Comoros: Score Justification Summary

1.1.1a National plan for AMR priority pathogens

Score: 50

Comoros has a national multisectoral action plan for combating antimicrobial resistance for the period 2022-2026.

This plan outlines its vision to adapt and integrate global action plan recommendations into the national context to make the country resilient against the progression of antimicrobial resistance (p. 2, p. 13). The plan's objectives include strengthening knowledge and factual bases through surveillance and research, which directly indicates coverage of surveillance (p. 13). ¹

Furthermore, the operational action plan, detailed within the document, specifies activities directly related to surveillance, detection, and reporting. It mandates the identification and nomination of a national coordination structure for AMR surveillance (CNCS RAM), and the identification and nomination of two national reference laboratories for both human and animal health, along with sentinel sites (p. XV). The plan also includes reinforcing the capacities of these structures and laboratories (p. XV). To ensure reporting and integration into global systems, there is an activity to elaborate and make available a document describing the organization of the national surveillance system and to enroll the country in the Global Laboratory Surveillance System (GLASS) of the World Health Organization (p. XV). ²

While these elements indicate intent and preliminary frameworks for surveillance, detection, and reporting, there is currently insufficient evidence from publicly available sources that demonstrates full implementation or operationalization of these systems for priority AMR pathogens. For instance, while laboratories and sentinel sites are mentioned, there is no evidence that they are currently active or effectively conducting continuous reporting of priority pathogens. Additionally, while enrollment in GLASS is listed as an activity, there is no confirmation that this has already been achieved.

1.1.1b Capacity of national lab/lab system to test for AMR priority pathogens

Score: 0

There is no evidence that there is a national laboratory/laboratory system which tests for priority AMR pathogens.

The National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026, under its Strategic Objective 2, which focuses on "Strengthening Knowledge and Factual Bases through Surveillance and Research," includes concrete activities for laboratory system development (p. 13). The plan specifies the need to identify and nominate a national coordination structure for AMR surveillance (CNCS RAM), along with two national reference laboratories: one dedicated to human health and another for animal health. Additionally, it calls for the establishment of sentinel sites (p. XXVIII). A key component of these efforts involves reinforcing the technical and operational capacities of both the coordination structure and these newly designated reference laboratories, including the sentinel sites (p. XXIX). Furthermore, the plan intends to elaborate and disseminate a document detailing the organization of the national surveillance system and to enroll the country in the World Health Organization's Global Laboratory Surveillance System (GLASS), which is an international standard for AMR data collection and reporting (p. XXX). It also mandates the training of professionals in evaluating antimicrobial consumption and conducting punctual studies on antibiotic use in human and animal health, as well as on healthcare-associated infections (p. XXX, p. XXXI). The plan also notes the intention to reinforce the laboratory capacities of INRAPE for the control of environmental AMR (p. XIX). ³

A Joint External Evaluation (JEE) conducted in 2017 provided a baseline assessment of the country's capabilities, revealing significant gaps at that time. The JEE report explicitly stated that the capacities for managing antimicrobial resistance were "practically non-existent" (p. 2, p. 9). According to the 2017 assessment, only one laboratory, located at the Centre Hospitalier "El Maarouf," possessed the capability to detect AMR pathogens. This laboratory's primary diagnostic functions were for diseases such as HIV/AIDS, malaria, tuberculosis, meningitis, cholera, and measles (p. 9, p. 22). While a veterinary laboratory existed at INRAPE, its molecular biology unit was non-functional due to a lack of resources (p. 9). AMR-related activities in 2017 were limited to participation in specific studies, such as detecting Escherichia Coli resistance in urinary samples and Salmonella resistance in meat (p. 9). The JEE report highlighted the imperative to define a policy for the prevention and control of healthcare-associated infections and to improve the legislative framework for the responsible use of human and veterinary medicines (p. 11). It also recommended identifying the AMR pathogens circulating in the Union of Comoros, which indicates a previous lack of comprehensive and systematic testing for a wide range of resistant microorganisms (p. 10). ⁴

Other national documents, such as the National Community Health Strategy 2024-2028, the National Quality Policy of the Union of Comoros, and the National Health Development Plan 2015-2019, provide broader context on the health and quality infrastructure but do not specifically elaborate on a national laboratory system for testing priority AMR pathogens or whether it covers all seven plus one (7+1) WHO priority AMR pathogens. The National Community Health Strategy 2024-2028 discusses the overall health system structure, epidemiological surveillance, and the health information system, but does not detail specific laboratory capabilities for AMR pathogen testing. ⁵ The National Quality Policy of the Union of Comoros lists various laboratories involved in general quality control and conformity assessment, such as those at INRAPE for physico-chemical analyses, microbiology, and veterinary testing, but it does not specify their role in AMR pathogen detection (p. 24-25). This policy also notes general weaknesses across these laboratories, including insufficient maintenance, quality management, qualified personnel, and consumables (p. 25). ⁶ The National Health Development Plan 2015-2019 also acknowledges that "the supply of medical imaging and laboratory services is insufficient and of poor quality in health facilities," citing a lack of equipment, trained personnel, and regular supply of reagents (p. 42). It mentions specific labs for tuberculosis and leprosy diagnosis but not general AMR pathogen testing (p. 16, p. 57). ⁷

1.1.1c National environmental surveillance for AMR residues/organisms

Score: 0

There is no evidence the government of Comoros conducts environmental detection or surveillance activities (e.g., in soil, waterways) for antimicrobial residues or AMR organisms.

A strategic intervention specified within the National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 is to "Elaborate and implement a policy for surveillance and prevention of environmental contamination by antimicrobials, resistant microbes, and their residues" (p. XIX). Under this intervention, the plan lists activities such as "Elaborate regulations on the surveillance, prevention, and control of environmental contamination by antimicrobials, resistant microbes, and their residues" (p. XLVI, Activity 4.2.1). Additionally, the plan includes "Strengthening laboratory capacities for AMR control in the environment (INRAPE)" (p. XLVI, Activity 4.2.2). These are outlined as future actions or areas of development. ⁸

However, prior assessments in Comoros provide context on historical capabilities. The 2018 Joint External Evaluation (JEE) report stated that the country's capacity to manage AMR was "practically non-existent" (p. 9). The same report noted the absence of a national plan for biomedical waste management (p. 17), which relates to environmental health. ⁹ While the National Quality Policy of the Union of Comoros indicates that INRAPE conducts analyses of pesticide quality and their residues in food and the environment, it does not explicitly mention antimicrobial residues or AMR organisms in this context (p. 23). ¹⁰ The National Community Health Strategy 2024-2028 (p. 22, p. 33) and the National Health Development Plan 2015-2019 (p. 23, p. 42) reference broader environmental health issues, including water and sanitation and waste management, but do not detail specific environmental AMR surveillance activities. ¹¹¹²

The National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 therefore outlines the government's intention to establish a regulatory framework and strengthen laboratory capacity at INRAPE for environmental detection and surveillance of antimicrobial residues and AMR organisms. The document describes planned activities rather than current, fully implemented, and operational programs for such surveillance. ¹³

1.1.2a National law(s) requiring prescription for antibiotic use (humans)

Score: 50

Comoros has some existing regulations concerning the prescription and sale of antimicrobials; however, enforcement appears to be weak, and comprehensive implementation remains a challenge.

The 2022 Situational Analysis on AMR for Comoros indicates the presence of a National Pharmaceutical Policy from 2018, serving as a strategic and legal tool for pharmaceutical regulation, market control, and combating illicit drug trade. However, this same analysis explicitly notes a "lack of specific regulation on antimicrobials in general (importation, distribution, dispensation)" (p. 12), and its "Snapshot of country policies and regulations on use" section effectively checks "NO" for the country having regulation on antibiotic prescription and sale, including human prescription requirements (p. 25). This suggests that while a broader pharmaceutical regulatory environment is present, concrete and dedicated legislation specifically mandating prescriptions for all human antibiotic use, with robust enforcement, is not firmly established or is highly deficient. ¹⁴

Further supporting this assessment, the 2018 Joint External Evaluation (JEE) report highlighted the crucial need to "Strengthen the legislative framework on the use of antibiotics for human and animal health" (p. 11), indicating that existing provisions were inadequate or poorly enforced at that time. ¹⁵ Additionally, the National Health Development Plan 2015-2019 noted in December 2014 that the public health code, enacted in July 2011, was "still not implemented due to the absence of implementing texts" (p. 35), underscoring a broader challenge in legislative operationalization. ¹⁶ The more recent National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 outlines objectives to "Optimize the use of antimicrobial agents" and includes interventions to "Develop and implement good practice policies for good antimicrobial use in all involved sectors," with plans to elaborate "national technical guidelines for the good use of antibiotics in human health" (p. 13, p. XVIII, Activity 4.1.1). These planned actions, while positive, serve as further evidence that the current regulatory landscape for specific human antibiotic prescription requirements is still in development or requires significant bolstering, rather than being a fully established and implemented national mandate. ¹⁷ Therefore, while a foundational pharmaceutical policy exists, the specific requirement for human antibiotic prescriptions is characterized by weak enforcement and a lack of detailed, implemented regulatory texts.

1.1.2b National law(s) requiring prescription for antibiotic use (animals)

Score: 50

While there is national legislation and regulation in place that implicitly requires prescriptions for antibiotic use in animals, its enforcement and practical implementation are significantly weak.

The West African Economic and Monetary Union (UEMOA) Regulation N° 02/2006/CM/UEMOA, which establishes community procedures for the marketing authorization and surveillance of veterinary medicinal products, applies to member states like Comoros. This regulation outlines the responsibilities of veterinary doctors in administering medicines (Article 23) and includes provisions for the "prescription and dispensing conditions" to be included on product labeling (Article 39). ¹⁸

The Frontiers in Veterinary Science (2025) review further confirms that UEMOA members have successfully harmonized and adopted this regional legislation into their national frameworks for regulating veterinary medicinal products (Table 1, p. 6). However, despite the formal adoption of this regulatory framework, its practical application at the national level in Comoros faces significant challenges. ¹⁹

The 2022 Situational Analysis on Animal Medicines (AMR) explicitly highlights that "The use of pharmaceutical products in animal health is not supervised by professionals; resistance is already observed in vector ticks and other diseases" and that "The sale and appropriate use of plant protection products by professionals, the public, and especially farmers, are not regulated" (p. 13). This indicates a critical lack of professional oversight and regulated practice in the field. ²⁰

Reinforcing this concern, the 2018 Joint External Evaluation (JEE) report specifically noted the need to "Strengthen the legislative framework on the use of antibiotics for human and animal health" (p. 11). ²¹ Although the National Multisectoral Action Plan to Combat AMR 2022-2026 aims to "Develop and implement good practice policies for good antimicrobial use in all involved sectors" (p. 13), these are prospective actions, and the 2022 Situational Analysis assessed the country as scoring 'A' ("No national policy or legislation relating to quality, the safety and effectiveness of antimicrobials as well as their distribution, sale or use") for optimizing antimicrobial use in animal or plant health, indicating an absence of effective national policy or legislation in practice (p. 24). ²²²³ Therefore, while a regulatory framework exists through UEMOA harmonization, its actual enforcement and effective implementation at the national level are severely lacking.

1.2.1a Laws/plans on zoonotic disease

Score: 0

While the Union of Comoros has documented efforts and strategies related to zoonotic disease prioritization, detection, and reporting, particularly within the framework of the "One Health" approach, a comprehensive and formally elaborated national reporting framework is not in place.

The country has identified specific zoonotic diseases as priorities. The 2018 Joint External Evaluation (JEE) report explicitly states, "The country has identified the following priority zoonoses: Rift Valley Fever (RVF), Q Fever, and Salmonellosis" (p. 12). This prioritization is further supported by ongoing surveillance activities for some of these diseases, such as RVF and Q Fever, which have been operational since 2016 through the SEGA project of the Indian Ocean Commission (IOC) (p. 13). ²⁴ The "One Health" approach, which emphasizes intersectoral collaboration between human, animal, and environmental health, was officially launched in Comoros in 2014 (p. 12). This approach aims to improve coordinated detection of zoonotic threats. The JEE report notes existing sentinel surveillance for fevers in human health that are part of animal disease surveillance networks (RENESMAC) and mentions joint investigations between veterinary and human health services for disease outbreaks (p. 13). ²⁵ The National Health Development Plan 2015-2019 also acknowledges the need for an active animal health surveillance system to detect cases like Rift Valley Fever (p. 17). ²⁶

While the National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 primarily focuses on AMR, it strongly adheres to the "One Health" approach, recognizing that AMR concerns human, animal, agricultural, agri-food, and environmental sectors, thereby implicitly including zoonoses in its broader surveillance and research objectives (p. v, p. 1). ²⁷

The 2018 JEE report indicates that disease outbreaks are subject to joint investigation by veterinary and human health services (p. 13). It also highlights the presence of a functional OIE Focal Point that regularly communicates information to the World Organisation for Animal Health (OIE) via the World Animal Health Information System (WAHIS) (p. 27). This suggests a mechanism for reporting animal health events, which would include zoonoses. However, the JEE report also identified significant gaps in formal reporting and response mechanisms. It scored "Mechanisms for established and functional response to infectious zoonoses and potential zoonoses" as 1 (limited/non-existent) and explicitly recommended the elaboration of "national plans for zoonoses control" and the inclusion of a veterinary services representative in the public health coordination committee (p. 14). This indicates that while some informal or ad-hoc reporting and investigation existed, a comprehensive and formally elaborated national reporting framework for all priority zoonoses was not fully established as of 2017. ²⁸

1.2.1b Laws/plans on zoonotic disease spillover from animals to humans

Score: 0

The Union of Comoros recognizes the threat of zoonotic diseases and the critical importance of preventing spillover events from animals to humans, particularly through the adoption of a "One Health" approach. However, comprehensive national legislation, detailed plans, or equivalent strategy documents explicitly outlining proactive measures for risk identification and reduction specifically targeting zoonotic disease spillover appear to be in developmental stages or have been identified as areas requiring significant reinforcement.

The understanding of animal-to-human transmission is evident in national health documents. For instance, the National Health Development Plan 2015-2019 directly states that Rift Valley Fever is a viral zoonosis affecting both animals and humans, underscoring the necessity of an active animal health surveillance system to alert public health services rapidly (p. 17). ²⁹

The 2018 Joint External Evaluation (JEE) report explicitly set a target for zoonoses, focusing on policies and practices that minimize transmission from animal to human populations, directly addressing the concept of spillover prevention (p. 12). ³⁰ However, the 2018 JEE report pointed to significant gaps regarding explicit plans for zoonotic spillover risk reduction. It assigned a low score of 1 (indicating limited or non-existent capacity) to "Mechanisms established and functional for responding to infectious zoonoses and potential zoonoses" (p. 14). As of 2017, formalized and functional plans specifically designed to prevent or effectively manage zoonotic spillover events were largely lacking. Consequently, the JEE report made a recommendation to "Elaborate a program for surveillance and control of zoonoses, including a control plan for each priority zoonosis" (p. 12). ³¹

The "One Health" approach, which is foundational for addressing zoonotic risks, was officially launched in Comoros in 2014, signaling a commitment to intersectoral collaboration across human, animal, and environmental health (p. 12). The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 further solidifies this commitment by emphasizing the "One Health" framework as crucial for combating AMR in human health, animal health, agriculture, food production, and environmental sectors (p. v, p. 1). ³² Existing efforts also include the prioritization of specific zoonotic diseases, such as Rift Valley Fever, Q Fever, and Salmonellosis, and the existence of surveillance activities (p. 12-13). Joint investigations between veterinary and human health services for disease outbreaks are also noted (p. 13). ³³

1.2.1c Laws/plans for surveillance & control of multiple zoonotic pathogens

Score: 100

The Union of Comoros has established national strategies and plans that incorporate measures for the surveillance and control of multiple zoonotic pathogens of public health concern, primarily through the adoption of the "One Health" approach and the Integrated Disease Surveillance and Response (IDSR), referred to as SIMR in Comoros.

The "One Health" approach serves as a guiding principle across several national health documents, explicitly promoting the integration of human, animal, and environmental health sectors to address health threats, including those that manifest at the human-animal interface. The National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 prominently features this integrated approach as fundamental to combating antimicrobial resistance and other health challenges (p. v, p. 1). ³⁴ The 2018 Joint External Evaluation (JEE) report confirms the official launch of the "One Health" approach in 2014 and highlights the identification of multiple priority zoonoses within the country, specifically mentioning Rift Valley Fever, Q Fever, and Salmonellosis (p. 12). This report also details the existence of an epidemio-surveillance network for animal diseases in Comoros (RENESMAC) and notes that human health surveillance for fevers is linked to this animal disease network, indicating an established, albeit potentially limited, cross-sectoral detection effort (p. 13). Joint investigations of outbreaks are also conducted collaboratively by veterinary and human health services (p. 13). ³⁵ The 2018 JEE report elaborates that a "SIMR technical guide adapted since 2011" is utilized for indicator-based and event-based surveillance, signifying a structured approach to monitoring multiple health events (p. 25). ³⁶

Furthermore, the National Health Development Plan 2015-2019 refers to the "Surveillance Intégrée des Maladies et Ripostes (SIMR)," which is an IDSR framework designed for the comprehensive surveillance and control of various diseases, including those with zoonotic potential (p. 45). ³⁷ The National Community Health Strategy 2024-2028 reinforces the importance of epidemiological surveillance and rapid response mechanisms at community, district, and regional levels, which encompass the control of multiple zoonotic pathogens. This strategy emphasizes event surveillance, multi-risk assessment, and risk communication, creating a general framework applicable to zoonotic threats (p. 26, p. 31, p. 33). ³⁸

1.2.1d Cross-ministerial department/agency/unit for zoonotic disease

Score: 0

Currently, the Union of Comoros has no evidence of a dedicated, multi-sectoral coordinating mechanism specifically tailored to zoonotic diseases. While the country has taken steps toward multi-sectoral coordination under the "One Health" framework, there are notable gaps in its implementation for zoonoses.

