key: cord-0764489-2qzb1qa8 authors: Cuschieri, Sarah; Pallari, Elena; Hatziyianni, Amalia; Sigurvinsdottir, Rannveig; Sigfusdottir, Inga Dora; Sigurðardóttir, Árún Kristín title: Mortality comparisons of COVID-19 with all-cause and non-communicable diseases in Cyprus, Iceland and Malta: lessons learned and forward planning date: 2021-04-21 journal: Public Health DOI: 10.1016/j.puhe.2021.03.025 sha: 7c5920c3412607b3b6613f98e3ef940f2e9320ce doc_id: 764489 cord_uid: 2qzb1qa8 Objectives The COVID-19 pandemic has spread throughout the world, including Cyprus, Iceland and Malta. Considering the small population sizes of these three island countries, it was anticipated that COVID-19 would be adequately contained, and mortality would be low. This study aims to compare and contrast COVID-19 mortality with mortality from all-causes and common non-communicable diseases (NCDs) over 8 months between these three islands. Study design Methods Data were obtained from the Ministry of Health websites and COVID dashboards from Cyprus, Iceland and Malta. The case-fatality ratio (CFR) and years of life lost (YLLs) were calculated. Comparisons were made between the reported cases, deaths, CFR, YLLs, swabbing rates, restrictions and mitigation measures. Results Low COVID-19 case numbers and mortality rates were observed during the first wave and transition period in Cyprus, Iceland and Malta. The second wave saw a drastic increase in the number of confirmed cases and mortality rates, especially for Malta, with high CFR and YLLs. Similar restrictions and measures were evident across the three island countries. Results show that COVID-19 mortality was generally lower than mortality from NCDs. Conclusions The study highlights that small geographical and population size, along with similar restrictive measures, did not appear to have an advantage against the spread and mortality rate of COVID-19, especially during the second wave. Population density, an ageing population and social behaviours may play a role in the burden of COVID-19. It is recommended that a country-specific syndemic approach is used to deal with the local COVID-19 spread based on the population’s characteristics, behaviours and the presence of other pre-existing epidemics. The COVID-19 pandemic spread across the European continent in early 2020, affecting every country in Europe, including the islands of Cyprus, Iceland Of these three countries, Iceland reported the first COVID-19 case on the 28 th February 2020, followed by Malta (7 th March 2020) and Cyprus (9 th March 2020) 1 . Similar to other countries, their governments implemented a number of restrictions to curb the viral spread during the first wave and these were subsequently reintroduced in late summer when the second wave prevailed 1 . It was hypothesised that the small geographical and population sizes of these three islands would be an advantage, in addition to the implementation of COVID-19 measures, to curb the viral spread and keep mortality rate low. This study aims to compare and contrast COVID-19 mortality with mortality from all-causes and common noncommunicable diseases (NCDs) over 8 months (March to November 2020) between the three small islands of Cyprus, Iceland and Malta. Data were obtained from the Ministry of Health websites and COVID-19 dashboards from Cyprus, Iceland and Malta, in addition to local published studies. Comparisons were made J o u r n a l P r e -p r o o f between the reported cases, deaths, swabbing rates, restrictions and mitigation strategies. No distinction was made between individuals dying 'with' COVID-19 and individuals dying 'due to' COVID-19 as a result of lack of such data from Iceland and Malta. The reported COVID-19 positive cases and deaths were subdivided into three phases: (1) the first wave (6 th March to 7 th May); (2) the transitional period (8 th May to 13 th August); and (3) the second wave (14 th August to 30 th November). The case-fatality ratio (CFR) for each COVID-19 phase was calculated by subdividing the confirmed number of positive cases by the confirmed number of deaths and then multiplying by 100 2 . Years of life lost (YLL) is a metric used in population health to measure the number of years lost due to premature death from a particular cause. This metric is calculated by identifying the number of deaths in an age group and multiplying it by a standard life expectancy for that particular age group. The World Health Organisation life expectancy age groups tables for each country were used for this analysis 3 A synergistic relationship between the number of COVID-19-positive cases and mortality rate was expected as a result of the high infectivity rate and morbidity related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Of these three islands, Malta reported the highest rate of COVID-19 mortality since the onset of the pandemic with 27.31 per 100,000 population, followed by Iceland with 7.14 per 100,000 population and Cyprus with 6.39 per 100,000 population. On subdividing the 8-month study period of the pandemic into three phases, as shown in Figure 3 , it can be seen that the islands experienced a higher mortality rate during the second wave, which coincides with higher community spread and identified cases. All three islands reported the spread of COVID-19 within nursing homes, especially during the second wave 6, 8, 9 . Indeed, Iceland reported