Making the case for cross-border public health stratagies: a compartivie assessment of Covid-19 epidemiological trends in the Balkan countries across 17 months.
-
Sarah Cuschieri
,
Amy Carabott
,
Rebecca Caruana
,
Mariah Farrugia
,
Anthea Ferriggi
,
Elizabeth Grech
,
Anneka Pacw
,
Tamara Attard-Mallia
,
Nicole Attard
,
Nathalie Attard
,
Emma Camilleri
,
Jeanella Calleja
,
Martina Baldacchino
,
David Magri
,
Neriah Mangion
,
Andrea Cuschieri
Abstract
Introduction: COVID-19 spread globally, including across the Balkans, resulting in different morbidity and
mortality outcomes in different countries. The aim of this study was to review the impact of COVID-19
over 17 months with regards to pandemic progression, implemented mitigation strategies, and COVID-19
vaccination programs across the Balkan countries, while identifying any valuable pieces of information
acquired serendipitously throughout the pandemic that can be implemented in future action plans.
Methods: A longitudinal ecological study was conducted across the Balkan countries from the onset of
COVID-19 in these countries up until 1st August 2021. Epidemiological data was obtained from Our World
in Data databases, while Ministry of Health websites for each respective country as well as local newspapers
were utilized to review COVID-19-related mitigation and vaccination strategies. Comparisons of vaccination
coverage, incident cases and mortality were made across neighboring countries, by converting the respective
data to rates per 100,000 population for each country using Microsoft® Excel for mac (Version 16.59).
Results: More than 10 million positive COVID-19 cases and 164,470 deaths were observed across the Balkan
countries up until 1st August 2021. Trends in COVID morbidity and mortality outcomes were evident across
neighbouring countries. A staggered vaccination rollout was observed, with various rollout speeds, although
gradual decline in both morbidity and mortality occurred.
Conclusion: Results obtained from this study strongly indicate that COVID-19 outcome for a particular
country is not only dependent on the country’s own level of viral transmission, mitigations, and vaccination
rates but also on neighbouring countries’ COVID-19 situation. Hence, cross-border governance action and
recovery plans are recommended along with targeting vaccination hesitance.
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6. Hasell J, Mathieu E, Beltekian D, Macdonald B, Giattino C, Ortiz-Ospina E, et al. A cross-country database of COVID-19 testing. Sci Data [Internet]. 2020 Dec 8 [cited 2021 Jun 15];7(1):345. Available from: http://www. nature.com/articles/s41597-020-00688-8.
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12. COVID-19 Vaccine Tracker. Greece – COVID19 Vaccine Tracker [Internet]. COVID-19 Vaccine Tracker. 2021 [cited 2021 Sep 12]. Available from: https://covid19. trackvaccines.org/country/greece/.
13. COVID-19 vaccine tracker. Romania – COVID19 Vaccine Tracker [Internet]. COVID-19 vaccine tracker. 2021 [cited 2021 Sep 12]. Available from: https://covid19. trackvaccines.org/country/romania/
14. Nacionalni institut za javnp zdravje. Cepljenje proti covod-19 v Sloveniji [Internet]. Nacionalni institut za javnp zdravje. 2021 [cited 2021 Sep 12]. Available from: shorturl. at/gEX02.
15. Spina S, Marrazzo F, Migliari M, Stucchi R, Sforza A, Fumagalli R. The response of Milan’s Emergency Medical System to the COVID-19 outbreak in Italy. Lancet (London, England) [Internet]. 2020 [cited 2021 Sep 13];395(10227):e49–50. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/32119824.
16. Al-Salem W, Moraga P, Ghazi H, Madad S, Hotez PJ. The emergence and transmission of COVID-19 in European countries, 2019–2020: a comprehensive review of timelines, cases and containment. Int Health [Internet]. 2021 Sep 3 [cited 2021 Sep 13];13(5):383–98. Available from: https://academic.oup.com/inthealth/ article/13/5/383/6333378.
17. Nanda M, Aashima, Sharma R. Review of COVID-19 epidemiology and public health response in Europe in 2020. Clin Epidemiol Glob Heal [Internet]. 2021 Oct 1 [cited 2022 Apr 7];12:100882. Available from: http://www. ncbi.nlm.nih.gov/pubmed/34746513.