Historically, the 2018 Joint External Evaluation (JEE) report indicated a gap in this area. It noted that while the "One Health" approach was officially launched in 2014, its implementation for zoonoses was challenging, partly due to a lack of resources and human capacity in animal health. Critically, the JEE recommended the establishment of a "discussion framework dedicated to zoonoses" involving the Directorate of Livestock, INRAPE, and the Ministry of Health, along with their regional counterparts (p. 12). While general multi-sectoral committees for epidemic preparedness and response were in place, they were often activated only during crises and lacked detailed, consistent cross-ministerial coordination specific to zoonoses (p. 7). ³⁹

The National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 details a comprehensive multi-sectoral governance and coordination structure. This structure includes a high-level Comité National de Pilotage (CNP) de la RAM (National Steering Committee for AMR), which is described as the supreme decision-making body and includes ministers from key sectors, national institutions, and representatives from the Quadripartite Alliance (WHO, FAO, OMSA, PNUE). Its mission specifically involves ensuring synergy and complementarity of actions across key sectors for AMR (p. 5). Supporting the CNP is the Organe de Coordination Multisectorielle (OCM) (Multi-sectoral Coordination Body), comprising the National Executive Secretariat for AMR, sectoral focal points, technical staff, and representatives from the Quadripartite Alliance. The OCM's mission is to supervise and coordinate all AMR-related activities across all sectors (p. 8). Additionally, multi-sectoral Groupes Techniques de Travail (GTTs) (Technical Working Groups) can be established by the OCM for specific missions requiring diverse technical expertise (p. 9). However, the OCM and GTTs mandates revolve around AMR, and zoonoses are not clearly addressed. ⁴⁰

The National Community Health Strategy 2024-2028 also further supports the establishment of national and regional multi-sectoral committees for community health, which would provide a platform for broader health coordination, including aspects relevant to zoonoses (p. 39). While this could potentially address zoonoses as part of broader community health concerns, it is in its early stages of implementation. ⁴¹

1.2.1e Presence of One Health strategic plan

Score: 0

Comoros does not currently have a finalized National One Health Strategic Plan, but the country is actively working towards developing one through initiatives like the 2024 One Health workshop, which focused on creating a joint action plan to strengthen intersectoral coordination for human and animal health.⁴²⁴³

1.2.2a Surveillance/reporting mechanism for zoonotic disease for livestock owners

Score: 0

There is no explicit evidence of a national mechanism, either voluntary or mandatory, that specifically requires or enables owners of livestock to directly conduct and report on disease surveillance to a central government agency in the Union of Comoros.

The available information primarily highlights the role of official veterinary services and established networks in animal disease surveillance. The 2018 Joint External Evaluation (JEE) report mentions the "National Network for Epidemio-surveillance of Animal Diseases in Comoros (RENESMAC)" and indicates that disease outbreaks are subject to "joint investigation between veterinary services and human health services" (p. 13). It also points to the existence of a "functional OIE Focal Point, which uses the World Animal Health Information System (WAHIS) for reporting animal diseases to the OIE" (p. 27). These mechanisms describe official, professional surveillance and reporting channels rather than direct participation by individual livestock owners. ⁴⁴ The JEE report also identified the need to "Improve the surveillance system by integrating ante and post mortem examination of animals, inspection of imported live animals and official collaboration with field veterinary stakeholders" (p. 13). Furthermore, a key recommendation from the JEE was to "Elaborate a program for surveillance and control of zoonoses," which would include strengthening laboratory capacities, but did not specify direct reporting by owners (p. 12). ⁴⁵

The National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026, while strongly advocating for the "One Health" approach and recognizing animal health as a key sector, focuses on strengthening the capacity of professionals in animal health and developing biosafety guides for animal farming (p. XVIII, Activity 3.2; p. XXX, Activity 2.1.5). There is no mention of a formal mechanism for livestock owners to conduct or report surveillance directly. ⁴⁶

Similarly, the National Health Development Plan 2015-2019 emphasizes the importance of an "active animal health surveillance system to detect cases" of zoonoses like Rift Valley Fever, which is intended to alert "authorities of veterinary and public health services" (p. 17). ⁴⁷

1.2.2b Laws/regulations on data confidentiality to protect livestock owners

Score: 0

There is no explicit mention of national legislation or regulations that safeguard the confidentiality of information generated through animal disease surveillance activities specifically for owners of livestock in the Union of Comoros.

Documents such as the National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026, the 2018 Joint External Evaluation report, the National Community Health Strategy 2024, the National Quality Policy 2020, and the National Health Development Plan 2015-2019, discuss various aspects of health surveillance, data collection, and information sharing across human and animal health sectors. ^4849505152 For instance, the Joint External Evaluation report mentions the importance of surveillance systems, reporting mechanisms to international bodies like the OIE, and the need for improved data sharing and coordination between different agencies (p. 13, p. 25, p. 27). ⁵³ The National Multisectoral Action Plan also emphasizes effective communication and coordination among all stakeholders, including the regular collection and sharing of data (p. 6). ⁵⁴

However, these documents primarily focus on the operational aspects of surveillance, the need for data to inform public health decisions, and the strengthening of capacities within government agencies and laboratories. They do not delve into the legal or regulatory specifics concerning the protection of private information belonging to individual livestock owners obtained during these surveillance activities. Therefore, while data is collected and shared, the mechanisms for ensuring the confidentiality of that data for owners are not detailed within these texts. ^5556575859

According to UNCTAD, Comoros does not have laws on data privacy or cybersecurity. ⁶⁰

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁶¹

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁶²⁶³

1.2.2c Wildlife zoonotic disease surveillance

Score: 0

The Union of Comoros conducts surveillance activities for zoonotic diseases primarily within its livestock populations, with evidence of some vector-related awareness. However, specific evidence for conducting active surveillance of zoonotic disease in poultry and wildlife is not clearly documented.

The country has proactively prioritized several zoonotic diseases, notably Rift Valley Fever (RVF), Q Fever, and Salmonellosis (p. 12). Surveillance efforts for RVF and Q Fever have been operational since 2016 through the SEGA project of the Indian Ocean Commission (IOC) (p. 13). ⁶⁴

In livestock, surveillance is a key component of the national strategy. The National Health Development Plan 2015-2019 underscores the significance of an "active animal health surveillance system to detect cases" of zoonoses like Rift Valley Fever, ensuring that veterinary and public health authorities are promptly alerted (p. 17). ⁶⁵ Joint investigations between veterinary services and human health services are conducted for disease outbreaks, highlighting inter-sectoral collaboration in detection (p. 13). The National Institute for Research in Agriculture, Fisheries and Environment (INRAPE) plays a crucial role with its veterinary laboratory, which aids in epidemiological investigations and sentinel surveillance. For instance, INRAPE was involved in a study assessing the prevalence of salmonella in meat, revealing a significant percentage of positive samples (p. 13). Measures to strengthen surveillance in livestock further include integrating "ante and post mortem examination of animals" and "inspection of imported live animals" (p. 13). ⁶⁶

For poultry, it is not always explicitly detailed as a separate category, surveillance is just encompassed within broader animal health programs. The existence of vaccination campaigns for poultry-specific diseases such as Newcastle disease, avian cholera, and avian smallpox, are outlined in the National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 (p. XVII). While the AMR Action Plan 2022-2026 mentions vaccination campaigns for poultry-specific diseases, this does not directly confirm surveillance for zoonotic diseases within poultry population. ⁶⁷

Regarding wildlife and other disease vectors, awareness exists for vector-borne zoonoses. The high prevalence of arboviroses like Dengue and Chikungunya in Comoros and the wider Indian Ocean region demonstrates an understanding of the role of insect vectors in disease transmission (p. 17). ⁶⁸ The country's animal health system also engages with international reporting mechanisms; a functional OIE Focal Point utilizes the World Animal Health Information System (WAHIS) for reporting animal diseases (p. 27). ⁶⁹ However, the national texts do not detail dedicated surveillance programs specifically targeting zoonotic diseases in wild animals or proactive surveillance mechanisms for insect vectors themselves.

1.2.3a Annual reporting to OIE on zoonotic disease incidence

Score: 100

There is publicly available evidence of a mechanism for reporting notifiable diseases to The World Organisation for Animal Health (WOAH), formerly known as the OIE.

The 2018 Joint External Evaluation (JEE) report for the Union of Comoros explicitly states the existence of a functional OIE Focal Point responsible for this task. As detailed in the "Notification" section of the report, specifically on page 27: "There is also a functional OIE Focal Point, which uses the World Animal Health Information System (WAHIS), a secure website of the global zoo-sanitary information system, for the notification of animal diseases to the OIE (aquatic and/or terrestrial animals and wild animals)." ⁷⁰

Furthermore, under the (Strengths/best practices for indicator D.3.1 "Effective notification system to WHO, FAO and OIE" on page 28, the report reinforces this point: "The OIE focal point exists and regularly communicates information to the OIE through the WAHIS platform." ⁷¹

This confirms that the OIE focal point is in place and regularly transmits information to the OIE via the WAHIS platform. This mechanism ensures that the Union of Comoros reports on animal diseases, including those that are notifiable, to the international body responsible for animal health.

1.2.4a Number of veterinarians per 100,000 people

Score: 0

1.2.4b Number of veterinary para-professionals per 100,000 people

Score: 0

1.2.5a Inclusion of private sector in national plan/law on zoonotic disease

Score: 0

National plans and related legislation in the Union of Comoros feature mechanisms for working with the private sector in various health-related domains, but the documents do not offer evidence of such mechanisms within a plan specifically dedicated to zoonotic diseases.

Firstly, the National Multisectoral Action Plan to Combat Antimicrobial Resistance (AMR) 2022-2026 provides direct evidence of private sector inclusion in a coordinating body that inherently addresses zoonotic pathogens. The composition of the Multi-sectoral Coordination Body (OCM), which supervises and coordinates all AMR-related activities across sectors, explicitly includes "Principal representatives of the private sector on medicines" (p. 8). Given that antimicrobial resistance is a significant concern in zoonotic diseases, this mechanism directly involves the private pharmaceutical sector in a multi-ministerial coordinating effort that impacts zoonotic control. The plan's preface also broadly commits to "Mobilize, encourage and involve all stakeholders in the country, beyond governmental institutions" (p. v), which encompasses the private sector. However, the plan's explicit focus is on AMR, not zoonoses as a distinct disease category. ⁷²

The National Quality Policy (PNQ), a critical document for food safety and product standards—areas highly relevant to zoonoses—explicitly aims to foster a quality culture within the private sector and promotes Public-Private Partnerships (PPP) for funding and implementation (p. 4, p. 33, p. 38). It establishes a National Quality Committee, which is described as a "body associating the administration, the private sector and civil society" (p. 38). This committee's role in coordinating quality initiatives, including those pertaining to food safety and animal products, provides a structured mechanism for private sector collaboration in areas impacting zoonotic disease. The PNQ also outlines activities under "Strengthening public-private dialogue to promote quality," with specific actions to encourage private sector participation in financing and activities related to quality infrastructure (p. 67-68). While food safety is highly relevant to controlling foodborne zoonoses, the PNQ is not a plan specifically for zoonotic disease. ⁷³

The National Health Development Plan (PNDS) 2015-2019 emphasizes the "effective involvement of all public and private stakeholders" ( p. 9) in the health sector. It describes the private sector as growing, comprising both for-profit (clinics, pharmacies) and non-profit (NGOs) entities (p. 29). Furthermore, the PNDS intends for its high-level coordination bodies to be "integrative frameworks for government structures, civil society organizations and associations, private health sector actors, and technical and financial partners" (p. 70). It also highlights "Weak partnership with private sector personnel" as a challenge under Human Resources (p. 48), indicating a recognized need and desire for stronger collaboration with the private sector. Specific interventions, such as those for Tuberculosis control, also explicitly mention "Develop public-private partnership" (p. 58). However, this is a general health development plan, not a zoonotic disease plan. ⁷⁴

Similarly, the National Community Health Strategy (SNSC) 2024-2028 acknowledges the presence and role of both for-profit and non-profit private health sectors (p. 15). It supports strengthening collaboration with Civil Society Organizations (CSOs), NGOs, and health mutuals in community interventions, which could involve private entities in health service delivery or promotion, but its scope is broad community health rather than zoonotic diseases specifically. (p. 41). ⁷⁵

Finally, the 2018 Joint External Evaluation (JEE) report, in its assessment of human resources, points to a "weak partnership with private sector personnel" (p. 30). This suggests a general deficiency in engaging the private sector across the health domain, implicitly extending to zoonoses. Furthermore, within the JEE's specific section on zoonoses, while recommendations are made for establishing a consultation framework between governmental bodies (e.g., Direction de l’élevage, INRAPE, Ministère de la santé) and for developing a zoonoses surveillance and control program, there is no explicit mention of integrating the private sector into these mechanisms or plans (p. 12). This indicates that, as of the JEE, specific private sector engagement in zoonotic disease control plans was not identified as a strength or even a planned mechanism. ⁷⁶

1.3.1a Updated national records of especially dangerous pathogen/toxin inventories

Score: 0

There is no explicit evidence of a national record, updated within the past five years, of facilities where especially dangerous pathogens and toxins are stored or processed, including details on inventories and inventory management systems for those facilities in the Union of Comoros.

In fact, the 2018 Joint External Evaluation (JEE) report specifically identified this as a significant gap and made a clear recommendation for its establishment. Under the section on Biosecurity and Biosafety, the report notes the absence of national legislation or regulation in this area, stating that the capacities for biosecurity and biosafety were non-existent, scoring a 1 (inexistent capacity) for relevant indicators (p. 17, p. 18). The priority measures recommended in the JEE report explicitly call for: "Map laboratories handling pathogens and establish a pathogen tracking system (list of pathogens, registers, and containment)." This recommendation directly addresses the need for a record of facilities, inventories, and inventory management systems for dangerous pathogens. ⁷⁷

While this recommendation was made in 2017, none of the more recent documents, such as the National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 or the National Community Health Strategy 2024-2028, specifically detail the implementation or current existence of such a comprehensive record or system for especially dangerous pathogens and toxins. These later documents focus more broadly on strengthening laboratory capacities, surveillance, and overall health system governance, but they do not provide the granular information requested regarding specific inventories and management systems for dangerous biological agents in a centralized, updated record. ⁷⁸⁷⁹

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁸⁰

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁸¹⁸²

1.3.1b Biosecurity laws on facility security for especially dangerous pathogens

Score: 0

The Union of Comoros has recognized the critical need for legislation and regulations concerning biosecurity, but as of the latest detailed assessment, such comprehensive frameworks were either absent or still under development.

The most direct and explicit information regarding biosecurity legislation comes from the 2018 Joint External Evaluation (JEE) report. In the section dedicated to Biosecurity and Biosafety, the report critically notes a significant gap: "However, it should be noted the absence of national legislation or regulation in the field of biosecurity and biosafety…" (p. 17). The report further elaborated that capacities in this domain were practically non-existent, assigning a score of 1 (inexistent capacity) for relevant indicators. The priority measures recommended in the JEE report directly address these deficiencies, calling for the establishment of comprehensive legal and regulatory frameworks: "Develop regulatory texts for the global management of biological safety and security" (p. 18). This explicitly calls for legislation that would likely encompass requirements such as physical containment, operational practices, and potentially other aspects like failure reporting systems and cybersecurity, although these specific details are not itemized in the recommendation itself. While the JEE noted some existing practices, such as a technical group for poliovirus containment and organized circuits for transporting samples, these were operational procedures rather than overarching legislation or regulations (p. 17). ⁸³

More recent documents, such as the National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026, advocate for strengthening laboratory capacities and developing biosafety guides (p. 12, p. XVII, p. XVIII, p. XIX). However, these mentions focus on capacity building and practical guidelines, which, while crucial, do not explicitly confirm the existence of comprehensive legislation and regulations that mandate specific biosecurity requirements like physical containment levels, failure reporting systems, or cybersecurity for facilities handling dangerous pathogens and toxins. The Action Plan's focus is on AMR, and while biosafety is related, it doesn't detail a broad legal framework for all dangerous pathogens and toxins. ⁸⁴

The Updated National Strategy and Action Plan for Biological Diversity focuses on the conservation and sustainable use of biodiversity, as well as the control of invasive alien species. While it discusses legal frameworks for environmental protection, it does not contain specific legislation or regulations related to laboratory biosecurity, physical containment, operational practices, failure reporting, or cybersecurity for facilities handling dangerous human or animal pathogens and toxins. ⁸⁵

The National Community Health Strategy 2024-2028 focuses on community-level health interventions, primary healthcare, and strengthening health security at the community level. Its scope does not include detailed legislation or regulations for laboratory biosecurity, physical containment, or related operational and cybersecurity requirements for dangerous pathogens and toxins. ⁸⁶

The National Quality Policy outlines the national quality infrastructure, including standardization, metrology, and conformity assessment (e.g., laboratory testing). While it aims to ensure product safety and quality, and mentions improving laboratory capacities, it does not provide details on specific legislation or regulations governing biosecurity requirements (physical containment, operational practices, failure reporting, cybersecurity) for facilities handling dangerous pathogens and toxins. The document does note "lacunes quant aux moyens humains et matériels, aux infrastructures appropriées pour le stockage des pesticides, aux infrastructures de quarantaine phytosanitaire" (shortcomings in human and material resources, appropriate infrastructure for pesticide storage, phytosanitary quarantine infrastructure) (p. 20), indicating infrastructural gaps, but this is distinct from biosecurity legislation for dangerous pathogens. ⁸⁷

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁸⁸

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁸⁹⁹⁰

1.3.1c Agency for enforcement of biosecurity laws/regulations

Score: 0

There is no explicit evidence of an established agency (or agencies) primarily responsible for the enforcement of comprehensive biosecurity legislation and regulations concerning requirements like physical containment, operational practices, failure reporting systems, and/or cybersecurity for facilities storing or processing especially dangerous pathogens and toxins.

