Managing COVID-19 in four small countries: Initial response to the pandemic in San Marino, Montenegro, Malta and Cyprus

Excess Mortality on Italian Small Islands during the SARS-CoV-2 Pandemic: An Ecological Study

“…After a transition stage lasting from May to August 2020, Italy was involved in the “second wave” of the SARS-CoV-2 pandemic. During the “second wave”, the small islands exhibited a substantial increase in mortality rates, and again, such results were consistent with available international estimates, where this trend was explained by hasty relaxation of NPIs, including bans on national and international travel [ 6 , 9 , 10 ]. The removal of travel bans during summer 2020 and the subsequent resumption of tourism activities could likely explain such a trend.…”

“…According to the pre-pandemic evidence, living on small islands was usually considered an advantage when dealing with infectious diseases because of their small populations, geographical size, easier implementation of containment measures, and absence of land borders [ 5 , 6 , 7 , 8 , 9 , 10 , 18 ]. Nonetheless, during the management of the COVID-19 pandemic, studies from small island states in the Mediterranean Sea (i.e., Cyprus and Malta) [ 6 , 9 , 10 ], as well as reports from Iceland [ 6 , 9 ] and small island states in the Pacific Ocean [ 7 ], stressed a more diverse pattern.…”

“…According to the pre-pandemic evidence, living on small islands was usually considered an advantage when dealing with infectious diseases because of their small populations, geographical size, easier implementation of containment measures, and absence of land borders [ 5 , 6 , 7 , 8 , 9 , 10 , 18 ]. Nonetheless, during the management of the COVID-19 pandemic, studies from small island states in the Mediterranean Sea (i.e., Cyprus and Malta) [ 6 , 9 , 10 ], as well as reports from Iceland [ 6 , 9 ] and small island states in the Pacific Ocean [ 7 ], stressed a more diverse pattern. In smaller settings, not only can medical resources be rapidly depleted, but very small and episodic mistakes in the management of the pandemic (particularly with the lifting of NPIs) may be enhanced by high population density and the forced sharing of spaces and resources, quickly leading to substantial spreading of the pathogen [ 8 , 9 ].…”

“…On the other hand, small islands may be unprepared to respond efficiently to a pandemic because of the limited availability of health resources [ 7 ]. Moreover, small islands are often involved in tourism and migratory routes: particularly in the earlier stages of the pandemic, the influx of individuals from areas where the virus was active may have provided a fertile ground for its uncontrolled spread [ 7 , 8 , 9 , 10 ].…”

“…However, scarce evidence has been collected, and mostly from small island states such as Malta and Cyprus, whose size and resources still appear as not comparable to those of small islands [ 6 , 8 , 9 , 10 ].…”