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. © 2020 Elsevier B.V.