This absence is directly linked to the fact that, as highlighted in the 2018 Joint External Evaluation (JEE) report, the fundamental legal and regulatory framework for biosecurity and biosafety was missing. The report explicitly stated: "However, it should be noted the absence of national legislation or regulation in the field of biosecurity and biosafety" (p. 17). Given this identified lack of national biosecurity legislation, it logically follows that a dedicated agency for its enforcement would not have been formally established or described in the documents. The JEE report's recommendations focused on the creation of such legislation and the establishment of a multidisciplinary and multisectoral technical group on biosecurity and biosafety, rather than the identification of an existing enforcement body (p. 18). The JEE report did mention a technical group for poliovirus containment (p. 17). However, this is a specific, ad-hoc group for a particular pathogen and not a permanent, broad enforcement agency. ⁹¹

While other documents mention various oversight and regulatory bodies, their mandates do not appear to encompass the specific enforcement of comprehensive biosecurity legislation for dangerous pathogens and toxins in facilities. The National Quality Policy details inspection bodies and regulators (p. 19, 34) in the context of product quality, food safety, and technical regulations (p. 16). These agencies enforce standards related to consumer products and agricultural inputs, which can have biosafety components (e.g., pathogen control in food), but they are not described as enforcing broad biosecurity legislation for high-containment laboratories or facilities handling dangerous toxins. ⁹²

The National Multisectoral Action Plan to Combat Antimicrobial Resistance focuses on strengthening capacities and developing guides for biosafety in animal husbandry (p. XVIII, Activity 3.2.3) and laboratory control of AMR (p. XIX, Activity 4.2.2). While contributing to safe practices, these are more about guidelines and specific sectorial biosafety practices than the enforcement of overarching biosecurity legislation for specialized facilities. ⁹³

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁹⁴

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁹⁵⁹⁶

1.3.1d Consolidation of especially dangerous pathogens into minimum # of facilities

Score: 0

There is no public evidence indicating that the Union of Comoros has taken action to consolidate its inventories of especially dangerous pathogens and toxins into a minimum number of facilities.

The 2018 Joint External Evaluation (JEE) report, which provides the most direct assessment of biosecurity and biosafety capacities, highlights significant gaps in this area. Far from discussing consolidation, the report indicates that even the foundational steps of identifying and tracking pathogens were yet to be fully established. Specifically, under the Biosecurity and Biosafety section, the JEE report notes a clear absence of a comprehensive framework: "However, it should be noted the absence of national legislation or regulation in the field of biosecurity and biosafety" (p. 17). The report gave a score of 1 (inexistent capacity) for relevant indicators, underscoring the early stage of biosecurity development. Among its priority recommended measures, the JEE report called for: "Map laboratories handling pathogens and establish a pathogen tracking system (list of pathogens, registers, and containment)" (p. 18). This suggests that in 2017, the priority was still on identifying where pathogens were stored and establishing basic inventory and containment principles, rather than actively consolidating them into fewer facilities. Consolidation typically occurs after a robust inventory and tracking system is already in place and fully functional. ⁹⁷

None of the other recent documents offer evidence of such consolidation. The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 focuses on strengthening laboratory capacities and developing biosafety guides for animal husbandry, but does not mention consolidation of pathogen inventories. ⁹⁸ The National Community Health Strategy 2024-2028 and the National Quality Policy 2020 do not address the specific issue of consolidating dangerous pathogen and toxin inventories. ⁹⁹¹⁰⁰ The National Quality Policy does mention gaps in infrastructure for pesticide storage and phytosanitary quarantine (p. 20), which are related but not directly about consolidating especially dangerous pathogens or toxins. ¹⁰¹

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹⁰²

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹⁰³¹⁰⁴

1.3.1e Capacity to conduct tests for anthrax/Ebola without culturing live pathogens

Score: 0

There is no explicit public evidence of in-country capacity to conduct Polymerase Chain Reaction (PCR)–based diagnostic testing specifically for anthrax and/or Ebola.

While the National Research Institute for Agriculture, Fisheries and the Environment (INRAPE) now has a functional molecular biology unit capable of performing PCR tests, as confirmed by its official website, the website does not explicitly list anthrax or Ebola among the specific pathogens for which diagnostic testing is offered. The PCR service mentioned is primarily for "travelers who wish to go abroad", implying tests for commonly required travel-related pathogens (e.g., COVID-19). ¹⁰⁵

The 2018 Joint External Evaluation (JEE) report from Comoros noted that INRAPE's molecular biology unit was previously non-functional due to lack of financial resources (p. 9). While it indicates an intent to strengthen molecular biology capabilities, it does not specify diagnostic capacity for anthrax or Ebola within the country. ¹⁰⁶

The National Health Development Plan (PNDS) 2015-2019 mentions that the country developed a national plan for the Prevention and Response to Ebola fever (p. 17), ¹⁰⁷ but this document was not found online.

While a general PCR testing capacity for certain pathogens has been established at INRAPE, there is no direct evidence in the provided materials explicitly stating that this capacity extends to PCR-based diagnostic testing for anthrax and/or Ebola.

1.3.2a Biosecurity training using a standardised, required approach

Score: 0

There is no public evidence that the Union of Comoros currently requires biosecurity training, using a standardized, required approach such as a common curriculum or a train-the-trainer program, for personnel working in facilities housing or working with especially dangerous pathogens, toxins, or biological materials with pandemic potential.

The most direct information regarding biosecurity training comes from the 2018 Joint External Evaluation (JEE) report. This report explicitly identified the lack of such a program as a significant gap: "However, it should be noted the absence of national legislation or regulation in the field of biosecurity and biosafety, of a national biomedical waste management plan and of a biosecurity and biosafety training program" (p. 17). The priority recommended measures) in the JEE report directly addressed this by calling for: "Implement a common biosecurity and biosafety training program" (p. 18). This recommendation highlights the recognized need for such a standardized program. While the JEE report mentions training of customs officers on safety standards for the transport of biological samples to regional laboratories and training of laboratory technicians in the field of biological safety and security as existing practices (p. 18), these are described as individual trainings rather than a required, standardized, comprehensive program for all personnel handling dangerous pathogens/toxins in relevant facilities. The overall assessment still pointed to a lack of a formal "programme." ¹⁰⁸

The National Multisectoral Action Plan to Combat Antimicrobial Resistance mentions strengthening capacity and training in various areas, such as AMR, infection prevention and control (PCI), and biosafety in animal husbandry (p. XVIII, Activity 3.2.3). While these contribute to biosafety, they do not specifically describe a standardized, required training program for personnel working with dangerous pathogens or toxins in facilities, focusing more on broader infection control and specific sectoral guidelines. ¹⁰⁹

The National Community Health Strategy discusses training for community health workers and health professionals for broader health services, but not specialized biosecurity training for facilities handling dangerous biological materials. ¹¹⁰

The National Quality Policy mentions training in quality management systems (e.g., ISO, HACCP) relevant to product safety, but this is distinct from biosecurity training for laboratory or storage personnel dealing with dangerous pathogens/toxins. ¹¹¹

The INRAPE website, while confirming molecular biology analysis capabilities, does not provide information on mandatory biosecurity training requirements for its personnel regarding dangerous pathogens or toxins. ¹¹²

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹¹³

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹¹⁴¹¹⁵

1.3.3a Personnel checks for permission to access to especially dangerous pathogens

Score: 0

The country lacks specific national legislation or regulations pertaining to biosafety and biosecurity.

The Joint External Evaluation notes "the absence of national legislation or regulations on biosafety and biosecurity" (p. 17), highlighting a significant gap in the legal framework that would underpin such specific personnel vetting requirements. Consequently, there are no regulations or licensing conditions that specify drug testing, background checks, or psychological or mental fitness checks for security personnel or other individuals with access to especially dangerous pathogens, toxins, or biological materials with pandemic potential. The recommended priority actions within the report include the elaboration of regulatory texts for the global management of biological safety and security (p. 18), which suggests that comprehensive provisions for personnel security screenings are yet to be developed. ¹¹⁶

Other national strategic documents further support this conclusion by not detailing such specific vetting processes. The Comoros National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), validated in July 2022, emphasizes the institutionalization of antimicrobial resistance efforts, strategic planning, and operational actions, including strengthening laboratory capacities and training for various personnel (p. xiv, xv, xix, xxvii). However, its extensive content does not include any mention of drug testing, background checks, or psychological evaluations as prerequisites for individuals working with biological materials. ¹¹⁷

Similarly, the Comoros National Health Policy (PNS), dated December 2014, (p. 18, 29) and the Comoros National Health Development Plan (PNDS) for 2015-2019 (p. 38-39) outline broad objectives for health system governance, human resources, and service delivery, recognizing the need for competent health personnel and robust health security measures. Yet, neither document specifies the types of security vetting required for personnel accessing dangerous biological agents. ¹¹⁸¹¹⁹

The Comoros National Quality Policy (PNQ), published in December 2020, also focuses on establishing an effective national quality infrastructure, including metrology and conformity assessment services, and discusses the importance of qualified technical personnel (p. 9, 25). However, its scope is limited to general quality assurance and does not extend to the detailed security screening protocols for individuals handling hazardous biological substances. ¹²⁰

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹²¹

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹²²¹²³

1.3.4a National transport regulations for Category A and B infectious substances

Score: 0

The Comoros does not have publicly available national regulations on the safe and secure transport of infectious substances, including those specifically categorized as A and B.

The Joint External Evaluation (JEE) report, following its mission in August 2017, explicitly identifies this as a significant gap in the country's biosafety and biosecurity framework. The report notes the absence of national legislation or regulation concerning biosafety and biosecurity (p. 17). While some practices related to the transport of specific biological materials are mentioned, they do not constitute comprehensive national regulations for all infectious substances. For instance, the JEE report refers to an "organized circuit for transport and transfer of samples to an external WHO collaborating laboratory" for poliovirus containment, and training on "safety standards for the shipment of biological samples" for customs officers and laboratory technicians (p. 17). However, these are described as existing circuits or training initiatives rather than a formalized, publicly available national regulatory framework covering Categories A and B infectious substances. ¹²⁴

The Areas to strengthen/challenges section of the Comoros JEE directly addresses this deficiency by recommending "Establish a harmonized national system for secure transport of suspected biological samples" and "Develop guidelines for sampling, packaging, and transport of samples" (p. 23). This indicates that, as of the JEE's assessment, a comprehensive, harmonized, and publicly available national regulatory system for the transport of infectious substances was not in place and was identified as a priority for future development. ¹²⁵

The other national documents, such as the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), the National Health Policy (PNS), the National Health Development Plan (PNDS), and the National Quality Policy (PNQ), address broader health and quality system objectives. While they discuss laboratory strengthening and general health security, none of these documents provide publicly available details on national regulations specifically governing the safe and secure transport of infectious substances, including those classified under Categories A and B. Their focus remains on strategic planning, human resource development, and quality infrastructure without delving into the specific regulatory requirements for such specialized biological transport. ^126127128129

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹³⁰

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹³¹¹³²

1.3.5a Laws/regulations on cross-border transfer and end-user screening

Score: 0

There is no publicly available information indicating comprehensive legislation and/or regulations specifically in place to oversee the cross-border transfer and end-user screening of especially dangerous pathogens, toxins, and pathogens with pandemic potential in Comoros.

The Comoros Joint External Evaluation (JEE) report, following its mission in August 2017, explicitly states the "absence of national legislation or regulation concerning biosafety and biosecurity" (p. 17). This fundamental lack of a comprehensive legal framework for biosafety and biosecurity suggests that specific provisions for cross-border transfer and end-user screening of high-risk biological materials are also absent or underdeveloped. While the JEE mentions an "organized circuit for transport and transfer of samples to an external WHO collaborating laboratory" for poliovirus and training on "safety standards for the shipment of biological samples" (p. 17), these are described as existing practices for specific biological samples rather than a broad, legally mandated regulatory framework for all dangerous pathogens. The recommendations within the JEE to "Elaborate regulatory texts for the global management of biological safety and security" (p. 18) and to "Establish a harmonized national system for secure transport of suspected biological samples" (p. 23) further confirm that a comprehensive system for these issues needs to be established. ¹³³

Other national documents, such as the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), the National Health Policy (PNS), the National Health Development Plan (PNDS), and the National Quality Policy (PNQ), address broader aspects of health, quality infrastructure, and human resources. For example, the AMR Plan mentions strengthening the "legislative/regulatory framework on the proper use of human and veterinary medicine" (p. 10), but this pertains to pharmaceutical products, not dangerous pathogens. The PNQ discusses "control of imports of products from abroad" (p. 21) and "food safety" (p. 9, 33), but does not detail regulations for the cross-border transfer or end-user screening of dangerous biological agents. None of these documents provide specific legislation or regulations that would oversee the cross-border transfer and end-user screening of especially dangerous pathogens, toxins, and pathogens with pandemic potential. ^134135136137

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹³⁸

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹³⁹¹⁴⁰

1.4.1a Biosafety laws/regulations

Score: 0

Comoros does not have national biosafety legislation and/or regulations in place.

The Joint External Evaluation (JEE) report, following its mission in August 2017, explicitly identifies this absence. The report notes "absence of national legislation or regulation concerning biosafety and biosecurity" (p. 17). This indicates a foundational gap in the legal framework for biosafety. While training on "safety standards for the shipment of biological samples" has been provided to customs officers and laboratory technicians, and specific circuits for transporting polio samples exist, these are not comprehensive national biosafety legislation or regulations (JEE, p. 17). The JEE further recommends "Elaborate regulatory texts for the global management of biological safety and security" (p. 18), confirming that such a framework is yet to be established. ¹⁴¹

The National Strategy and Updated Action Plan for Biological Diversity (SPANB), while focusing on the protection and sustainable use of biological diversity and natural heritage, does not contain national biosafety legislation or regulations in the context of preventing accidental exposure to pathogens or their unintentional release from laboratories or facilities handling infectious substances (p. 19, 28, 33). This document addresses legal frameworks related to environmental protection, biodiversity conservation, and the management of invasive alien species p. 19-20, 33, 44). For example, it mentions improving legislation on invasive alien species (p. 44). However, its scope is primarily ecological and environmental, not the public health and laboratory-focused biosafety regulations. ¹⁴²

Other national documents, including the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), the National Health Policy (PNS), the National Health Development Plan (PNDS), and the National Quality Policy (PNQ), also do not provide evidence of national biosafety legislation or regulations. These documents outline broader strategic goals for health system strengthening, quality infrastructure, and disease control, but they do not include specific legislative or regulatory details concerning biosafety practices or containment measures for biological agents. ^143144145146

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹⁴⁷

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹⁴⁸¹⁴⁹

1.4.1b Agency for enforcement of biosafety laws/regulations

Score: 0

There is no established agency specifically responsible for the enforcement of biosafety legislation and regulations in Comoros.

This is primarily due to the explicit absence of national biosafety legislation and regulations themselves, as noted in the Joint External Evaluation (JEE) report. The JEE clearly states the "absence of national legislation or regulation concerning biosafety and biosecurity" (p. 17). Given this foundational gap, an agency tasked with enforcing such legislation would not logically exist. The priority recommendation from the JEE is to first "Elaborate regulatory texts for the global management of biological safety and security" (p. 18). This suggests that the establishment of a regulatory framework precedes the creation of an enforcement body. ¹⁵⁰

Other national documents, including the National Strategy and Updated Action Plan for Biological Diversity (SPANB), the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), the National Health Policy (PNS), the National Health Development Plan (PNDS), and the National Quality Policy (PNQ), do not identify any agency specifically mandated with biosafety legislation enforcement. While these documents discuss various regulatory and oversight bodies within their respective domains (e.g., environmental protection, health services, product quality), none are described as having the specific role of enforcing biosafety regulations for the safe handling and containment of dangerous biological materials. ^{151152153154155}

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹⁵⁶

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹⁵⁷¹⁵⁸

1.4.2a Biosafety training using a standardised, required approach

Score: 0

Comoros does not require biosafety training, using a standardized, required approach, such as through a common curriculum or a train-the-trainer program, for personnel working in facilities housing or working with especially dangerous pathogens, toxins, or biological materials with pandemic potential.

The Joint External Evaluation (JEE) report indicates the absence of such a framework. While some biosafety-related training has been organized, it does not constitute a required, standardized approach across all relevant personnel and facilities. For instance, the JEE notes that "training on safety standards for the shipment of biological samples to regional laboratories for customs officers" and "training on secure shipping procedures for potentially infectious biological samples for laboratory technicians" have been conducted (p. 17). However, these are presented as specific training initiatives rather than a nationally mandated, standardized curriculum. ¹⁵⁹

A key recommendation in the JEE is to "Develop and implement a common training program in biosafety and biosecurity" (p. 18). This recommendation, along with another to "Develop a plan for continuous training in biosafety and biosecurity for laboratory personnel" (p. 18), strongly suggests that a standardized and required approach to biosafety training is a future goal rather than a current practice. ¹⁶⁰

Other national documents, including the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), the National Health Policy (PNS), the National Health Development Plan (PNDS), and the National Strategy and Updated Action Plan for Biological Diversity (SPANB), focus on broader capacity building, general health training, or environmental protection, but do not provide evidence of a mandated, standardized biosafety training program for personnel working with dangerous biological materials. The AMR Plan, for example, discusses "targeted training programs for actors in the fight against AMR" (p. 3), and SPANB details training for environmental management and biodiversity conservation (p. 61-62), neither of which aligns with specific, standardized biosafety training for pathogen handling in the context of public health security. ^161162163164

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹⁶⁵

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹⁶⁶¹⁶⁷

1.5.1a Evidence of national assessment of dual-use research

Score: 0

There is no publicly available evidence indicating that Comoros has conducted an assessment to determine whether ongoing research is occurring on especially dangerous pathogens, toxins, pathogens with pandemic potential, and/or other dual-use research.

