key: cord-305281-vlsy1ofk authors: Cuschieri, Sarah; MEng, Elena Pallari; Hatziyiann, Amalia; Sigurvinsdottir, Rannveig; Sigfusdottir, Inga Dora; Sigurðardóttir, Árún Kristín title: Dealing with COVID-19 in small European island states: Cyprus, Iceland and Malta date: 2020-11-12 journal: Early Hum Dev DOI: 10.1016/j.earlhumdev.2020.105261 sha: doc_id: 305281 cord_uid: vlsy1ofk Background 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 a number of challenges but in the quest to curb the viral spread, 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. Method 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, swabbing rates, restrictions and mitigation measures and healthcare system structures. Results Malta contained the COVID-19 spread better than Cyprus and Iceland during the first wave. However, a significantly higher viral spread was observed in Malta during the second wave. Similar healthcare preparedness and services, restrictions and relaxation measures were implemented across the three islands with some exceptions such as the maximum number of people permitted in one gathering, free movement restrictions and airport regulations. 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 outcome during the transition phases and the onset of the second wave. COVID-19 is a pandemic that has affected every country across the world. The three small independent islands of the Republic of Cyprus, Iceland and Malta in Europe are no exceptions. Both the Republic of Cyprus and Malta are found within the Mediterranean Sea, having a total population of 850,000 and 514,564 respectively. Iceland is situated between the North Atlantic and Arctic Oceans with a total population of 364,134. Like the rest of the Infrastructural changes were made to Iceland's and Malta's state hospitals, with an increase in intensive care unit (ICU) beds and ventilators to accommodate potential COVID-19 surges in critical cases [1, 7] . In addition, in the two largest hospitals in Iceland, special COVID-19 wards were created with staff that was relocated from different services within each hospital. In Cyprus, the public Ammochostos General Hospital (AGH) was appointed to be the COVID-19 reference point in December 2019 by the Ministry of Health. Additionally, the Eden Resort Rehabilitation has been the centre for care for a total of 279 non-emergency COVID-19 positive patients to date, of whom 224 have been discharged. The Intensive Care Unit (ICU) of the AGH was equipped with ventilators and staff began treating patients with complications and increased severity (pneumonia with severe respiratory distress). In Cyprus an ICU in Nicosia General Hospital (NGH) was built for the same purposes in case of a high number of COVID-19 cases [8] . In very severe cases where hospitalization in the ICU was needed, the patient was transported intubated accompanied from the reference hospital by an anesthesiologist to the ICU of the NGH. The Accident and Emergency Department at AGH continued to operate normally by implementing a work rotation program in groups (nursesdoctors) to avoid possible transmission between staff. In Malta, a number of non-clinical areas within the hospital building (such as the Medical School library, lecture rooms and staff canteen) underwent infrastructural changes and were converted into temporary wards [7] . Malta's hospital public areas (such as hospital's foyer and outpatient's corridors) were also equipped with oxygen points in preparation for a potential need to increase the hospital beds [7] . Across all the three Islands, outpatient clinics and elective surgery were suspended (March to May 2020) in order to ensure that an adequate number of available beds were present for potential COVID-19 cases while simultaneously increasing the number of healthcare professionals to form part of the COVID-19 the management team [1, 9] . Concurrently, Public Health authorities established a contact tracing unit and case management teams in order to trace the positive cases contacts. Furthermore, in Cyprus the AGH, and later on in other hospitals, the focus in dealing with the COVID-19 pandemic was based on plans and set algorithms (brief clinical practice guidelines) provided by the European Centre for Disease Prevention and Control (ECDC). There was a predetermined programme in place to provide suitable guidance and training to 220 medical staff, nursing staff, cleaners, office staff, ward assistance staff, messengers, ambulance drivers and other personnel, for the implementation of these protocols. The Medical and Public Health Services (MPHS) also ensured that there were amble stocks of J o u r n a l P r e -p r o o f A number of similar restrictions and mandatory legislations were instituted by the governments of the three small Island countries as seen in Table 1 with a Public Health Emergency declared by each country [1, 3, 9, 10] . Concurrently, a number of economic stimulus packages and benefits were implemented by all governments to aid struggling businesses [1, 9, 10] . In Iceland, government gave all citizens a travel voucher to be used for recreation purposes to increase internal tourism [11] . Interestingly, the Republic of Cyprus provided additional aid to citizens through suspension of the contribution to the general healthcare system (GESY) for three months and a reduction in electricity tariffs for all [9, [12] [13] [14] , an initiative not implemented in the other Islands. Another restriction difference between the Republic of Cyprus and the other two Islands was the movement per day restriction measure. Cypriots were only allowed a single daily trip so as to avoid unnecessary travel, and only after being granted permission through sending a text message to a designated number. Those granted permission needed to have identification documents at all times