic factors

• Administrative / bureaucratic misassignment of regional attributes

• Difference in case recognition based on health resource utilization

• Differences in health resource utilization based on socioeconomic factors incl. disease awareness

Malta National Celiac Task Force Contacts with Societies etc.

• Adult / Internal Medicine: Dr Mario Vassallo

• Celiac Association: Chairperson Mary Rose Caruana, Chairperson / AOECS President Prof. C Scerri

• Ministry of Health: (Malcolm Vella Haber)

The Diagnostic Guidelines for Celiac Disease in Malta

• Serology: all antibody testing available free of charge if requested through Gvmt Health Services (anti-gliadin, EMA, anti-tTG IgA, IgG)

• ‘Celiac screen’ includes anti-tTG IgA / IgG• Difficulty routinely obtaining total serum IgA• SOC endoscopy: duodenal / jejunal biopsy/ies to

confirm serologic Dx • Variable wait period for endoscopy – Bx (6 – 9

months in Gvmt Health Service)

The New Diagnostic Guidelines for CD in Malta

• Inconsistency in serologic testing modalities

• Risk of clerical error

• Biopsy confirmation still standard of care

• Difficulty in assigning lifelong Dx / dietary limitations without (perceived) certainty of biopsy

• Difficulty understanding 'severe' symptoms

Training and dissemination in Malta

• Efforts directed toward general population– Appearances on TV programs Bongu (Feb. 2011) and Healthy

Living (Jan. 2011)

• Efforts directed toward Malta Celiac Association– Lecture / interactive talk (Nov 2011)

• Efforts directed toward junior trainee doctors– Foundation Program Didactic Lecture: Celiac Disease Dec 2010

• Efforts directed toward specialist care-providers – Malta Pediatric Association Meeting: Update on Celiac Disease

(Nov 2010)

• Efforts directed toward general medical community – Article Update on Celiac Disease – Synapse Medical Journal

(Mar 2011), talk 1st Malta Gastroenterology Meeting (Oct 2010)

Dissemination efforts: observations

• General population: lack of awareness of disease in general / disease in children

• Association members: lack of awareness need to regularly screen relatives / genetics

• Healthcare workers: lack of awareness of non-gastrointestinal / atypical presentations, more recent serology testing, duration of the disease

The Retrospective Study as Applied to Malta

• Inclusion of anonimized data still requires ethical review

• Difficulty identifying patients based on either endoscopy / histology findings, serologic screening results / entitlement to free drugs – need for prospective provider-based (pediatric) registry

• Average dx (Attard TM) ~ 2 / mo

• ? other providers / ? referral patterns