The Joint External Evaluation (JEE) report, published in 2018, explicitly highlights the absence of a biosafety and biosecurity framework. The report states the "absence of national legislation or regulation concerning biosafety and biosecurity" (p. 17). This fundamental lack of a regulatory framework for biosafety and biosecurity implies that a systematic assessment of dual-use research would likely not be in place.
Furthermore, the JEE identifies a critical gap in oversight mechanisms by recommending to "Evaluate laboratories manipulating pathogens and implement a program to monitor the maintenance of records and conditions of manipulation, storage, and containment of pathogens in laboratories" (p. 18). This recommendation suggests that even the basic inventory and monitoring of pathogens in laboratories were not comprehensively conducted or publicly documented at the time of the evaluation, let alone a specialized assessment for dual-use research. ¹⁶⁸

The National Strategy and Updated Action Plan for Biological Diversity (SPANB) focuses on biodiversity conservation and sustainable use, including research on the economic potential of species and ecosystems (p. 33, 43), but it does not address dual-use research or the assessment of dangerous pathogens in a public health security context. ¹⁶⁹ Other documents, such as the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), the National Health Policy (PNS), and the National Health Development Plan (PNDS), discuss general health research and surveillance, such as "operational research to gather factual data on the determinants and impacts of AMR" (AMR Plan, p. 3) or promoting "research in the field of non-communicable diseases" (PNDS, p. 54). However, none of these documents provide publicly available evidence of an assessment specifically targeting dual-use research or the presence of dangerous pathogens with a focus on their potential misuse. ^170171172

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹⁷³

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹⁷⁴¹⁷⁵

1.5.1b National law/regulation on oversight of dual-use research

Score: 0

There is no publicly available evidence of legislation and/or regulation in Comoros specifically requiring oversight of research involving especially dangerous pathogens, toxins, pathogens with pandemic potential, or other dual-use research.

The Joint External Evaluation (JEE) report, published in 2018, explicitly highlights the absence of a national framework for these areas, stating "absence of national legislation or regulation concerning biosafety and biosecurity" (p. 17). This fundamental lack of biosafety and biosecurity legislation means that comprehensive regulatory oversight mechanisms for such high-risk research would not be in place. The JEE further underscores this gap by recommending "Elaborate regulatory texts for the global management of biological safety and security" (p. 18), indicating that the establishment of such legal requirements is a future goal. Additionally, the recommendation to "Evaluate laboratories manipulating pathogens and implement a program to monitor the maintenance of records and conditions of manipulation, storage, and containment of pathogens in laboratories" (p. 18) implies that existing oversight for pathogen handling is insufficient, let alone for dual-use research specifically. ¹⁷⁶

While the National Health Development Plan (PNDS) mentions the existence of a National Ethics Committee for Life and Health Sciences (CNESS) created in 2014, with a mission "to give opinions on ethical problems raised by advances in knowledge in biology, medicine and health" (p. 47), its role is focused on ethical advice rather than regulatory enforcement specifically for dual-use research or dangerous pathogens. The existence of this committee does not contradict the JEE's finding of a general absence of biosafety and biosecurity legislation for comprehensive oversight. ¹⁷⁷

Other national documents, including the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), the National Health Policy (PNS), the National Quality Policy (PNQ), and the National Strategy and Updated Action Plan for Biological Diversity (SPANB), do not provide any evidence of legislation or regulations specifically requiring oversight of research with dangerous pathogens, toxins, or dual-use potential. Their focuses are on broader health, quality, or environmental objectives, and do not delve into the specifics of regulating high-risk biological research. ^178179180181

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹⁸²

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹⁸³¹⁸⁴

1.5.1c Existence of agency responsible for oversight of dual-use research

Score: 0

There is no established agency specifically responsible for the oversight of research involving especially dangerous pathogens, toxins, pathogens with pandemic potential, or other dual-use research in Comoros.

This lack of a dedicated oversight agency stems directly from the absence of national biosafety legislation and regulations. The Joint External Evaluation (JEE) report, published in 2018, explicitly states the "absence of national legislation or regulation concerning biosafety and biosecurity" (p. 17). Without such foundational legislation, an agency mandated to enforce it for high-risk research oversight would not logically exist. The JEE report's recommendations also highlight the need to first "Elaborate regulatory texts for the global management of biological safety and security" (p. 18) and to "Evaluate laboratories manipulating pathogens and implement a program to monitor the maintenance of records and conditions of manipulation, storage, and containment of pathogens in laboratories" (p. 18). These recommendations indicate that comprehensive oversight mechanisms, and by extension, an agency to implement them for such specific and high-risk research, are not yet in place. ¹⁸⁵

While the National Health Development Plan (PNDS) mentions a National Ethics Committee for Life and Health Sciences (CNESS) (p. 47), its mission is to provide ethical opinions on advances in biology, medicine, and health, not to serve as a regulatory or enforcement body for the oversight of dangerous pathogen research or dual-use concerns. Its role is advisory on ethical matters, which is distinct from regulatory oversight and enforcement. ¹⁸⁶

Other national documents, including the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan), the National Health Policy (PNS), the National Quality Policy (PNQ), and the National Strategy and Updated Action Plan for Biological Diversity (SPANB), do not identify any agency with this specific oversight responsibility. Their focus areas are broader and do not delve into the institutional structures for regulating high-risk biological research. ^187188189190

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹⁹¹

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ¹⁹²¹⁹³

1.5.2a Requirement to screen synthesised DNA against list prior to sale

Score: 0

There is no publicly available evidence of legislation and/or regulation in Comoros specifically requiring the screening of synthesized DNA (deoxyribonucleic acid) against lists of known pathogens and toxins before it is sold.

The Joint External Evaluation (JEE) report explicitly states the "absence of national legislation or regulation concerning biosafety and biosecurity" (p. 17). This foundational gap strongly suggests that highly specialized regulations, such as those governing the screening of synthesized DNA for biosecurity risks, are not in place. The recommendations in the JEE focus on establishing basic biosafety and biosecurity frameworks, such as elaborating regulatory texts for general biological safety and security (p. 18), rather than detailing advanced controls for synthetic biology products.

Other national documents also do not provide any information regarding such regulations. The National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan) focuses on the proper use of antimicrobial agents and strengthening the regulatory framework for medicine, but does not extend to the control of synthesized DNA. The National Health Policy (PNS) and the National Health Development Plan (PNDS) outline broad health objectives, governance, and resource management within the health sector, with no mention of specific regulations for synthetic DNA. The National Quality Policy (PNQ) addresses general quality infrastructure, standardization, and product certification, but does not refer to synthesized biological materials or their sale. The National Strategy and Updated Action Plan for Biological Diversity (SPANB) focuses on the conservation and sustainable use of naturally occurring genetic resources and biodiversity, and while it discusses intellectual property related to traditional knowledge and genetic resources, it does not cover the screening or sale of synthesized DNA. ^{194195196197198}

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ¹⁹⁹

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ²⁰⁰²⁰¹

1.6.1a Immunization rate for humans (measles/MCV2)

Score: 0

1.6.1b Availability of vaccination figures for livestock (FMD) through OIE database

Score: 0

Based on the information available through the World Organisation for Animal Health (formely OIE) database for Comoros, there is no publicly available vaccination data specifically for Foot-and-Mouth Disease for livestock. The dashboard shows other control measures, but current vaccination figures are not displayed for FMD in Comoros's profile within this database. ²⁰²

1.6.1c Equitablenature of national immunization strategy/plan

Score: 100

The Union of Comoros meets all the criteria regarding a national immunization strategy and its inclusive components. The nation operates with a clear framework for vaccination that explicitly addresses equitable distribution and actively implements strategies to overcome various barriers to access.

Firstly, a national immunization strategy and plan is firmly in place. This is predominantly driven by the Expanded Program on Immunization (PEV). The news titled "In the Comoros, vaccination works…" repeatedly highlights the “extended vaccination program (EPI)” as a critical health intervention for saving lives and notes the ongoing efforts and financial investments made within this program. ²⁰³ Similarly, "In the Comoros, digital innovation is transforming vaccination campaigns" discusses a national vaccination campaign against measles and rubella within the context of the EPI, underscoring its central role in the country's health modernization initiatives with support from WHO and Gavi. ²⁰⁴ Beyond the EPI, the broader National Community Health Strategy 2024-2028 (SNSC) integrates vaccination as a key "Preventive Service," outlining activities such as supporting health centers for advanced vaccination strategies, generating demand, identifying target populations, and participating in intensive vaccination efforts, as detailed in Table 8: Results of preventive services offered within the SNSC. ²⁰⁵

Secondly, the national immunization strategy actively incorporates a plan to ensure equitable distribution. The news "In the Comoros, vaccination marches…" explicitly states the objective to "ensure the right to vaccination for all children." It also champions the "Reaching Every Child" approach, which is fundamentally designed to ensure that "no child is left behind." ²⁰⁶ This commitment to equitable access is further reinforced by the news "In the Comoros, digital innovation is transforming vaccination campaigns", which details the use of geospatial mapping to "facilitate micro-planning and ensure no one is left behind," ensuring comprehensive coverage. ²⁰⁷ The SNSC solidifies this commitment with its Objective 2, which aims to "Provide quality and equitable health services at the community level," and explicitly under Strategy 2.3, to "Strengthen quality community health services for all, with a particular focus on vulnerable populations." ²⁰⁸

Finally, the national immunization strategy includes specific approaches to address socioeconomic inequalities, geographical challenges, cultural or linguistic differences, and gender barriers to vaccination. In addressing socioeconomic inequalities, "In the Comoros, vaccination works…" acknowledges "Vaccination coverage in the Comoros remains desperately low despite the efforts made and the funds injected into the EPI. The causes are multiple, ranging from weak coordination, lack of public awareness, lack of human resources, weak service provision, and poor quality of services offered." ²⁰⁹ The broader strategies within the Comoros SNSC, especially under Strategy 2.3, aim to counteract these disparities by focusing on "Identify and map different vulnerable populations and respond to their needs." ²¹⁰ Geographical barriers are tackled through investments in infrastructure, as detailed in "In the Comoros, vaccination works…", which mentions efforts to upgrade the cold chain with "24 solar refrigerators" and the "solarization of the three Regional Health Directorates and the central cold room" to ensure vaccine viability across the islands, indicating a direct response to challenges like intermittent electricity. ²¹¹ The "In the Comoros, digital innovation is transforming vaccination campaigns" explicitly utilizes "geospatial maps identifying areas with a high concentration of target children" to improve micro-planning and reach remote areas. ²¹² The SNSC further identifies "Inaccessibility of the population to health facilities in certain areas due to the poor quality of roads in some localities and the very rugged terrain" as a challenge (p. 35) and proposes Strategy 2.5 to "Strengthen community health for special populations" by developing specific approaches for these hard-to-reach populations, including equitable distribution of Community Health Workers (CHWs) based on population size and geographical factors (p. 46). ²¹³ To overcome cultural and linguistic differences, "In the Comoros, vaccination works…" points to "the lack of awareness among the population" as a barrier and emphasizes "very important community mobilization." The "In the Comoros, digital innovation is transforming vaccination campaigns" highlights the training of "More than 612 agents" for social mobilization to ensure community engagement, suggesting culturally sensitive outreach.²¹⁴ The SNSC includes Strategy 2.1 to "Strengthen demand generation and health promotion" and leverages "Community relays (Father Leader/Mother Leader, Influential Women, Influential Youth, Village Health Committees)" as key local actors (p. 15) to facilitate communication tailored to local contexts. While not explicitly detailing gender barriers, the SNSC prioritizes “pregnant women and children under 5” as vulnerable groups (p. 9, 38) and includes “Influential Women” among community relays (p. 27), indicating an awareness of and efforts to address gender-related aspects of health access and utilization through targeted interventions and community engagement. ²¹⁵

1.6.1d Vaccine hesitancy and build public trust coverage in vaccines in national immunization strategy/plans

Score: 100

The national immunization strategy and associated plans in Comoros comprehensively address vaccine hesitancy and include measures to build public trust in vaccines. This is achieved through various strategies focused on community engagement, targeted communication, and educational initiatives.

The Expanded Program on Immunization (PEV), as highlighted in the news "In the Comoros, vaccination works…", explicitly aims to “Generate demand through social mobilization and public awareness”, which directly targets hesitancy by fostering public awareness and encouraging participation. The document identifies “lack of public awareness” as a reason for low vaccination coverage, indicating that awareness campaigns are considered crucial to overcoming this barrier. Furthermore, the document mentions the “Reach Every Child” approach, which relates to “the very important community mobilization at the level of all the islands” to ensure no child is left behind. Specific strategies to influence behavioral change include "Promoting vaccination of children and pregnant women: Mother leaders in action through a social and behavioral change approach", indicating an approach that leverages trusted community figures. For adolescents, "Awareness-raising sessions conducted by young reporters in different localities as part of the adolescent vaccination campaign" demonstrate peer-to-peer communication to address concerns and build trust. ²¹⁶

The news "In the Comoros, digital innovation transforms vaccination campaigns" ​​notes that over 612 agents were trained by the WHO "to ensure social mobilization, vaccination, recording, and data transmission". While digital tools primarily enhance transparency, accountability, and efficiency, which indirectly contribute to trust, the emphasis on "social mobilization" underscores a proactive approach to engaging communities. ²¹⁷

The National Community Health Strategy 2024-2028 (SNSC) provides a detailed framework for addressing vaccine hesitancy and building trust through its foundational principles and strategic axes. The strategy's summary states its aim to "address community health challenges through a participatory, inclusive, and consensual approach" and "strengthen and integrate community health supply and demand into the national health system" (p. 9), both of which are central to fostering public confidence. A key component is Axis 6: Community Engagement, which includes Strategy 6.1 to "Establish a social accountability mechanism to strengthen the leadership and coordination of community actors" (p. 43). Interventions under this strategy include "Reinvigorating village committees to improve multisectoral collaboration and coordination links," and "Strengthening collaboration between civil society actors/CSOs, including community media, and the Ministry of Health" (p. 43). These actions aim to leverage local community structures and trusted communication channels to disseminate accurate information and address community concerns directly. Furthermore, Axis 2, focused on "Strengthening People-Centered Service Offering and Community Health," includes Strategy 2.1 to "Strengthen Demand Generation and Health Promotion" through interventions like "Promoting Community Health Education" (p. 39), which are essential for informing the public and countering misinformation. The SNSC lists "IEC/BCC Awareness Raising" (Information, Education, Communication / Communication for Change in Behavior) as a core promotional service provided by community health workers and other actors, specifically mentioning "Vaccination Awareness Raising" (p. 51), indicating direct educational efforts. The engagement of "Father Leader/Mother Leader, Influential Women, Influential Youth, Village Health Committees" as community relays (pp. 15, 27, 56) is a deliberate strategy to utilize influential local figures to promote health messages and build trust. Moreover, the strategy involves "Journalists" and "Youth Reporters" to "Broadcast health-related spots," "Conduct street interviews," and "Conduct peer (youth) awareness raising" (p. 57), employing diverse media and peer-to-peer methods to reach the population and address various health topics, including those pertinent to vaccination trust. ²¹⁸

1.6.1e National advisory group for immunization strategy/plan

Score: 100

National documents from the Union of Comoros indicate the presence of a specialized coordinating body directly involved with immunization activities, which, through its functions, provides technical guidance and advice on the immunization strategy and plan. While not explicitly termed a "national advisory group" whose sole function is to advise, the mandate and activities of this body align with such a role within the governmental structure.

The National Health Development Plan 2015-2019 (p. 34) explicitly details the existence of the Inter-Agency Coordination Committee (CCIA). This committee is clearly defined as being "responsible for monitoring and coordinating vaccination activities." Its creation dates back to February 21, 2001, through "Order No. 01-0061/MSPASCF/CAB" (p. 35). The responsibility for monitoring and coordination of vaccination activities requires an understanding of technical aspects, program performance, and strategic alignment, which inherently involves providing guidance for the immunization strategy to the government and relevant agencies. This is a specific function related to vaccination, distinguishing it from broader health committees mentioned in the PNDS, such as the National Health Committee (CNS) or the National Technical Health Committee(CTNS), whose mandates encompass the entire health sector rather than solely immunization (p. 34). The fact that the CCIA is responsible for coordination also implies ensuring that different agencies and partners involved in vaccination efforts work in alignment with an overarching strategy, thereby contributing to the technical direction and advice for the immunization plan. ²¹⁹

Moreover, a critical component bolstering public trust is the presence of a National Immunization Technical Advisory Group (NITAG), which Comoros reported having to the WHO. This NITAG is defined as a multidisciplinary group of national experts responsible for providing independent, evidence-informed advice to policymakers and program managers on immunization and vaccine-related issues. The document for Comoros in 2024 confirms that the country has a standing NITAG with formal written terms of reference, representing at least five areas of expertise. Crucially, members are required to disclose conflicts of interest, ensuring the independence and integrity of their recommendations. The fact that the NITAG issued recommendations, and one or more of these were subsequently adopted by the Ministry of Health, demonstrates that national immunization policies are guided by impartial, expert scientific consensus. Furthermore, the practice of distributing meeting agendas and background documents prior to meetings and the presence of a legislative or administrative basis for the group underscore a commitment to transparency and structured decision-making, all of which are fundamental to cultivating public confidence in vaccine programs. ²²⁰

1.6.1f Presence of an immunization programme for influenza

Score: 0

Comoros does not have an immunization program for influenza.

There is no data available on World Health Organization's Immunization Data portal for Comoros. ²²¹

The WHO Strategic Preparedness and Response Portal (SPH) notes that for an "Influenza Plan," the status is "No Plan or Plan not publicly available (0 Influenza Plan)". ²²²

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ²²³

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ²²⁴²²⁵

1.7.1a Strategy/plan for resilience of health system

Score: 100

There is substantial evidence across the national documents that the Union of Comoros has a comprehensive strategy and plan to develop a health system resilient to the challenges posed by climate change and changing seasonal weather patterns, specifically including the threat of infectious diseases. This strategic approach is multi-faceted, integrating disaster risk reduction, public health preparedness, and community-level interventions.

