Tehran University of Medical Sciences Journal of Biostatistics and Epidemiology 2383-4196 8 2 2022 08 03 181 194 Sarah Cuschieri Faculty of medicine and Surgery, University of Malta, Msida, Malta Amy Carabott Faculty of medicine and Surgery, University of Malta, Msida, Malta Rebecca Caruana Faculty of medicine and Surgery, University of Malta, Msida, Malta Mariah Farrugia Faculty of medicine and Surgery, University of Malta, Msida, Malta Anthea Ferriggi Faculty of medicine and Surgery, University of Malta, Msida, Malta Elizabeth Grech Faculty of medicine and Surgery, University of Malta, Msida, Malta Anneka Pacw Faculty of medicine and Surgery, University of Malta, Msida, Malta Tamara Attard-Mallia Faculty of medicine and Surgery, University of Malta, Msida, Malta Nicole Attard Faculty of medicine and Surgery, University of Malta, Msida, Malta Nathalie Attard Faculty of medicine and Surgery, University of Malta, Msida, Malta Emma Camilleri Faculty of medicine and Surgery, University of Malta, Msida, Malta Jeanella Calleja Faculty of medicine and Surgery, University of Malta, Msida, Malta Martina Baldacchino Faculty of medicine and Surgery, University of Malta, Msida, Malta David Magri Faculty of medicine and Surgery, University of Malta, Msida, Malta Neriah Mangion Faculty of medicine and Surgery, University of Malta, Msida, Malta Andrea Cuschieri Faculty of medicine and Surgery, University of Malta, Msida, Malta 2022 02 26 2022 04 24  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. https://jbe.tums.ac.ir/index.php/jbe/article/view/896