during their trip [9] . Cyprus instituted a traffic ban between 10pm and 6pm and mandated that employees working in supermarkets, bakeries, nursing homes, fruit markets, kiosks, mini markets, groceries, butchers and fishmongers undergo testing for SARS-CoV-2 by midnight on 28 th of April 2020 [9] . In Malta, nursing homes employees were tested for SARS-CoV-2 before Lifting and the re-introduction of COVID-19 restrictions In the beginning of May 2020, Cyprus, Iceland and Malta started to gradually lift the restrictions that were instituted at the beginning of the pandemic. The lifting of restrictions followed a transitional phase, as illustrated in Table 2 , however, it could be observed that some restrictions were re-introduced mid-Summer in Iceland and Malta [1, 3, 9, 15, 16] . During the first phase of restrictions lifting (4 th May 2020), Cyprus instructed pharmacies and supermarkets to provide special opening hours (till 10am) for the vulnerable groups, people of 60 years of age and over as well as people with disability to shop exclusively and with limited exposure [9] . On the 21 st of May the traffic ban and movement restriction were lifted. It is important to note that mitigation guidelines were instituted by all of the three small Islands to aid different the sectors in the transition period to a "new normality" while minimizing the spread of the virus within the community. resurgence with a balancing act between stimulating the economy and minimizing morbidity/mortality from COVID-19 [18, 19] . The Republic of Cyprus was observed to have had the best curbing ability of the viral infection (up till the time of writing) out of the three small Islands as restrictions were eased, including the re-opening of the airports. A number of fluctuating small peaks were observed in Cyprus during the month of August 2020, as seen in Figure 3 . However, a higher spike could be observed just 10 days after school opened on the 13 th of September. Meanwhile, Iceland's second wave was reported at the end of July with speculations that a football game was the triggering factor [20] . This surge in cases ( Figure 3 ) led to Greenland (11 th August) and Norway (16 th August), followed by the UK (September) to list Iceland as a red listed country. Concurrently new restrictions were introduced to try to curb this new wave ( Table 2 ). The re-introduced restrictions appeared to curb the spread [21] . Indeed, on the 7 th of September some measures were relaxed (Table 2) . However, a significant spike in positive cases could be observed ten days following the relaxation of these measures, as seen in Figure 3 . A different scenario could be observed for the island of Malta, where the viral spread was well controlled up till mid-July until organized mass events conducted between 17 and 23 rd July 2020, with over 800 attendees gathered together, resulted in a significantly spike of new positive cases ( Figure 3 ) and high community spread [15] . This led to a number of European countries and the US to list Malta as a red listed country [15] . The reintroduction of restrictions as seen in Figure 3 and Table 2 led to a slight reduction in daily cases however the spread within the community was still high with a significant spill off to elderly nursing homes [4, 15] . Consequently, another high spike in positive cases and 14 deaths in just a week, was observed among the elderly population [4] . In fact, a 1.23% case fatality rate was observed between 1 st of September and 23 rd September in Malta [4] . Malta does not appear to have been the re-opening of the airport or port but rather the unrestrictive capping of people gathered in one place [15] unlike in Cyprus and Iceland. Despite the re-introduction of restrictions, Malta to date (25 th September) is still struggling with high community spread and has been noted to be the seventh highest infective country out of the countries in Europe [5] . At a population level (per 100,000) Iceland appears to be currently experiencing a significant infectivity rate [3, 5] . Out of these three Islands and compared to other countries in Europe, only Cyprus appears to be effectively curbing viral spread [5] . In 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 outcome during the transition phase and the second wave. It is therefore paramount that as COVID-19 Spread in Cyprus The Directorate of Health, The Department of Civil Protection and Emergency Management, COVID-19 in Iceland COVID-19 Public Health Response Team -Ministry for Health, COVID-19 Data Management System European Centre for Disease Prevention and Control, COVID-19 situation update for the EU/EEA and the UK, as of Clinical features of patients infected with 2019 novel coronavirus in Wuhan Malta's healthcare escalation for COVID-19 KNEWS, Coronavirus ICU builders turn down bonus Presidency of the Republic of Cyprus COVID-19 Status & Response A gift for domestic traveling Press Office, Ministry Announcements & Circulars, Non-payment of the additional contribution to the GESS for a period of three months World Health Organization, Policy responses for Cyprus, COVID-19 Heal Maintaining essential services&Type=Section Re-engineering the Cypriot healthcare service system Mass Events Trigger Malta's Second Peak After Initial Successful Pandemic Suppression Press and Information Office, Clarifications on the maximum number of persons allowed at mass gatherings The Extent of COVID-19 Pandemic Socio-Economic Impact on Global Poverty. A Global Integrative Multidisciplinary Review Covid-19: Risk of second wave is very real, say researchers A risk balancing act -tourism competition using health leverage in the COVID-19 era Second wave of COVID-19 feared in Iceland amid rising cases Iceland Has Tamed Second Wave, Says Chief Epidemiologist Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.