The National Strategy for Disaster Risk Reduction (SNRRC) 2024-2030 and its Action Plan serve as a foundational document. It explicitly acknowledges that "The Union of the Comoros is among the countries most vulnerable to natural and climatic hazards due to its geographical position" (p. 1). This vulnerability is further exacerbated by "climate change, environmental degradation, and rapid and uncontrolled urbanization" (p. 1). The strategy's overarching vision is to transform Comoros into "a country resilient to shocks and protected from all damage, in all dimensions of sustainable development, taking into account natural disasters" by 2030 (p. 1). Crucially, the document directly links climate change to health impacts, stating that observed and projected climate changes, such as decreased annual rainfall, increased temperatures, and rising sea levels, will "increase the prevalence of diseases" (p. 4). This recognition forms a direct connection between climate change and infectious disease threats. The SNRRC also explicitly includes "biological (epidemics of cholera, malaria, typhoid fever)" among the principal hazards and risks faced by the country (p. 6), signaling a direct focus on infectious diseases within its risk reduction framework. To address these, the strategy's Priority 1 emphasizes understanding "disaster risk in all its dimensions of vulnerability, capacity, exposure of people and assets, risk characteristics including seasonal biological and health risks" (p. 12). Furthermore, Strategic Axis 8, which focuses on "Strengthening the capacities and skills of DRR actors for preparedness, response and recovery," includes actions to "Periodically update disaster preparedness and emergency response plans taking into account climate change scenarios" (p. 16). This demonstrates a clear intent to adapt health and emergency response plans to anticipated climate change scenarios. ²²⁶

Complementing this, the Joint External Evaluation (JEE) of the Comoros' IHR Capacities from 2018 underscores the country's efforts in preparing for public health emergencies, including those related to climate. Under the "Preparation" section, it notes that "The country has a national contingency plan which includes the health sector. Updated every two years, the plan is managed by the DGSC… It takes into account hydrometeorological risks… and epidemiological ones" (p. 32). This explicitly confirms that national contingency plans for emergency response already integrate climate-related risks (hydrometeorological) with epidemiological risks (infectious diseases), highlighting a strategy for dealing with climate-sensitive health threats. The document also discusses the surveillance and response capacities for zoonoses, which are often climate-sensitive infectious diseases (p. 12). ²²⁷

The National Community Health Strategy (NCHS) 2024-2028 further integrates health system resilience at the community level. The NCHS acknowledges that "the country is vulnerable to several meteorological and geological risks leading to emergencies and natural disasters" (p. 22), reinforcing the recognition of climate-related hazards. The strategy aims for the "integration of health activities into the communal development plan" and "local and integrated resolution of health problems as well as aspects related to health security" (pp. 54, 62). This bottom-up approach to health management, including public health security, enables communities to better withstand and adapt to various health shocks, including those exacerbated by climate change. The strategy’s focus on “improving the health status of the Comorian population through the reduction of mortality and morbidity” (p. 38) in vulnerable contexts would inherently involve addressing climate-sensitive infectious diseases like malaria and diarrheal diseases, which are prevalent (p. 21). ²²⁸

Finally, the country profile on the WHO website provides current evidence of how climate-related health challenges are being addressed. In its "Highlighted Results" for "Responding strategically to the cholera epidemic in the Comoros", it notes that "Improving the representation of the environment and water sectors in coordination frameworks and raising public awareness are key to strengthening epidemic response". This highlights a multisectoral strategy for addressing infectious disease outbreaks, acknowledging environmental factors often linked to climate change impacts on water quality and disease transmission. Furthermore, for "Enhancing maternal and child health services in the Comoros," the related outputs include "#Environmental determinants & climate change", explicitly confirming that climate change considerations are integrated into broader health programming. ²²⁹

2.1.1a Capacity of national lab system to conduct 5 or more WHO core tests

Score: 100

The national laboratory system in Comoros demonstrates the capacity to conduct diagnostic tests for at least six distinct types of diagnostic tests for human diseases: Rapid Diagnostic Tests (RDTs), Bacteriological Culture & Antimicrobial Susceptibility Testing, Microscopy, Serology/Immunoassay, Hematology, and Biochemistry.

Firstly, Rapid Diagnostic Tests (RDTs) are explicitly mentioned as being conducted for HIV/AIDS and malaria in peripheral laboratories, according to the Joint External Evaluation (JEE) (p. 23) and the National Community Health Strategy 2024-2028 (p. 30-31, p. 55). This clearly identifies RDTs as one type of diagnostic test performed. ²³⁰²³¹

Secondly, the capacity for Bacteriological Culture & Antimicrobial Susceptibility Testing is evident. The El Maarouf hospital laboratory, identified as the national reference laboratory, has the capacity to detect antimicrobial-resistant pathogens (p. 9). ²³² This directly indicates the capacity for bacteriological testing, which encompasses various techniques for bacterial identification and often includes culture and antimicrobial susceptibility testing. Furthermore, according to the National Quality Policy, analyses microbiologiques are explicitly conducted by the food hygiene laboratory and veterinary laboratory at the National Research Institute for Agriculture, Fisheries and the Environment (INRAPE) (p. 24). ²³³

Thirdly, Microscopy is a confirmed diagnostic capability for human diseases. The El Maarouf hospital laboratory is capable of diagnosing malaria, tuberculosis, and meningitis (p. 21), all of which commonly rely on microscopic examination. ²³⁴

Fourthly, Serology/Immunoassay tests are conducted. El Maarouf diagnoses HIV/AIDS (p. 21) and is certified by the WHO for measles diagnosis (p. 22), both of which typically involve serological methods for antibody detection. ²³⁵ The PNQ also lists "serology" as a basic analysis performed at El Maarouf and regional hospitals (p. 25). ²³⁶

Fifthly, Hematology testing is performed. The PNQ clearly states that El Maarouf, along with regional hospitals, conducts "basic analyses (hematology)" (p. 25). ²³⁷ This includes various blood cell counts and analyses crucial for diagnosing numerous human conditions.

Finally, Biochemistry analyses are also part of the national laboratory system's capabilities. The PNQ explicitly notes that "basic analyses (biochemistry)" are performed at the national reference laboratory (El Maarouf) and regional hospitals (p. 25). ²³⁸ These tests measure chemical substances in the blood, supporting diagnosis of metabolic, organ, and other systemic diseases.

However, it is important to acknowledge that while the capacity for these specific tests exists, the broader laboratory system faces significant challenges. The JEE report notes that "The capacities of the national laboratory system to detect public health events related to epidemics, zoonoses, food safety, and chemical risks remain limited" (p. 2). ²³⁹ Both the JEE and the National Quality Policy (PNQ) indicate that many laboratories are "not yet accredited" (PNQ, p. 24) and suffer from insufficient resources, including equipment, consumables, maintenance, and qualified personnel (JEE, p. 21; PNQ, p. 25). ^240241242 The National Health Development Plan 2015-2019 specifically mentions that the "offer of medical imaging and laboratory services is insufficient and of poor quality in health facilities" (p. 42). ²⁴³ These issues suggest that while the core diagnostic capabilities are present, their efficiency, quality assurance, and widespread accessibility across the country require substantial strengthening. Despite these systemic challenges, the documented ability to perform key diagnostic tests at the central level confirms that Comoros meets the criterion of having the capacity for at least five WHO-defined core tests.

2.1.1b Plan to conduct testing during a public health emergency

Score: 0

While Comoros has established foundational public health emergency preparedness plans and strategies for surveillance, a comprehensive national plan or similar document specifically for conducting testing during a public health emergency, which explicitly includes considerations for novel pathogens, scaling capacity, and defining goals for testing, is either not yet fully developed or not publicly detailed.

The Joint External Evaluation (JEE) report provides the most direct assessment of the country's capabilities in these areas. While it acknowledges the existence of a "national contingency plan that includes the health sector" (p. 32), it critically notes that the 2007 national plan for public health emergency preparedness and response "has not been updated" and "standardized operational procedures are also lacking" (p. 32). This is a significant gap, as an outdated plan is unlikely to adequately address emerging threats like novel pathogens or the dynamic needs of scaling capacity. ²⁴⁴

Furthermore, the JEE highlights limitations in the laboratory system, stating, "The capacities of the national laboratory system to detect public health events related to epidemics, zoonoses, food safety, and chemical risks remain limited" (p. 2). A key observation is "the absence of a national laboratory policy and strategy, a national public health laboratory network, and a secure sample transfer and transport system" (p. 21). These are fundamental components for any robust testing strategy, especially one dealing with novel pathogens and rapid scaling. The report's recommendations strongly advocate for future development, including "Develop a laboratory development policy and strategy" and "Strengthen the capacities of national human and animal health laboratories for the diagnosis of priority pathogens and establish agreements with external reference laboratories" (p. 22). The explicit recommendation to "Develop and implement a multi-hazard and multi-sectoral national public health emergency preparedness and response plan" (p. 33) further implies that such a comprehensive plan is not yet fully in place. ²⁴⁵

The National Emergency Preparedness and Response Plan, dating from November 2007, pre-dates many significant novel pathogen outbreaks (e.g., COVID-19) and the JEE's critical assessment of its currency. While it serves as a general emergency response plan with a health section, focusing on "epidemics" and "epidemic potential diseases" (p. 40), it does not explicitly detail a testing strategy that includes provisions for novel pathogens. Its "Minimal Standards" for communicable disease control primarily focus on surveillance and containment rather than specific testing protocols or how to adapt for unknown agents. There is no detailed discussion of how testing capacity would be scaled beyond general medical supplies, nor does it define specific goals for testing in different emergency phases. The JEE's finding that this plan "has not been updated" is a crucial context for its current relevance. ²⁴⁶²⁴⁷

The National Community Health Strategy 2024-2028 highlights "health security" at the community level, defining it as "the reduction of population vulnerability to serious health threats" (p. 33). It acknowledges that "The advent of the COVID-19 pandemic highlighted all the shortcomings in this regard and also led to the initiation of a number of interventions at the community level to address these shortcomings and strengthen community-based surveillance" (p. 33). It also states that community-level service delivery "must integrate health security aspects to prevent avoidable disasters, detect threats early, and enable rapid and effective community-level response" (p. 40). While this shows clear awareness of early detection of threats and mentions "COVID-19," it focuses on community-based surveillance and response functions rather than a national laboratory testing plan that details methodologies for novel pathogens, scaling, or specific testing goals. ²⁴⁸

The National Health Development Plan 2015-2019 and National Health Policy 2015-2024 outline broader strategic directions for the health sector. The PNDS mentions strengthening "the special early detection and response mechanism against epidemic potential diseases including emerging ones (hemorrhagic fevers, arboviruses…)" (p. 54) and "Ensuring integrated epidemiological surveillance of diseases" (p. 54). The PNS similarly calls for strengthening the "integrated disease surveillance system" and implementing "screening and management interventions for major communicable and non-communicable diseases" (p. 24). ²⁴⁹²⁵⁰

2.1.2a Existence of an accredited national lab serving as a reference facility

Score: 0

There is no publicly available evidence that a national laboratory in Comoros serving as a reference facility is accredited by international standards such as ISO 15189 or CLIA.

The Joint External Evaluation (JEE) report (2018) identifies the laboratory at "El Maarouf" Hospital in Moroni as "the only reference laboratory in the country" (p. 21). While noting its affiliation with "several external quality assessment programs" and that "some laboratories are certified for measles diagnosis by WHO" (p. 21), these are indicators of quality assurance participation and specific test certification, not comprehensive international accreditation like ISO 15189 or CLIA for the entire facility as a national reference laboratory. In fact, under the "National laboratory system" section, the JEE highlights a key challenge: "the absence of a national laboratory policy and strategy…and a laboratory quality system" (p. 21). One of the recommended actions is to "Develop a program for external quality assessment for all laboratories" and "Elaborate laboratory norms and standards for medical analyses" (p. 23), further indicating that comprehensive, standardized quality management systems leading to accreditation were not fully established at the time of the evaluation. ²⁵¹

More recent documents, such as the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan) (2022-2026) and the National Community Health Strategy (SNSC) (2024-2028), reinforce the focus on strengthening laboratory capacities without mentioning current accreditation status for a national reference facility. The AMR Plan mentions identifying and naming "two national reference laboratories (human and animal health)" (p. XV, activity 2.1.2) and stresses the need to "strengthen the capacities of the two structures (coordination and reference laboratories)" (p. XV, activity 2.1.3). The plan also includes an intervention to "Reinforce laboratory capacity for AMR control in the environment (INRAPE)" (p. XVIII, activity 4.2.2). The overarching goal for laboratories is to "improve the process of management…through a reinforcement of monitoring-evaluation, standardization and regulation" (p. 5), indicating that these are ongoing efforts rather than already achieved accreditation. The plan aims to "enroll the country in the WHO GLASS system" (p. XV, activity 2.1.4), which is a global surveillance system for AMR, requiring robust laboratory data but not explicitly stating accreditation as a prerequisite or current status. ²⁵²²⁵³

The SNSC (2024-2028), while very recent, focuses primarily on community-level health interventions, human resources for health, and the overall health system. It discusses the national health system structure and challenges (p. 14-19) but does not contain specific information about the accreditation status of national reference laboratories, as its scope is broader than detailed laboratory infrastructure. ²⁵⁴

2.1.2b External quality assurance of a national lab serving as a reference facility

Score: 100

There is evidence of a national laboratory in Comoros that serves as a reference facility and is subject to external quality assurance review.

The Joint External Evaluation (JEE) report (2018) explicitly states that the laboratory of the "Centre Hospitalier El Maarouf" in Moroni, which is identified as "the only reference laboratory in the country," is "affiliated with several external quality assessment programs" (p. 21). Furthermore, the report notes that "Some laboratories are certified for measles diagnosis by WHO" (p. 22), indicating that at least for specific diagnostic areas, external quality evaluations lead to certification. However, the JEE also points to the need for broader and more systematic external quality assessment across the entire national laboratory system. Under indicator D.1.4, Laboratory quality system, the report recommends to "Develop an external quality assessment program for all laboratories" (p. 23). ²⁵⁵

More recent documents, such as the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan) (2022-2026), also implicitly support the concept of external quality assurance for laboratories. The AMR Plan aims to "Reinforce the capacities of national human and animal health laboratories for the diagnosis of priority pathogens" (p. XVI, activity 2.1.3), and emphasizes "strengthening capacities" (p. XV). It also states the country's intent to "enroll the country in the GLASS system" (Global Laboratory Surveillance System) (p. XV, activity 2.1.4). ²⁵⁶

The National Community Health Strategy (SNSC) (2024-2028), while not delving into specific laboratory EQA mechanisms, reiterates the broader goal of strengthening health services and systems (p. 10). ²⁵⁷

2.2.1a Nationwide specimen transport system

Score: 0

A comprehensive, harmonized nationwide specimen transport system is not fully established in Comoros, and its development is identified as a priority area for strengthening.

The Joint External Evaluation (JEE) report (2018) provides the most direct information on this matter. Under the "National laboratory system" section, it explicitly states "the absence… of a secure sample transfer and transport system" (p. 21). While acknowledging some existing mechanisms, the JEE notes them as specific circuits rather than a unified national system: "Existence of a circuit for the transport and transfer of samples within the framework of polio surveillance" and "Existence of a circuit for the transport of samples within the framework of surveillance of diseases with epidemic potential" (p. 23). Despite these specific disease-focused circuits, the overall assessment highlights significant gaps. The challenges identified include the need to: "Establish a harmonized national system for the secure transport of suspected biological samples" (p. 23), "Develop guidelines for the collection, packaging, and transport of samples" (p. 23), and "Train laboratory personnel and other actors involved in sample transfer on biosecurity and biosafety measures" (p. 23). ²⁵⁸

While the more recent National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan) (2022-2026) and the National Community Health Strategy (SNSC) (2024-2028) focus on strengthening laboratory and community health services respectively, they do not detail the establishment or current functionality of a nationwide specimen transport system, suggesting that the gaps identified in the JEE largely persist or are still being addressed. The AMR Plan, for instance, focuses on strengthening laboratory capacities for diagnosis and surveillance but doesn't specifically outline a transport system. ²⁵⁹²⁶⁰

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ²⁶¹

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ²⁶²²⁶³

2.2.2a Plan to rapidly authorize/license laboratories to scale-up testing during an outbreak

Score: 0

There is no explicit plan in place that details a mechanism to rapidly authorize or license laboratories to supplement the capacity of the national public health laboratory system for scaling up testing during an outbreak.

The Joint External Evaluation (JEE) report from 2018 repeatedly highlights gaps in comprehensive emergency preparedness and laboratory system strategy. It explicitly states that there is an "absence of a national laboratory policy and strategy, a national public health laboratory network, and a secure sample transfer and transport system" (p. 21). The JEE's recommendations include the need to "Develop a laboratory development policy and strategy" and to "Reinforce the capacities of national human and animal health laboratories… and establish agreements with external reference laboratories" (p. 22). ²⁶⁴

Furthermore, the JEE notes that the 2007 national emergency preparedness plan (PNPU) "has not been updated" and that "standard operating procedures are also lacking" (p. 32). The JEE's priority recommendation to "Develop and implement a multi-hazard and multi-sectoral national public health emergency preparedness and response plan" (p. 33) further underscores this systemic gap. ²⁶⁵

While the National Quality Policy (PNQ) from 2016 discusses the broader development of a national quality infrastructure, including laboratory accreditation, it focuses on general, long-term accreditation processes (e.g., ISO standards) rather than rapid emergency authorization (p. 24-28). It notes that "most laboratories… are not yet accredited" (p. 24). ²⁶⁶

More recent documents, such as the National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan) (2022-2026) and the National Community Health Strategy (SNSC) (2024-2028), focus on strengthening existing laboratory capacities, establishing surveillance systems, and improving community-level health services. The AMR Plan details efforts to build up national reference laboratories and sentinel sites (p. XV-XVI) for AMR surveillance, but it does not describe a mechanism for rapidly bringing additional laboratories online or authorizing them during an outbreak. The SNSC, while acknowledging lessons from COVID-19 regarding "health security" and early threat detection (p. 33), does not delve into specific laboratory authorization or licensing protocols for emergency scale-up. ²⁶⁷²⁶⁸

2.3.1a Evidence of ongoing event-based and indicator-based surveillance and analysis

Score: 50

Comoros is conducting ongoing event-based and indicator-based surveillance and analysis for notifiable and novel infectious diseases, though specific evidence for daily analysis of all data is not present in the national documents, with monthly validation being explicitly stated for some processes.