18. Lone SA, Ahmad A. COVID-19 pandemic - an African perspective. Emerg Microbes Infect [Internet]. 2020 Dec [cited 2022 Apr 7];9(1):1300–8. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/32458760.
19. Leal Filho W, Lütz JM, Sattler DN, Nunn PD. Coronavirus: COVID-19 Transmission in Pacific Small Island Developing States. Int J Environ Res Public Health [Internet]. 2020 [cited 2022 Apr 7];17(15). Available from: http:// www.ncbi.nlm.nih.gov/pubmed/32731327.
20. Flaxman S, Mishra S, Gandy A, Unwin HJT, Mellan TA, Coupland H, et al. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe. Nature [Internet]. 2020 Jun 8 [cited 2020 Aug 3];1–5. Available from: http://www.nature.com/articles/s41586- 020-2405-7.
21. Iftekhar EN, Priesemann V, Balling R, Bauer S, Beutels P, Calero Valdez A, et al. A look into the future of the COVID-19 pandemic in Europe: an expert consultation. Lancet Reg Heal - Eur [Internet]. 2021 Sep 1 [cited 2021 Sep 25];8:100185. Available from: https:// www.sciencedirect.com/science/article/pii/ S2666776221001629?via%3Dihub.
22. Priesemann V, Brinkmann MM, Ciesek S, Cuschieri S, Czypionka T, Giordano G, et al. Calling for pan-European commitment for rapid and sustained reduction in SARS-CoV-2 infections. Lancet. 2021;397(10269):92–3.
23. European Centre for Disease Prevention and Control (ECDC). Objectives of vaccination strategies against COVID-19 [Internet]. Stockhol,; 2021 [cited 2021 Sep 24]. Available from: https://www.ecdc.europa.eu/ sites/default/files/documents/Objectives-of-vaccination-strategies-against-COVID-19.pdf.
24. Barovic A, Cardenas NC. COVID-19 diplomacy: analysis of Serbia COVID-19 vaccine strategy in the western Balkans. J Public Health (Bangkok) [Internet]. 2021 Sep 17 [cited 2021 Oct 2]; Available from: https:// academic.oup.com/jpubhealth/advance-article/ doi/10.1093/pubmed/fdab306/6372107.
25. Sinoruka F. AstraZeneca Fears Make Albanian Teachers ‘Hesitant’ About Jab | Balkan Insight [Internet]. Balkan Insight. 2021 [cited 2021 Oct 2]. Available from: https:// balkaninsight.com/2021/03/18/astrazeneca-fears-make-albanian-teachers-hesitant-about-jab/.
26. Colarossi N. 1 in 4 People Scheduled for AstraZeneca Vaccine in Croatia Not Showing Up [Internet]. Newsweek. 2021 [cited 2021 Oct 2]. Available from: https://www.newsweek. com/1-4-people-scheduled-astrazeneca-vaccine-croatia-not-showing-1582132.
27. Fojnica A, Osmanovic A, Đuzic N, Fejzic A, Mekic E, Gromilic Z, et al. Lack of lockdown, open borders, and no vaccination in sight: is Bosnia and Herzegovina a control group? medRxiv [Internet]. 2021 Mar 3 [cited 2021 Oct 2];2021.03.01.21252700. Available from: https://www.medrxiv.org/content/10.110 1/2021.03.01.21252700v1.full.
28. UNICEF. U-Report in Kosovo: Perceptions on vaccination and COVID19 vaccine acceptance. 2021.
29. Nikolov K. Many Bulgarians do not want the COVID-19 vaccine [Internet]. EURACTIV.com. 2021 [cited 2021 Oct 2]. Available from: https://www.euractiv.com/ section/politics/short_news/many-bulgarians-do-not-want-the-covid-19-vaccine/.
30. Holt E. COVID-19 vaccination among Roma populations in Europe. The Lancet Microbe [Internet]. 2021 [cited 2021 Oct 2];2(7):e289. Available from: www.thelancet. com/microbe.
31. Amiel S. Why did Romania’s vaccination campaign derail after such a good start? [Internet]. Euronews. 2021 [cited 2021 Oct 2]. Available from: https://www. euronews.com/2021/06/08/why-did-romania-s-vaccination-campaign-derail-after-a-successful-start.
