We evaluated COVID-19 epidemiology and vaccine uptake among 7,734 adults with severe acute respiratory infection in six middle-income countries and areas (CAs) in Europe during 2022–2024. A higher proportion of COVID-19 cases required mechanical ventilation (30[8.2%] vs. 23 [2.8%], p <0.001) and intensive care (70 [8.4%] vs. 48 [13.1%], p =0.016) during May 2023– April 2024 compared to May 2022–April 2023; however, COVID-19 vaccination in the last 12 months decreased from 25% in 2022–2023 to 3% in 2023–2024. Most CAs had not updated vaccine policies to recommend annual vaccination, and only two had vaccines available.