Indicator-Based Surveillance (IBS) is clearly established and regularly practiced. The Joint External Evaluation (JEE) report (2018) explicitly scores Comoros a 3 out of 5 for Indicator-based surveillance systems, noting the "Existence of indicator-based and event-based surveillance systems" and the "Use of the SIMR technical guide adapted since 2011" (p. 25). ²⁶⁹ SIMR, or Integrated Disease Surveillance and Response, is a well-recognized framework that combines both indicator-based and event-based surveillance. The National Health Development Plan (PNDS) 2015-2019 further reinforces this by including "Ensure integrated epidemiological surveillance of diseases" as a strategic intervention (p. 54). ²⁷⁰ Similarly, the National Health Policy (PNS) 2015-2024 calls for strengthening the integrated disease surveillance system (p. 24). ²⁷¹ The National Multisectoral Action Plan Against Antimicrobial Resistance (AMR Plan) 2022-2026 outlines a detailed plan to "progressively establish a continuous surveillance system for AMR", including activities to "enroll the country in the WHO GLASS system", which is a specific form of indicator-based surveillance for resistant pathogens (p. XV). ²⁷²

Event-Based Surveillance (EBS) is also in operation. The JEE report notes the "Existence of syndromic sentinel surveillance in all regions", which is a key component of EBS, often used to detect unusual or novel events (p. 25). ²⁷³ The National Community Health Strategy (SNSC) 2024-2028 highlights the role of Community Health Workers (ASC) in EBS, stating that they "Ensure notification of disease cases under surveillance and unusual events related to community health", although noting its effectiveness as moderately effective (p. 32). ²⁷⁴ This demonstrates an existing mechanism for detecting events beyond routine indicators. For notifiable diseases, the JEE explicitly confirms the "Existence of the list of notifiable diseases in the animal sector" (p. 26). The SIMR framework generally includes a list of human notifiable diseases. ²⁷⁵

Regarding novel infectious diseases, the PNDS 2015-2019 directly addresses this by including a strategic intervention to "Strengthen the special early detection and response mechanism against epidemic potential diseases including emerging ones (hemorrhagic fevers, arboviruses…)" (p. 54). ²⁷⁶ Furthermore, the SNSC (2024-2028) acknowledges the impact of the COVID-19 pandemic, stating that its "occurrence… highlighted all the shortcomings in this regard and also led to the initiation of a number of community-level interventions… and strengthen community-based surveillance" (p. 33). ²⁷⁷ This indicates a direct adaptation and learning process from a novel pathogen event to enhance surveillance.

Finally, for ongoing analysis, the JEE report states that there is "Analysis of surveillance data" with "Organization of monthly data validation meetings" and "Use of data for decision-making" (p. 25). ²⁷⁸ While these validation meetings are monthly, indicating a regular analytical process, the documents do not explicitly state that analysis occurs on a daily basis. The SNSC (2024-2028) also mentions that at the regional level, there is "Collection and analysis of data from health districts, and epidemiological surveillance and response teams" (p. 26). The strategy also aims to "Strengthen digital tools, surveillance, information systems…" and to "Equip and train CHWs [community health workers] with digital tools for data entry, reporting and decision-making" (p. 42). ²⁷⁹

2.3.1b Evidence of a mechanism (such as IHR focal point) for reporting notifiable diseases to the WHO within the set timeline

Score: 100

Comoros has established a mechanism for reporting notifiable diseases, primarily through its International Health Regulations (IHR) National Focal Point (PFN-RSI), which was deemed functional and capable of urgent communication with the World Health Organization (WHO) contact point, according to the Joint External Evaluation (JEE). ²⁸⁰

The country's Public Health Code outlines legislative and regulatory frameworks for surveillance and response, enabling the implementation of the IHR (p. 1, 5). Managers associated with the PFN-RSI demonstrated a good understanding of the country's obligations for notifying the WHO about events that could constitute a Public Health Emergency of International Concern (PHEIC) (p. 27). Standard Operating Procedures (PON) for notification, including the Integrated Disease Surveillance and Response (SIMR) technical guide, are in place nationally, though their effective utilization is sometimes hampered by a lack of training (p. 27). Despite these existing frameworks, the JEE noted that the capacity for an effective notification system to WHO, FAO, and OIE was rated as 'limited' (p. 4, 28). ²⁸¹

Challenges persist in fully operationalizing these mechanisms. The JEE highlighted that while intersectoral collaboration for detection and response to public health events, including zoonoses, exists, these mechanisms are often only activated during crises (p. 1). Improvements are needed to strengthen the integrated disease surveillance and response system (SIMR), enhance animal health epidemio-surveillance networks, and improve analytical capacities and regular information exchange (p. 1). The country’s preparedness plan for public health emergencies, developed in 2007, requires updating, and standardized operational procedures are lacking (p. 32). ²⁸² In the realm of antimicrobial resistance (AMR), the 2022-2026 National Multisectoral Action Plan notes that the 2018 JEE identified "inexistence of capacities" in this area (p. 3). The plan aims to address this by establishing a National Coordination Committee for AMR surveillance and identifying national reference laboratories (p. XXII, XXVIII). ²⁸³

The National Contingency Plan for 2017-2018 also outlines general procedures for emergency management, which would apply to disease outbreaks (p. 15-22). This plan indicates alert levels from 'blue' (normal situation) to 'red' (maximum, engaging operational means) and specifies who can trigger these alerts, such as the relevant sector, the Directorate General of Civil Security (DGSC), or the Minister of Interior/Insular Authority (p. 14). The DGSC is responsible for coordinating information management and crisis communication, working with various entities including the National Meteorology Agency, the Karthala Volcanological Observatory, and the Directorate General of Health (p. 13). The Public Health Division (DGS) and the national focal point are tasked with elaborating intervention plans and training healthcare providers on protocols (p. 20). Communication and information sharing during an epidemic involve the DGSC, the fixed command post (PC fixe), the public health sector, and partners, to inform, educate, and raise awareness among the population via media (p. 21). ²⁸⁴

The National Community Health Strategy (2024-2028) highlights the role of community health workers (ASC) in disease surveillance, noting they participate in the notification of maternal deaths and other reportable conditions, though this often occurs orally (p. 31). ASCs are also involved in surveillance of conditions with epidemic potential, such as detecting and notifying new cases (p. 55). The strategy emphasizes integrating the community health component into a digitalized national health information system and equipping ASCs with digital tools for data entry, reporting, and decision-making (p. 42). The aim is to improve the management and quality of routine data and establish a dashboard for community health activities (p. 42). However, challenges include insufficient coordination and collaboration among community actors, a lack of harmonization in data collection tools, and insufficient follow-up and supervision (p. 34). ²⁸⁵

2.3.2a Electronic national and sub-national reporting surveillance system

Score: 100

The government of Comoros operates an electronic reporting surveillance system at both national and sub-national levels.

The Ministry of Health, through the Directorate of Health Information System (DISS), implemented the DHIS2 system in August 2022, according to the National Community Health Strategy 2024-2028 (p. 19). This system is operational in 84 out of 100 configured health facilities, representing an 84% coverage rate. These facilities are equipped with necessary information technology tools, including laptops, desktop computers, tablets, printers, and internet connections, to facilitate regular data entry (p. 19). ²⁸⁶

Prior to this, the Joint External Evaluation conducted in 2017 indicated the existence of an electronic notification system for notifiable animal diseases (p. 25). However, at that time, there was a recommendation to implement a similar electronic notification system for notifiable human diseases, implying it was not fully in place for human health (p. 25). ²⁸⁷

The National Community Health Strategy 2024-2028 further details the intention to enhance digital reporting capabilities. It outlines plans to integrate the community health aspect into the national digitalized health information system (p. 42). This includes equipping and training Community Health Workers (ASC) with digital tools for data entry, reporting, and decision-making (p. 42). The strategy also states that data collection tools and monthly reporting templates will be digitized to ensure timely information availability and ease of analysis and decision-making at the community level (p. 61). ²⁸⁸

Despite these advancements, the Strategic Partnership for Health Security and Emergency Preparedness (SPAR) 2024 submission for Comoros indicated a 40% average capacities score for surveillance (C6), with a 60% score for early warning functions based on indicator and event-based surveillance (C.6.1), and a lower 20% score for the mechanism for event management (C.6.2) (p. 2). ²⁸⁹

2.3.2b Collection of ongoing/real-time lab data by electronic surveillance system

Score: 100

The government of Comoros operates an electronic reporting surveillance system that collects ongoing data, including laboratory-related information, and aims for disaggregation and analysis.

According to the National Community Health Strategy 2024-2028, the Ministry of Health implemented the DHIS2 system in August 2022, which is operational in 84 out of 100 configured health facilities, facilitating the regular entry of data and equipping these structures with the necessary IT tools for this purpose (p. 19). It highlights that "data on healthcare and services comes from daily collection at basic health facilities, including community-based services, hospitals, and certain health programs and projects. However, data collection is still not effective in the private sector" (p. 20). Regarding laboratory data specifically, the National Community Health Strategy lists "number of RDTs performed by Community Health Workers for Malaria, HIV" as an indicator for monitoring and evaluation (p. 61). This indicator refers to specific laboratory data (RDT results) collected, and its inclusion within the strategy's monitoring framework, coupled with the DHIS2 system's "regular entry of data," explicitly confirms ongoing collection of such laboratory information. ²⁹⁰ The 2022-2026 National Multisectoral Action Plan for Antimicrobial Resistance (AMR) also outlines plans to establish a national coordination structure for AMR surveillance, identify national reference laboratories, and enroll the country in the Global Laboratory Surveillance System (GLASS) of the World Health Organization (p. XXVIII, XXX). This plan explicitly indicates electronic collection and utilization of laboratory data for surveillance. ²⁹¹ The 2018 Joint External Evaluation (JEE) report recommended "real-time sharing of information, including laboratory data" as a priority to be strengthened (p. 25). ²⁹²

Regarding disaggregation and analysis, the DHIS2 system is designed to support such functions, enabling data to be analyzed for informed decision-making (p. 19, 61). The National Community Health Strategy (2024-2028) mentions that "the health data collected, in the form of indicators, are of various types: socio-economic, demographic, health status (mortality, morbidity, disease control, nutrition, HIV, etc.), hospitalizations, transfers, and laboratory data" (p. 20). It also lists various indicators for monitoring and evaluation, such as the "percentage of pregnant women sensitized," "number of children taken care of," "number of infants followed for malnutrition," and "number of RDTs performed by CHW (Malaria, HIV)" (p. 61). ²⁹³ These examples explicitly show data related to specific age groups (children, infants) and demographic/physiological status (pregnant women) that would be subject to analysis within the DHIS2 system. While ethnicity is not explicitly mentioned as a disaggregation category in the national texts, the strategy explicitly defines indicators for data categorized by age and specific demographic groups for public health analysis.

2.3.3a National wastewater surveillance programme or initiative

Score: 0

There is no evidence of an ongoing national- or sub-national level wastewater surveillance programmes for detecting contaminants or pathogens in Comoros. While the country does not have running websites for its Ministry of Health, the MoH does have a Facebook page. On this page, the MoH provides updates on progress on surveillance efforts, however, there is limited evidence on whether these efforts are ongoing at the national or sub-national level. These updates are high-level and focus more on "surveillance" more broadly and "l’analyse épidémiologique" (i.e. epidemiological analysis), with no explicit differentiation between wastewater surveillance, environmental surveillance or AFP surveillance.²⁹⁴ There is no further information about environmental or wastewater surveillance mechanisms from the GPEI. ²⁹⁵²⁹⁶

2.4.1a Common usage of electronic health records

Score: 0

Electronic health records are not commonly used in Comoros. The information available points to the implementation and use of health information systems for data collection and reporting, rather than individual patient records.

According to the National Community Health Strategy 2024-2028, the Ministry of Health introduced the DHIS2 system in August 2022. This system is currently operational in 84 out of 100 configured health structures, achieving an 84% coverage rate within these specific facilities. These structures have been equipped with essential information technology tools, such as laptops, desktop computers, tablets, printers, photocopiers, and internet access, to facilitate regular data entry (p. 20). ²⁹⁷ However, DHIS2 is a platform designed for aggregate health data management, surveillance, and program monitoring, not for storing individual patient medical records (EHRs). The strategy also notes that maternal death notifications are predominantly handled orally, with an identified need to "digitalize this process" (p. 31), which further suggests a lack of comprehensive patient-level electronic record-keeping. The broader goal is described as digitalizing "all data collection tools and monthly reports" (p. 61), indicating a focus on reporting rather than individual patient records. ²⁹⁸

According to the National Health Development Plan (PNDS) 2015-2019, previously, the country had attempted to computerize its health information system with the GESIS software, introduced around 2012. This system was used for collecting routine data, but its completeness rate was low, and its data was not always considered credible for assessing the health situation (p. 46). GESIS, like DHIS2, functions as a health information system for aggregated data rather than patient-level EHRs. The PNDS also mentions "dossier médical" (medical file) in the context of improving service quality (p. 52), but does not specify whether these files are electronic. ²⁹⁹

2.4.1b Public health system access to individual electronic health records

Score: 0

The national public health system in Comoros does not have access to electronic health data pertaining to individuals within the country. The information available points to the implementation and use of health information systems for aggregate data collection and reporting, rather than individual patient records accessible by the national system.

The National Community Health Strategy 2024-2028 mentions the implementation of the DHIS2 system by the Ministry of Health in August 2022, which is operational in 84 out of 100 configured health structures (p. 19). This system is used for "regular entry of data" to ensure "timely information availability" and to "facilitate analysis and decision-making" (p. 19, p. 61). However, DHIS2 is a platform designed for managing and analyzing aggregated health data, surveillance, and program monitoring, not for storing individual patient-level electronic health records. Furthermore, the strategy notes that maternal death notifications are predominantly handled orally, and identifies a need to "digitalize this process" (p. 31), which indicates that individual health events, even critical ones, are not yet routinely captured electronically at the patient level. The document also suggests that integrating smartphone usage for Community Health Workers (ASC) for "data entry, reporting and decision-making" is a future enhancement (p. 42, p. 44), focusing on reporting rather than comprehensive patient histories. ³⁰⁰

Similarly, the National Health Development Plan (PNDS) 2015-2019 refers to an earlier effort to computerize the health information system using GESIS software around 2012. This system was also for the computerization of the Health Information System for data collection and reporting (p. 45-46). Like DHIS2, GESIS is described as an information system for aggregated data rather than individual patient EHRs. While the PNDS mentions "dossier médical" (medical file) in the context of improving service quality (p. 52), it does not specify if these are electronic or paper, and concerns about non-archiving of files further suggest potential issues with any type of systematic record-keeping, electronic or otherwise, at the time (p. 48). ³⁰¹

2.4.1c Existence of data standards for health record data comparability

Score: 100

In the Comoros, efforts are being made towards data standardization and comparability, particularly within the health sector, though challenges remain.

The National Health Development Plan (PNDS) 2015-2019 notes that the country has adopted a Framework of Standards for its health information system (SIS) in 2013, which includes the definition and harmonization of national indicators (p.45). This framework is crucial for ensuring that data collected across different health facilities and programs can be consistently understood and compared. ³⁰²

Specifically, within the laboratory system, some international certifications indicate adherence to data and quality standards. For instance, certain laboratories are certified by the World Health Organization (WHO) for measles diagnostics, as mentioned in the Joint External Evaluation (p.23). However, there is a recognized need to establish a comprehensive external quality evaluation program for all laboratories and to develop specific standards for medical analysis laboratories (p.23). ³⁰³

The National Policy on Quality (PNQ) also emphasizes the importance of standardization in a broader sense. It notes that about 80 Codex Alimentarius standards have been adopted but not yet promulgated as national standards, which would facilitate regulatory consistency. The PNQ also highlights the role of the National Quality Service (SNQ) as the national standardization body, responsible for developing, coordinating, and promoting technical standards. This includes harmonizing and adopting standards from organizations like COMESA (p.12). The PNQ itself is framed within national, regional (COMESA, PAQI), and international (WTO/TBT agreements, Arab Strategy for Standardization and Quality, SMIIC) reference frameworks, all of which aim to ensure consistency and comparability in quality infrastructure and standards (p.32). ³⁰⁴

Despite these initiatives, challenges persist. For example, monthly reports from the routine data of 2013 showed that information collected at the district level was often not organized or analyzed locally, and the intermediate level would compile health information without adequate analysis or feedback to the peripheral level. The quality and completeness of data entry in monthly canvasses were also not consistently mastered (p.46). ³⁰⁵

Within the National Community Health Strategy 2024-2028, there is an objective to strengthen the health information system by integrating community health data into a digitalized national system. This involves harmonizing data production tools and processes across different actors at all levels (p.42). The use of DHIS2, which is operational in many health structures, inherently supports a level of data standardization, as such platforms are designed to handle data in a structured and comparable manner (p.19). There is also an ongoing effort to digitalize data collection tools and monthly reports to improve data availability and facilitate analysis and decision-making (p.61). ³⁰⁶

2.4.2a Data sharing mechanisms

Score: 0

There is insufficient evidence of established mechanisms in Comoros for data sharing between relevant ministries responsible for animal, human, and wildlife surveillance, particularly within the framework of the "One Health" approach. These mechanisms are still evolving and require further formalization for comprehensive daily data exchange.