32. Gadzo M. In Serbia, COVID vaccine supply outweighs demand amid mistrust [Internet]. Aljazeera. 2021 [cited 2021 Feb 10]. Available from: https://www.aljazeera. com/news/2021/4/6/supply-of-covid-vaccines-outpaces-demand-amid-hesitancy-in-serbia.
33. France 24. As the Balkans ready for vaccination, sceptics make a stand [Internet]. France 24. 2020 [cited 2021 Oct 2]. Available from: https://www.france24.com/en/live-news/20201218-as-the-balkans-ready-for-vaccination-sceptics-make-a-stand.
34. Daily Sabah. Turkey’s health care crews fight vaccine hesitancy amid pandemic [Internet]. Daily Sabah. 2021 [cited 2021 Oct 2]. Available from: https://www.dailysabah. com/turkey/turkeys-health-care-crews-fight-vaccine-hesitancy-amid-pandemic/news.
35. Sypsa V, Roussos S, Engeli V, Paraskevis D, Tsiodras S, Hatzakis A. Trends in COVID-19 vaccination intent, determinants and reasons for vaccine hesitancy: results from repeated cross-sectional surveys in the adult general population of Greece during November 2020-June 2021. medRxiv [Internet]. 2021 Jun 24 [cited 2021 Oct 2];2021.06.23.21259376. Available from: https://www.medrxiv.org/cont ent/10.1101/2021.06.23.21259376v1.
36. UNICEF. More than half of citizens in Montenegro intend to get vaccinated against COVID-19 [Internet]. UNICEF Montenegro. 2021 [cited 2021 Feb 10]. Available from: https://www.unicef.org/montenegro/en/stories/ more-half-citizens-montenegro-intend-get-vaccinated-against-covid-19.
2. Spiteri G, Fielding J, Diercke M, et al. First cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020. Eurosurveillance 2020; 25: 2000178.
3. World Health Organization (WHO). WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020, https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 (2020, accessed 15 April 2020).
4. Our World in Data. COVID-19 Data Explorer [Internet]. Our World in Data. 2021 [cited 2021 May 12]. Available from: https:// ourworldindata.org/explorers/coronavirus-data-explorer?zoomToSelection=true&pickerS ort=desc&pickerMetric=population&Metric= People+vaccinated&Interval=Cumulative&Re lative+to+Population=true&Align+outbreaks= false&country=DEU~ISR~GBR~USA~MLT~ European.
5. Boytchev H. Covid-19: Why the Balkans’ vaccine rollout lags behind most of Europe. BMJ [Internet]. 2021 Oct 5 [cited 2022 Apr 7];375:n2412. Available from: http://www. ncbi.nlm.nih.gov/pubmed/34610944.
6. Hasell J, Mathieu E, Beltekian D, Macdonald B, Giattino C, Ortiz-Ospina E, et al. A cross-country database of COVID-19 testing. Sci Data [Internet]. 2020 Dec 8 [cited 2021 Jun 15];7(1):345. Available from: http://www. nature.com/articles/s41597-020-00688-8.
Strategy [Internet]. Public health. 2021 [cited 2021 Jun 5]. Available from: https://ec.europa. eu/info/live-work-travel-eu/coronavirus-response/public-health/eu-vaccines-strategy_ en.
8. European Medical Agency. Covid-19 vaccines: authorised [Internet]. Covid-19. 2021 [cited 2021 May 11]. Available from: https:// www.ema.europa.eu/en/human-regulatory/ overview/public-health-threats/coronavirus-disease-covid-19/treatments-vaccines/ vaccines-covid-19/covid-19-vaccines-authorised.
9. Radio Bulgaria. Bulgaria expects delivery of Pfizer, Moderna and AstraZeneca vaccines [Internet]. Radio Bulgaria. 2021 [cited 2021 Sep 12]. Available from: https://bnr.bg/ en/post/101443828/bulgaria-expects-delivery-of-31000-doses-of-pfizer-51000-of-moderna-and-150000-of-astrazeneca-vaccines.
10. On Air Bulgaria. Започва имунизацията с ваксината на Janssen у нас - Bgonair [Internet]. On Air Bulgaria. 2021 [cited 2021 Sep 12]. Available from: https://www. bgonair.bg/a/2-bulgaria/225015-zapochva-imunizatsiyata-s-vaksinata-na-janssen-u-nas.