extensive COVID-19 spread J o u r n a l P r e -p r o o f among the geriatric department of Landakot hospital, as well within nursing homes and a rehabilitation centre 10 . CFR was measured to assess the impact of the pandemic on the mortality of the population. Interestingly, even though the second wave showed a higher mortality rate for all three islands, the CFR for Malta exceeded the other islands. Indeed, on assessing mortality from COVID-19 as a fraction of the reported all-cause mortality for 2019 for each country, mortality from COVID-19 represented 3.73% of all-cause mortality in Malta, 1.23% in Iceland and 0.64% in Cyprus 4 . As shown in figure 4, when stratification was performed by age and gender, the highest morality occurrences were seen in men and the elderly (>85 years) across the three islands. Non-communicable diseases (NCDs) have been reported to be responsible for a substantial burden of disease, including increases in years-lived with disability (YLDs) and years of life lost (YLLs) 11 . Comparisons were made between COVID-19 and common NCDs mortality (per 100,000 population) and YLLs among the populations of Cyprus, Iceland and Malta, as shown in Table 1 . COVID-19 mortality and YLLs were calculated for the study period of 8 months, whereas NCD and injury mortality and YLLs were calculated for the year 2019. However, it is still evident that COVID-19 has resulted in substantial burden for each of the three island countries, especially Malta. In fact, in Malta, COVID-19 had a higher mortality rate (per 100,000) than road traffic accidents and diabetes mellitus. Small islands are considered to be at an advantage when controlling infectious diseases due to their small population and geographical sizes. In small islands, containment measures at a with spikes in mortality occurred in Malta. This study showed that, similar to other countries, these small islands showed a higher mortality among the elderly population, particularly among men 16 . Despite similar reintroduction of restrictions at the onset of the second wave in the three islands, the COVID-19 burden in Malta predominated with a higher CFR than Cyprus and Iceland. Such CFR differences have been attributed to differences in patient characteristics, prevalence of diagnostic testing and healthcare system availability 17 . However, Cyprus and Malta have been reported to have similar patient metabolic characteristics and healthcare system preparedness for COVID-19 1,18-20 . The PCR testing strategy in Cyprus, Iceland and Malta has been very similar 1 . However, Iceland reported the highest prevalence of testing rate, followed by Malta and Cyprus. A number of limitations need to be acknowledged for this study. COVID-19 data and analyses were limited to the available data from online sources, such as dashboards, platforms and other ministerial sites. Mortality data identifying individuals dying 'with' COVID-19 as opposed to dying 'due to' COVID-19 were available for Cyprus, but not for Iceland and Malta. Furthermore, it is expected that a proportion of COVID-19 mortality has been unreported, as individuals may die without officially being identified as COVID-19 positive. This may impact the analyses and conclusions of this study. Another limitation is the lack of data on confounding factors that might have had an impact on mortality rates. Allcause mortality, mortality attributed to NCDs and YLLs were reported for the year 2019, while the COVID-19 mortality and YLLs were calculated based on a period of 8 months. These comparisons provide a general overview of the effect of COVID-19 within the study period. However, conclusive comparisons could not be achieved, especially as the pandemic is ongoing and variables, including the rate of spread, restriction measures and epidemiological data, rapidly change. The spread of the COVID-19 pandemic exhibits no boundaries and has affected all countries across the world, including the small islands of Cyprus, Iceland and Malta. The current study highlights that small geographical and population sizes, along with similar restrictive public health measures, did not have an advantage against the viral spread and mortality rate, Dealing with COVID-19 in small European island states: Cyprus, Iceland and Malta. Early Hum Dev Estimating mortality from COVID-19. Scientific Brief Life tables by country [Internet]. World Health Organization (WHO) Institute for Health Metrics and Evaluation (IHME). Global Health Data Exchange The Directorate of Health, The Department of Civil Protection and Emergency Management. 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Front Public Heal COVID-19 is ageist, sexist, ruthless, dispassionate and opportunistic -Protecting our vulnerable Offline: COVID-19 is not a pandemic COVID-19 mortality by age groups and gender in Cyprus, Iceland and Malta between Mortality from COVID-19 by sex and age groups in Cyprus, Iceland and Malta Cyprus Cyprus Iceland Iceland Malta Malta Tweet Does small geographical and population size have an advantage against COVID-19 mortality rate? Here, we look at mortality comparisons of COVID-19 with all-cause and noncommunicable diseases in Cyprus The authors would like to thank Ms Margarita Kyriakou, Press Officer of the Ministry of Health, for the provision and validation of the provided data for Cyprus. Ethical approval Not required. None declared. None declared.