According to the Joint External Evaluation (JEE) conducted for Comoros in 2018, the "One Health" approach, recognizing the interconnectedness of human, animal, and environmental health, was officially launched in Comoros in 2014. However, its implementation has been challenging (p. 12). The JEE notes that although some joint investigations of disease outbreaks between veterinary and human health services occurred, routine and formalized data sharing mechanisms across ministries were still lacking (p. 12-13). The JEE explicitly recommended establishing an effective multisectoral mechanism or platform for the exchange of information and decision-making between these sectors (p. 28). ³⁰⁷

Evidence from more recent documents, such as the 2024 Strategic Partnership for Health Security and Emergency Preparedness (SPAR) report and the 2024-2028 National Community Health Strategy, continues to highlight that while there is an acknowledgment of the need for inter-ministerial data sharing for surveillance, established and fully functional mechanisms for this purpose remain limited. ³⁰⁸³⁰⁹

The 2024 SPAR report, which assesses Comoros' capacities, indicates a score of 40% for "Multi-sectoral IHR coordination mechanisms" and a similar score of 40% for "Collaborative effort on activities to address zoonoses". ³¹⁰ These low scores suggest that comprehensive and effective data sharing between ministries responsible for human, animal, and wildlife surveillance is not yet robustly established. This aligns with earlier findings from the 2018 Joint External Evaluation (JEE) report, which noted that while a "One Health" approach was officially launched in 2014 and some joint investigations of disease outbreaks between veterinary and human health services occurred, routine and formalized data sharing mechanisms across ministries were still lacking (p.12-13). The JEE report had explicitly recommended establishing an effective multisectoral mechanism or platform for the exchange of information and decision-making between these sectors (p.28). ³¹¹

The 2024-2028 National Community Health Strategy also acknowledges the persistent challenges related to coordination. It identifies "insufficient coordination and collaboration of community actors" and the "absence of national coordination mechanisms and a community health management structure" as weaknesses or threats to effective health interventions (p.34). As part of its strategic objectives, this strategy plans to "Establish a national committee and regional multisectoral committees on community health" (p.39). However, this is described as a planned intervention rather than an existing, fully operational mechanism for inter-ministerial data sharing on surveillance. The strategy's focus is primarily on community health within the health sector, with broad goals of "Coordination and strategic partnership with different actors intervening in community health" by the Ministry of Health (p.52), but it does not detail specific data sharing protocols for surveillance across different ministries like those for animal or wildlife health. ³¹²

2.4.3a Availability of de-identified health surveillance data on disease outbreaks

Score: 0

While Comoros actively collects health data for surveillance and decision-making, direct evidence from the national documents regarding the routine public availability of de-identified health surveillance data on infectious diseases via government websites (such as those of the Ministry of Health or Ministry of Agriculture) is limited.

The national health information system (SIS), managed by the Directorate of Information and Health Statistics (DISS), aims for "the production and diffusion of health statistical data", as noted in the National Community Health Strategy 2024-2028 (p.66). ³¹³ The Joint External Evaluation (JEE) mentions that the country produces statistical yearbooks, such as the Statistical Yearbook 2014-2015 (p.52), which likely contain aggregated health statistics, including some related to infectious diseases. ³¹⁴ However, the Health Statistics Yearbook is not available on the The National Institute of Statistics and Economic and Demographic Studies (INSEED) website. ³¹⁵

A significant observation from the JEE report highlighted a specific challenge: the "Lack of a website to communicate on health issues" (p.41). ³¹⁶ This indicates a foundational lack of a dedicated online platform that would typically be used for disseminating public health information, including surveillance data. While there has been progress in digitalizing internal data management through DHIS2 since then (p.19), this progress is primarily geared towards improving internal data flow and analysis for decision-makers rather than routine public dissemination of detailed, de-identified surveillance information. ³¹⁷

Although mechanisms for multisectoral coordination in surveillance exist, such as through the "One Health" approach involving human and animal health services for zoonoses, these are geared towards collaborative management and response, with no explicit mention of making raw or de-identified surveillance data publicly accessible online (p.12-13). ³¹⁸

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ³¹⁹

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites and only have an online presence on Facebook. ³²⁰³²¹

2.4.4a Confidentiality legislation/regulations for identifiable health information

Score: 100

Comoros has legislation and ethical frameworks in place that safeguard the confidentiality of identifiable health information, significantly strengthened by a recent dedicated data protection law.

The most comprehensive safeguard is the Protection of Personal Data Law, enacted on June 29, 2021. This law establishes a comprehensive legal framework for data protection in the country. It applies to the processing of personal data related to identified or identifiable natural persons (Article 1, p. 2 and Article 4, p. 2), which would include identifiable health information generated through surveillance. Key obligations for data controllers and processors, outlined in Chapter V, include taking "all useful precautions… to preserve the security of data and, in particular, prevent them from being distorted, damaged or accessed by unauthorized third parties" (Article 50, p. 14). The law also explicitly grants individuals rights regarding their data, such as the right to oppose processing (Article 10, p. 5), the right to be informed about the processing (Article 12, p. 5), the right to access (Article 13, p. 5), and the right to rectification, completion, update, locking, or erasure of inaccurate or incomplete data (Article 15, p. 6). The law also established an independent "Commission nationale de l’informatique et des libertés" (CNIL) (National Commission for Information Technology and Freedoms) to ensure its application (Article 19, p. 7). ³²² The Review of the Comoros Data Protection Law further elaborates on this, stating it "aligns with international data protection principles" and includes "Data Protection Principles" such as integrity and confidentiality, and "Security Measures" to protect data. ³²³

The Law N°11-001/AU of March 26, 2011, which constitutes the Public Health Code, includes specific provisions addressing patient confidentiality. Article 214 of this code stipulates that health practitioners are bound by professional secrecy and are prohibited from divulging information related to a patient's health, except as permitted by existing legislation (p.43). Furthermore, Article 569 extends this obligation to health establishments, requiring them to protect the confidentiality of information they hold on individuals they serve (p.105). The confidentiality of blood donor results is also explicitly guaranteed under Article 546 (p.100). These articles establish a legal basis for patient data confidentiality within the health sector. ³²⁴

According to the National Health Development Plan 2015-2019, the establishment of the National Committee of Ethics for Life Sciences and Health (CNESS) in 2014, with its mission to provide opinions on ethical issues in biology, medicine, and health, further underscores a commitment to ethical standards that would inherently include data privacy (p.47). ³²⁵

However, despite the existence of these legal and ethical underpinnings, assessments indicate significant shortcomings in the practical implementation and comprehensiveness of such safeguards, especially concerning health surveillance activities. The 2018 Joint External Evaluation (JEE) report noted that the 2011 health code had not always been effectively applied due to a lack of necessary implementing texts (p.36). ³²⁶

2.4.4b Inclusion of cyber protections in health data confidentiality law/regulation

Score: 0

Comoros possesses legislative provisions that safeguard the confidentiality of identifiable health information. However, it does not contain specific legislation or regulations that detail protections against modern cyber threats such as ransomware or other forms of cyber attacks.

Specifically, the professional secrecy of health practitioners is explicitly mandated. According to the Public Health Code, a practitioner is bound by professional secrecy and cannot disclose information related to a patient's health status, except where legal derogations apply (p. 43, Article 214). This obligation to maintain confidentiality also extends to health establishments. These establishments are required to implement information systems that respect medical secrecy and patient rights, and they are responsible for protecting the confidentiality of the information they hold concerning individuals they care for (p. 105, Article 569). ³²⁷ While these provisions establish a general framework for the confidentiality of health information, including data generated through health surveillance activities, the emphasis in the legal text is on the traditional concept of professional secrecy and the general duty of confidentiality within health settings.

The National Community Health Strategy 2024-2028 mentions the intention to integrate community health into a national digitized health information system and to equip community health agents with digital tools for data entry, reporting, and decision-making (p. 42). ³²⁸ Similarly, the National Health Development Plan 2015-2019 discusses the development of the National Health Information System (SNIS) and the implementation of software like GESIS for data management, highlighting the need for better data management and the utilization of new information and communication technologies (p. 45, p. 66). ³²⁹ However, these documents do not elaborate on specific legislative or regulatory safeguards designed to protect this digitized health information from cyber attacks.

The Joint External Evaluation 2018 report also notes the existence of electronic notification systems for animal health and recommends implementing one for human health, as well as strengthening IT infrastructure generally. It also addresses the need for secure transfer of biological samples (p. 25). However, this evaluation, which assesses the country's capacities to prevent, detect, and respond to public health threats, does not include any findings or recommendations regarding legislation or regulations specifically for protection against cyber attacks on health information systems. ³³⁰

According to UNCTAD, Comoros does not have laws on data privacy or cybersecurity. ³³¹

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ³³²

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ³³³³³⁴

2.4.5a Cooperative commitments or agreements within regions

Score: 100

The government of Comoros has made a clear commitment to sharing surveillance data with other countries and international organizations during public health emergencies, as evidenced by its legislative framework and active participation in cooperative agreements. These commitments are broad in scope, covering multiple communicable diseases and public health events.

Comoros's Public Health Code mandates that national health measures align with international treaties, specifically the International Health Regulations (IHR 2005), thereby legally obliging the country to notify the World Health Organization (WHO) of any public health events that could pose an international concern, inherently covering a wide range of diseases and public health threats. ³³⁵ While this legally binding framework necessitates the sharing of surveillance data with the WHO, iy does not specify provisions to share with other countries.

Furthermore, Comoros maintains a designated and functional National IHR Focal Point (PFN-RSI), whose personnel are well-versed in the country's notification responsibilities to the WHO for potential Public Health Emergencies of International Concern (PHEICs), as noted in the Joint External Evaluation. This role is by definition focused on any event with international public health implications, not just one specific disease. In the animal health sector, a functional OIE focal point consistently utilizes the World Animal Health Information System (WAHIS) to share information about a variety of animal diseases with the World Organisation for Animal Health (OIE), demonstrating a parallel commitment to international data exchange in this critical area (p. 27). ³³⁶

Beyond these national mechanisms, Comoros is an active participant in the Indian Ocean Commission's (IOC) SEGA – One Health network, a cooperative agreement specifically designed to bolster regional coordination in the detection and response to diverse public health events. The training of numerous field epidemiologists through this program prepares them to address various health crises on both national and regional scales, inherently requiring the exchange of surveillance data among member states. ³³⁷³³⁸ This regional collaboration is further reinforced by the emphasis on "Joint surveillance, field investigation and response" as a key priority from the One Health workshop, ³³⁹ and the broader efforts to develop collaboration with neighboring countries through the COI's health surveillance unit.

2.5.1a National support to conduct contact tracing in the event of a public health emergency

Score: 50

Comoros has established a national health system, organized in a pyramidal structure from central to regional, peripheral, and community levels, which plays a role in public health emergency response, including activities related to what could be considered components of contact tracing.

According to the Joint External Evaluation (JEE), the country utilizes an Integrated Disease Surveillance and Response (SIMR) guide, adapted since 2011, for syndromic surveillance across all regions, demonstrating a degree of metrics standardization for identifying potential public health threats (p. 25). ³⁴⁰ Community Health Agents (ASCs) and community relays are tasked with participating in the surveillance of epidemic-prone diseases, including the detection and notification of new cases, and are involved in the follow-up of cases, such as those lost to follow-up for tuberculosis and leprosy, as noted in the National Community Health Strategy (SNSC) 2024-2028 (p. 31, p. 55,). ³⁴¹ There is also mention of joint investigation of cases with other related sectors in emergency situations, indicating a multisectoral approach to response (p. 35). ³⁴²

Regarding training, efforts are made to strengthen the capacities of ASCs in detection and notification of diseases, recognizing their crucial role at the community level. Epidemiological training programs, such as the Field Epidemiology Training Program (FETP), exist within the country, with four field epidemiologists trained as of 2017 (p. 24, p. 30). However, the JEE report recommends developing local intermediate and advanced epidemiology training programs and strengthening the number of FETP agents, highlighting an ongoing need for capacity building in this area (p. 30). ³⁴³ The SNSC further outlines specific training for ASCs and community relays, including post-training follow-up to ensure mastery and application of acquired knowledge on the ground (p. 46-47). ³⁴⁴ Despite these structures and training initiatives, significant challenges remain, particularly concerning financial resources and human resource distribution. The JEE report explicitly notes the absence of a specific budget line for the implementation of International Health Regulations (IHR) capacities, including mechanisms for timely and effective fund disbursement for public health emergencies (p. 6). It recommends establishing a readily mobilizable budget line for public health emergency preparedness and response (p. 33). The insufficiency of human resources across various disciplines, including epidemiology, and their inadequate distribution, especially in rural areas, are identified as weaknesses (p. 30). ³⁴⁵ While tools for data collection and reporting are provided to ASCs, harmonization of these tools and processes with various actors at all levels is still a goal to be achieved, along with equipping and training ASCs in digital tools for data entry and reporting (p. 34, p. 42). ³⁴⁶

The lack of a true functional system of maintenance for equipment and the need for improved coordination and communication mechanisms among health actors also pose barriers to a fully robust and consistently supported contact tracing system in public health emergencies, as noted in the National Health Development Plan 2015-2019 (p. 41). ³⁴⁷

2.5.1b Provision of wraparound services to enable self-isolation/quarantine as recommended

Score: 0

National documents offer limited direct information regarding comprehensive wraparound services, specifically economic support like paychecks or job security, to enable individuals and their contacts to self-isolate or quarantine during a public health emergency in Comoros.

The Public Health Code outlines general principles of health protection, including the state's responsibility to protect individuals, families, and communities against diseases and risks (p. 2, Article 3). This encompasses providing health services, combating diseases, and implementing plans to combat epidemics and disasters. In instances of contagious diseases, the Minister of Health can declare an 'state of health alert' in a locality or region, leading to mandatory hygiene and prophylaxis measures (p. 17, Article 79). However, while there are provisions to enforce quarantine and isolation, there is no explicit mention in the Public Health Code of the provision of wraparound services—such as financial or economic support, food delivery, or healthcare for those in isolation—to make compliance feasible. ³⁴⁸

Regarding medical attention during public health emergencies, the system is designed to provide care, though limitations exist. For example, during the Ebola crisis, the country developed a national prevention and response plan, as noted in the National Health Development Plan 2015-2019 (p. 17). It aims to ensure universal access to comprehensive, promotional, preventive, and curative health services, with a particular focus on vulnerable populations (p. 51). It also details actions to improve the quality of health services, including access to essential generic drugs and the development of community health services (p. 52). ³⁴⁹ However, the evidence does not explicitly state that these services are targeted or adapted to support individuals in quarantine or self-isolation. According to the 2018 Joint External Evaluation (JEE), the country also has limitations in emergency healthcare preparedness, including outdated operational procedures and insufficient pre-positioned emergency medical supplies (p. 32). While Comoros is working on emergency intervention systems, there is no specific evidence of targeted medical attention services for those isolating or quarantining. ³⁵⁰

On the economic support front, the documents highlight that the social protection system in Comoros is not very developed, covering only a small portion of the population (p. 12). Existing mechanisms primarily include a retirement fund, a social provident fund for occupational diseases, and military social schemes. Community health mutuals existed but covered only about 2.8% of the population in 2012 (p. 12). These mechanisms are not described as offering income replacement or job security during periods of self-isolation or quarantine. ³⁵¹

While there is a recognized need to reduce the burden of household health expenditures and explore innovative financing mechanisms like mandatory health insurance and solidarity funds, there is no explicit mention of mechanisms for income replacement, paycheck support, or job security for individuals during periods of self-isolation or quarantine. The PNDS 2015-2019 does propose "Establishment of care systems for the most disadvantaged" to ensure financial accessibility for vulnerable populations, including subsidizing or providing free care for specific groups and services (p. 53). However, this primarily pertains to healthcare costs rather than broader economic support for isolation. ³⁵²

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ³⁵³

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ³⁵⁴³⁵⁵

2.5.2a Strategy for tracing and quarantining international travelers

Score: 0

Comoros has legal frameworks and established mechanisms that suggest a cooperative intent between the public health system and border control authorities, but the national documents indicate that a fully integrated and consistently operational joint plan for identifying, tracing, and quarantining international travelers and their contacts in public health emergencies is still developing or facing challenges.

The Public Health Code explicitly states that the International Health Regulations (2005) will be applied to all aircraft, ships, and individuals in "international travel" (p. 31, Article 167). ³⁵⁶ This legal provision underscores the country's commitment to international health security at its borders. The Directorate General of Health is responsible for defining policies and strategies, and this includes coordinating interventions with other ministries and multisectoral partners, as noted in the National Community Health Strategy 2024-2028 (p. 59). ³⁵⁷

The Joint External Evaluation (JEE) report from 2018 highlights the existence of several intersectoral mechanisms. These include the National Multisectoral Committee for Preparedness and Response against Epidemics (CNMPRE) and a platform for all crises, including health issues (COSEP). There is also a coordination mechanism between relevant ministerial departments through the Airport Security Local Committee (COLSA) (p. 7). These committees and platforms involve various ministries, such as the Ministry of Agriculture, Fisheries, Environment, Land Use Planning and Urbanism (for control and food surveillance, and border inspection), the Ministry of Commerce (for import control), and the Ministry of Transport (for air and sea travel security) (p. 7). The "One Health" approach is also mentioned in the context of the Indian Ocean Commission's (COI) epidemiological surveillance and alert management network (SEGA), which aims to strengthen coordination in detecting and responding to public health events (p. 7). ³⁵⁸

However, the JEE report also identifies significant weaknesses and areas for improvement. While mechanisms for intersectoral collaboration exist, they "are only activated during times of crisis" (p. 1). A major challenge noted is the "insufficiency of multisectoral coordination in the implementation of the IHR (2005) and the lack of documentation and written procedures for a large number of activities" (p. 2). It is recommended to create a multisectoral, multidisciplinary, and multi-risk committee for responding to pandemics and major epidemics in line with the IHR, and to implement Standard Operating Procedures (PON) to facilitate coordination among sectors (p. 8). ³⁵⁹

Specifically concerning Points of Entry (PoE), the Comoros had not designated points of entry in accordance with the IHR as of 2017 (p. 44). While there are three airports (one international) and three ports, and an infirmary at the international airport, the PoE "do not have access to appropriate medical services in accordance with the IHR" (p. 44). There is a mechanism for checking vaccination cards for Comorian travelers at the international airport, and a functional team of phyto-sanitary agents at Moroni port, but no permanent phytosanitary control structure at the airport (p. 44). ³⁶⁰

2.6.1a Access to field epidemiology training program in country and/or abroad

Score: 100

Comoros demonstrably meets both criteria for applied epidemiology training. An applied epidemiology training program, specifically FETP-Frontline One Health, is available to its citizens, and resources are provided for their participation, largely through regional and international support.