11. COVID-19 vaccine tracker. Croatia – COVID19 Vaccine Tracker [Internet]. COVID-19 vaccine tracker. 2021 [cited 2021 Sep 12]. Available from: https://covid19. trackvaccines.org/country/croatia/.
12. COVID-19 Vaccine Tracker. Greece – COVID19 Vaccine Tracker [Internet]. COVID-19 Vaccine Tracker. 2021 [cited 2021 Sep 12]. Available from: https://covid19. trackvaccines.org/country/greece/.
13. COVID-19 vaccine tracker. Romania – COVID19 Vaccine Tracker [Internet]. COVID-19 vaccine tracker. 2021 [cited 2021 Sep 12]. Available from: https://covid19. trackvaccines.org/country/romania/
14. Nacionalni institut za javnp zdravje. Cepljenje proti covod-19 v Sloveniji [Internet]. Nacionalni institut za javnp zdravje. 2021 [cited 2021 Sep 12]. Available from: shorturl. at/gEX02.
15. Spina S, Marrazzo F, Migliari M, Stucchi R, Sforza A, Fumagalli R. The response of Milan’s Emergency Medical System to the COVID-19 outbreak in Italy. Lancet (London, England) [Internet]. 2020 [cited 2021 Sep 13];395(10227):e49–50. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/32119824.
16. Al-Salem W, Moraga P, Ghazi H, Madad S, Hotez PJ. The emergence and transmission of COVID-19 in European countries, 2019–2020: a comprehensive review of timelines, cases and containment. Int Health [Internet]. 2021 Sep 3 [cited 2021 Sep 13];13(5):383–98. Available from: https://academic.oup.com/inthealth/ article/13/5/383/6333378.
17. Nanda M, Aashima, Sharma R. Review of COVID-19 epidemiology and public health response in Europe in 2020. Clin Epidemiol Glob Heal [Internet]. 2021 Oct 1 [cited 2022 Apr 7];12:100882. Available from: http://www. ncbi.nlm.nih.gov/pubmed/34746513.
18. Lone SA, Ahmad A. COVID-19 pandemic - an African perspective. Emerg Microbes Infect [Internet]. 2020 Dec [cited 2022 Apr 7];9(1):1300–8. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/32458760.
19. Leal Filho W, Lütz JM, Sattler DN, Nunn PD. Coronavirus: COVID-19 Transmission in Pacific Small Island Developing States. Int J Environ Res Public Health [Internet]. 2020 [cited 2022 Apr 7];17(15). Available from: http:// www.ncbi.nlm.nih.gov/pubmed/32731327.
20. Flaxman S, Mishra S, Gandy A, Unwin HJT, Mellan TA, Coupland H, et al. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe. Nature [Internet]. 2020 Jun 8 [cited 2020 Aug 3];1–5. Available from: http://www.nature.com/articles/s41586- 020-2405-7.
21. Iftekhar EN, Priesemann V, Balling R, Bauer S, Beutels P, Calero Valdez A, et al. A look into the future of the COVID-19 pandemic in Europe: an expert consultation. Lancet Reg Heal - Eur [Internet]. 2021 Sep 1 [cited 2021 Sep 25];8:100185. Available from: https:// www.sciencedirect.com/science/article/pii/ S2666776221001629?via%3Dihub.
22. Priesemann V, Brinkmann MM, Ciesek S, Cuschieri S, Czypionka T, Giordano G, et al. Calling for pan-European commitment for rapid and sustained reduction in SARS-CoV-2 infections. Lancet. 2021;397(10269):92–3.
23. European Centre for Disease Prevention and Control (ECDC). Objectives of vaccination strategies against COVID-19 [Internet]. Stockhol,; 2021 [cited 2021 Sep 24]. Available from: https://www.ecdc.europa.eu/ sites/default/files/documents/Objectives-of-vaccination-strategies-against-COVID-19.pdf.
24. Barovic A, Cardenas NC. COVID-19 diplomacy: analysis of Serbia COVID-19 vaccine strategy in the western Balkans. J Public Health (Bangkok) [Internet]. 2021 Sep 17 [cited 2021 Oct 2]; Available from: https:// academic.oup.com/jpubhealth/advance-article/ doi/10.1093/pubmed/fdab306/6372107.
25. Sinoruka F. AstraZeneca Fears Make Albanian Teachers ‘Hesitant’ About Jab | Balkan Insight [Internet]. Balkan Insight. 2021 [cited 2021 Oct 2]. Available from: https:// balkaninsight.com/2021/03/18/astrazeneca-fears-make-albanian-teachers-hesitant-about-jab/.
26. Colarossi N. 1 in 4 People Scheduled for AstraZeneca Vaccine in Croatia Not Showing Up [Internet]. Newsweek. 2021 [cited 2021 Oct 2]. Available from: https://www.newsweek. com/1-4-people-scheduled-astrazeneca-vaccine-croatia-not-showing-1582132.
27. Fojnica A, Osmanovic A, Đuzic N, Fejzic A, Mekic E, Gromilic Z, et al. Lack of lockdown, open borders, and no vaccination in sight: is Bosnia and Herzegovina a control group? medRxiv [Internet]. 2021 Mar 3 [cited 2021 Oct 2];2021.03.01.21252700. Available from: https://www.medrxiv.org/content/10.110 1/2021.03.01.21252700v1.full.
28. UNICEF. U-Report in Kosovo: Perceptions on vaccination and COVID19 vaccine acceptance. 2021.
29. Nikolov K. Many Bulgarians do not want the COVID-19 vaccine [Internet]. EURACTIV.com. 2021 [cited 2021 Oct 2]. Available from: https://www.euractiv.com/ section/politics/short_news/many-bulgarians-do-not-want-the-covid-19-vaccine/.
30. Holt E. COVID-19 vaccination among Roma populations in Europe. The Lancet Microbe [Internet]. 2021 [cited 2021 Oct 2];2(7):e289. Available from: www.thelancet. com/microbe.
31. Amiel S. Why did Romania’s vaccination campaign derail after such a good start? [Internet]. Euronews. 2021 [cited 2021 Oct 2]. Available from: https://www. euronews.com/2021/06/08/why-did-romania-s-vaccination-campaign-derail-after-a-successful-start.
32. Gadzo M. In Serbia, COVID vaccine supply outweighs demand amid mistrust [Internet]. Aljazeera. 2021 [cited 2021 Feb 10]. Available from: https://www.aljazeera. com/news/2021/4/6/supply-of-covid-vaccines-outpaces-demand-amid-hesitancy-in-serbia.
33. France 24. As the Balkans ready for vaccination, sceptics make a stand [Internet]. France 24. 2020 [cited 2021 Oct 2]. Available from: https://www.france24.com/en/live-news/20201218-as-the-balkans-ready-for-vaccination-sceptics-make-a-stand.
34. Daily Sabah. Turkey’s health care crews fight vaccine hesitancy amid pandemic [Internet]. Daily Sabah. 2021 [cited 2021 Oct 2]. Available from: https://www.dailysabah. com/turkey/turkeys-health-care-crews-fight-vaccine-hesitancy-amid-pandemic/news.
35. Sypsa V, Roussos S, Engeli V, Paraskevis D, Tsiodras S, Hatzakis A. Trends in COVID-19 vaccination intent, determinants and reasons for vaccine hesitancy: results from repeated cross-sectional surveys in the adult general population of Greece during November 2020-June 2021. medRxiv [Internet]. 2021 Jun 24 [cited 2021 Oct 2];2021.06.23.21259376. Available from: https://www.medrxiv.org/cont ent/10.1101/2021.06.23.21259376v1.
36. UNICEF. More than half of citizens in Montenegro intend to get vaccinated against COVID-19 [Internet]. UNICEF Montenegro. 2021 [cited 2021 Feb 10]. Available from: https://www.unicef.org/montenegro/en/stories/ more-half-citizens-montenegro-intend-get-vaccinated-against-covid-19.
| Files | ||
| Issue | Vol 8 No 2 (2022) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/jbe.v8i2.10416 | |
| Keywords | ||
| Coronavirus Europe Morbidity Mortality Mass Vaccinations Epidemiology | ||
| Rights and permissions | |
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Cuschieri S, Carabott A, Caruana R, Farrugia M, Ferriggi A, Grech E, Pacw A, Attard-Mallia T, Attard N, Attard N, Camilleri E, Calleja J, Baldacchino M, Magri D, Mangion N, Cuschieri A. Making the case for cross-border public health stratagies: a compartivie assessment of Covid-19 epidemiological trends in the Balkan countries across 17 months. JBE. 2022;8(2):181-194.