Recent developments highlight a significant expansion of this capacity. As of May 10, 2024, 25 Comorian healthcare professionals received their FETP-Frontline One Health certification, marking the second cohort to complete this training. This short, 13-week intensive course combines theory and practice, with objectives including understanding and managing diseases in real-life environments, data collection and analysis, and effective communication for rapid action to prevent disease spread and protect public health. ³⁶¹ The program, offered as part of the Indian Ocean Commission's (IOC) SEGA – One Health Network, is supported by the French Development Agency and the European Union, indicating external resources facilitating this training; ³⁶²

Following this, a third cohort saw 22 healthcare professionals certified in October 2024, bringing the total number of certified field epidemiologists in Comoros to 65. This substantial increase from the 43 professionals certified before this third cohort, and the 18 from the first cohort, signifies a robust and ongoing in-country training effort. The practical impact of this training is evident, with 14 of these field epidemiologists mobilized in 2024 to combat a cholera epidemic, demonstrating their crucial role in real-time health crisis response. The training in Comoros is supported by the University of Comoros’ School of Medicine and Public Health, anchoring it institutionally within the country. ³⁶³

This current information significantly updates and expands upon the Joint External Evaluation (JEE) report from 2018, which previously noted the presence of four FETP-trained epidemiologists and the involvement in COI training (p. 24, p. 29). ³⁶⁴ The newer documents confirm a dramatic increase in the number of certified professionals and a consistent mechanism for training within the country, facilitated by regional networks. The training itself aims to equip each IOC Member State with human resources directly mobilizable during epidemics. ³⁶⁵

2.6.1b Existence of field epidemiology training for animal health professionals

Score: 100

The field epidemiology training programs available in Comoros, specifically the FETP-Frontline One Health program, are indeed explicitly inclusive of animal health professionals.

For instance, the first cohort of FETP-Frontline from 15 June 2023: "These 18 field epidemiologists are part of the first FETP-Frontline training cohort. These now certified learners specialize in human and animal health." This clearly indicates that the training program directly certifies individuals in both human and animal health, signifying the direct inclusion of animal health professionals or the integration of animal health specialization within the curriculum for participants. The FETP-Frontline training promotes a "One Health" approach, which is fundamentally based on the link between human, animal, and environmental health. ³⁶⁶

2.6.2a Evidence of at least 1 trained field epidemiologist per 200,000 people

Score: 100

There is public evidence that Comoros has more than 1 trained field epidemiologist per 200,000 people.

By 2024, 65 Comorians public health professionals successfully completed the Field Epidemiology Training Program (FETP) Frontline module, making them certified Field Epidemiologists. Given the current population of Comoros is 866,628 (2024), having 65 trained field epidemiologists significantly surpasses the requirement of at least 1 per 200,000 people. ³⁶⁷³⁶⁸

3.1.1a National emergency response plan for diseases with pandemic potential

Score: 33.33

Comoros possesses a national emergency response plan that addresses various types of disasters, including biological ones with epidemic potential. However, the public health component of this plan for effective preparedness and response to multiple communicable diseases, especially those with pandemic potential, has been identified as significantly underdeveloped and lacking a dedicated, up-to-date, multi-hazard operational framework.

Specifically, the National Emergency Preparedness and Response Plan, updated in November 2007, serves as a national emergency preparedness and response plan. This document explicitly covers various categories of emergencies, including "biological disasters," which are characterized by epidemics such as smallpox, malaria, yaws, cholera, avian flu, Rift Valley fever, chikungunya, dengue, and AIDS (p. 11). It outlines specific objectives for "Biological disasters," including managing cholera cases and stemming transmission, and contains a dedicated "Health and Nutrition" section with detailed objectives for epidemic response, such as preventing diseases with epidemic potential, ensuring vaccination, and providing mosquito nets (p. 27, p. 40). ³⁶⁹

Despite the existence of this national plan, the Joint External Evaluation (JEE) report highlighted critical deficiencies. While acknowledging that the country has a national contingency plan that includes the health sector and covers epidemiological risks, the JEE report states that "the public health emergency component remains underdeveloped" (p.1). It explicitly points out that "a multi-hazard national operational plan for public health emergencies should be developed" and that "a multisectoral multi-risk national plan for preparedness and response to major pandemics and epidemics does not exist" (p. 1, p. 7). The 2007 public health emergency plan is noted as outdated and lacking standardized operational procedures (p. 32). Consequently, a key recommendation from the JEE was to "Develop and implement a multi-risk and multisectoral national public health emergency preparedness and response plan" (p. 33). ³⁷⁰

Regarding funding for such a plan, explicit evidence of a dedicated and clearly outlined budget for the national public health emergency response plan is not consistently documented. The JEE report notes that "5% of the DGSC budget represents the emergency fund whose disbursement mechanisms are not known" (p. 32). This indicates a general emergency fund, but its direct allocation to, or operational mechanisms for, a specific public health emergency response plan for communicable diseases with epidemic potential are not detailed. Furthermore, the JEE recommends developing "a financing plan for the implementation of the RSI including a specific budgetary line" (p. 6). ³⁷¹

The 2024-2028 National Community Health Strategy also implicitly confirms this gap by noting that the COVID-19 pandemic exposed "all the shortcomings" in relation to risk communication, rapid risk assessment, and operational platforms for public health emergencies (p. 33). ³⁷²

The WHO Strategic Preparedness and Response Portal (SPH) notes that for a "NAPHS," the status for Comoros is "Conducted 2018". ³⁷³ While a workshop was indeed conducted, the document is not available. ³⁷⁴

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ³⁷⁵

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ³⁷⁶³⁷⁷

3.1.1b National public health emergency response plan published in past 3 years

Score: 0

While Comoros has a general national emergency plan, there is no explicit indication that an overarching national public health emergency response plan specifically designed to address planning for multiple communicable diseases with epidemic or pandemic potential has been comprehensively updated in the last three years.

The National Emergency Preparedness and Response Plan, initially updated in November 2007, serves as a broad national emergency preparedness and response framework. ³⁷⁸ However, the Joint External Evaluation (JEE) report from 2018 clearly highlighted that "The Union of the Comoros developed a national plan for preparing and responding to public health emergencies in 2007. Apart from the update, which has not been carried out, standard operating procedures are also lacking" (p. 32). The JEE further recommended that "A national multi-hazard operational plan for public health emergencies should be developed" (p. 2), indicating a recognized gap in a dedicated and updated overarching plan. ³⁷⁹

More recent documents from 2022 and 2024 continue to frame public health emergency preparedness as an ongoing area of development and improvement rather than confirming a recent update to an existing overarching plan. For instance, the National Community Health Strategy 2024-2028 notes that the COVID-19 pandemic "highlighted all the shortcomings" in health security, risk communication, and operational platforms, suggesting that a sufficiently robust overarching plan was not in place during that crisis (p. 33). This strategy looks forward to integrating health security aspects into community-level service delivery to "prevent avoidable disasters," "detect threats early," and "enable rapid and effective response" (p. 40), implying that these capabilities are still being developed. ³⁸⁰

Similarly, the National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 refers back to the 2018 JEE findings, confirming the (non-existence of capacities in AMR control, an integral part of public health emergencies (p. 3). ³⁸¹ The August 2024 "One Health workshop" also focused on developing a joint action plan and strengthening intersectoral coordination, with "Joint surveillance, field investigation and response" identified as a priority. ³⁸²

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ³⁸³

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ³⁸⁴³⁸⁵

3.1.1c One health principles by covering multiple threat types

Score: 0

While an overarching national emergency response plan dating from 2007 is in place, which generally addresses various disaster types including "biological disasters" (epidemics), it does not fully or explicitly integrate "One Health" principles across all listed threat types in a comprehensive, updated manner. ³⁸⁶

The 2018 Joint External Evaluation (JEE) identified significant gaps in this plan's public health component and its multisectoral, multi-risk approach. ³⁸⁷

The 2007 national emergency plan does not explicitly address antimicrobial resistance. ³⁸⁸ However, a dedicated National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 (PANM RAM) has been developed. This PANM RAM is explicitly rooted in "One Health" principles and involves a multisectoral governance structure with participation from health, agriculture, environment, and other relevant ministries. While it is a comprehensive plan for AMR, it operates as a distinct strategy rather than being an integrated component of the broader 2007 emergency response plan. ³⁸⁹

The 2007 plan includes "epidemics" under biological disasters, which would encompass zoonotic outbreaks. ³⁹⁰ The 2018 JEE noted the existence of intersectoral collaboration mechanisms for zoonoses, though these were primarily activated during crises. ³⁹¹ More recent initiatives, such as the FETP-Frontline One Health training and the SEGA – One Health Network of the Indian Ocean Commission, are specifically designed to strengthen capacity and coordination for zoonotic diseases within a "One Health" framework. ³⁹²³⁹³ This demonstrates a growing commitment to addressing zoonotic disease spillover through multisectoral collaboration, even if the 2007 overarching plan does not explicitly detail a "One Health" approach to these threats.

The 2007 plan refers to "biological disasters" and "epidemics" without specifically differentiating between natural outbreaks, accidental releases, or deliberate acts. ³⁹⁴ The 2018 JEE highlighted major deficiencies in national biosafety and biosecurity regulations and plans, noting the "lack of national biosafety and biosecurity legislation or regulations, a national biomedical waste management plan and a biosafety and biosecurity training program." ³⁹⁵

3.1.1d Vulnerable populations in national public health emergency response plan

Score: 100

The overarching national emergency plan in Comoros, particularly its public health components and more recent strategic documents, demonstrates a strong consideration for health equity and includes mechanisms for identifying and addressing the needs of vulnerable populations.

The "National Emergency Preparedness and Response Plan" from 2007, which serves as the broad emergency framework, explicitly incorporates principles of health equity by stating "non-discrimination" and prioritizing "vulnerable groups, specifically children and women, the elderly, the sick, and the disabled," as core guiding principles for emergency interventions (p. 17). This foundational document directly addresses the impact of health inequities by aiming to protect those disproportionately affected by crises. ³⁹⁶

Furthermore, within this plan, the "Protection and Education" sector outlines specific objectives and minimum standards to ensure vulnerable populations are identified and receive appropriate assistance. For instance, it sets out to "identify among the displaced population, groups needing special protection" and to "ensure the correct care of each identified vulnerable group by providing essential human and material resources" (p. 55). It also details minimum standards for the registration of births and deaths, identification and care for unaccompanied children, and psychosocial support for victims of violence, all of which are critical mechanisms for safeguarding vulnerable individuals during emergencies (p. 55). The plan includes a rapid multi-sectoral needs assessment form designed to collect critical data on affected populations, implicitly aiding in the identification of those most at risk (p. 73-79). ³⁹⁷

More recent strategic documents, such as the National Community Health Strategy 2024-2028, further strengthen this commitment by stating that the country's Constitution guarantees equity, gender equality, and the right to health (p. 10). This strategy aims to achieve Universal Health Coverage by ensuring equitable access to quality health services, with a specific focus on vulnerable populations including children under five, pregnant women, people with disabilities, and the elderly (p. 10). A strategic intervention within this plan is to "identify and map different vulnerable populations and respond to their needs," confirming a dedicated mechanism for systematically recognizing and addressing the specific requirements of these groups (p. 40). ³⁹⁸

3.1.2a Mechanism to engage private sector in outbreak preparedness/response

Score: 100

While an overarching general mechanism for all outbreaks might be absent or underdeveloped, a targeted mechanism for a specific type of public health emergency (AMR) involving the private sector, particularly pharmaceutical stakeholders, has been formalized.

The "National Emergency Preparedness and Response Plan" from 2007 mentions that logistics, such as transportation, can be "requisitioned by the state from public, private, and international institutions residing in Comoros" (p. 25). ³⁹⁹ However, this points to an ad-hoc mobilization rather than a pre-established, regular engagement mechanism. The "National Health Development Plan 2015-2019," identify the private sector as a component of the health system, but it also notes challenges such as its disorganized nature and lack of synergy with the public system, rather than outlining formal engagement protocols for emergencies (p. 30). ⁴⁰⁰

However, for the specific public health threat of Antimicrobial Resistance (AMR), a dedicated and formal mechanism for private sector engagement does exist. The "National Multisectoral Action Plan for Antimicrobial Resistance 2022-2026" establishes an Multi-sectoral Coordination Body (OCM). This OCM explicitly includes "the main representatives of the private sector on medicines" among its members (p. 8). This mechanism is designed to support the National Executive Secretariat for AMR in supervising and coordinating all activities related to AMR across various sectors, which includes preparedness and response specific to this threat. ⁴⁰¹

3.1.3a Policy/plan/guidelines in place to implement non-pharmaceutical interventions (NPIs)

Score: 0

While Comoros may not possess a single, overarching policy document solely dedicated to Non-Pharmaceutical Interventions (NPIs) during an epidemic or pandemic, the country's strategic frameworks do include provisions, guidelines, and foundational elements for implementing such measures.

The "National Emergency Preparedness and Response Plan" from 2007, while broad, highlights the importance of public information and hygiene during "biological disasters" which encompass epidemics (p. 11, p. 48). ⁴⁰²

The Joint External Evaluation (JEE) report from 2018 underscores the significance of risk communication, a critical NPI, noting the role of the Health Promotion Department (DPS) in disseminating information and mobilizing communities during epidemics, and recommends developing a national risk communication strategic plan (p. 40-41). The JEE also acknowledges the existence of specific disease response plans for cholera, Ebola, and influenza, although it points out a lack of standardized operational procedures for overall emergency response (p. 32, p. 35). ⁴⁰³

More recently, the National Health Development Plan 2015-2019 emphasizes "Strengthening prevention and health promotion interventions", including "Development of communication and awareness programs for behavior change" and "Strengthening control and regulatory mechanisms for hygiene and sanitation" (p. 54). ⁴⁰⁴ Similarly, the National Community Health Strategy 2024-2028 explicitly acknowledges that the COVID-19 pandemic exposed all shortcomings in health security, implying that NPIs were attempted but highlighting the need for better integration of health security aspects into community-level service delivery, including hygiene promotion and public awareness campaigns (p. 33, p. 32, p. 39-40). ⁴⁰⁵ Furthermore, the National Multisectoral Action Plan for Antimicrobial Resistance 2022-2026 contains a dedicated "Objective 3: Implement an Infection Prevention and Control program", which includes general hygiene measures and sanitation in human and animal health settings (p. 17). ⁴⁰⁶

3.2.1a Completion of biological-focused IHR exercise with the WHO in past year

Score: 100

The country has activated its national emergency response plan in response to a significant infectious disease outbreak within the past year. Specifically, the Union of the Comoros had been actively managing a cholera epidemic that commenced on February 2, 2024.

According to the WHO, in response to this outbreak, the national preparedness and response plan was promptly activated and implemented. This comprehensive plan covered several critical areas of public health intervention: prevention strategies, the organization of vaccination campaigns, robust risk communication efforts to inform and guide the public, and an enhanced surveillance system to monitor the spread and impact of the disease. The implementation of this national response received direct assistance from the World Health Organization (WHO), indicating a coordinated effort involving international partners. Key actions taken as part of this activated plan included strengthening local capacities to manage the outbreak, successfully conducting two distinct vaccination campaigns targeting vulnerable populations, and actively mobilizing additional resources necessary for an effective response. ⁴⁰⁷

3.2.1b Evidence of bio-focused exercise to identify gaps/best practices

Score: 0

There is no direct evidence that the country, in the past year, has identified a list of gaps and best practices in response through a qualifying mechanism (infectious disease response AAR or biological-threat focused exercise) and developed a plan to improve response capabilities.

Firstly, the National Community Health Strategy 2024-2028, published in March 2024, explicitly outlines an evaluation process of its predecessor, the 2018-2022 strategy. This evaluation involved an evaluation of the 2018-2022 strategy and a situational analysis of community health. This process led to the identification of strengths, weaknesses/shortcomings, threats, and opportunities, which constitute a clear list of identified gaps and areas for improvement in community health service delivery and coordination. For example, challenges like the inaccessibility of populations to health structures, insufficient coordination, and inadequate motivation mechanisms for community health workers were highlighted (p. 23-25, p. 39-43). However, this evaluation is a strategic review of a broad community health program, not a formal after-action review of a specific infectious disease response or a biological-threat focused exercise. ⁴⁰⁸

The 2024 Comoros country profile on the WHO website, detailing the WHO's contributions and results in Comoros, presents "LESSONS LEARNED" derived from recent health outcomes and responses, including the ongoing cholera epidemic (which began in February 2024). For instance, concerning the cholera epidemic response, it identifies areas for improvement such as "Strengthening regional coordination, investing in human resources, and ensuring continuity of services are important for effective epidemic response" and "Improving the representation of the environment and water sectors in coordination frameworks and raising public awareness are key to strengthening epidemic response and overcoming vaccine resistance." While this information pertains to an infectious disease response within the past year, these "LESSONS LEARNED" in a country profile do not constitute a formal after-action review (AAR) conducted by the country. ⁴⁰⁹

Finally, the National Multisectoral Action Plan for Antimicrobial Resistance 2022-2026, validated in July 2022, was developed following a Situational analysis of the fight against AMR. This analysis, conducted in April-May 2022, explicitly identified strengths, weaknesses, opportunities, and threats, which are essentially a list of gaps in AMR response. The entire plan, with its operational plan for 2023, was then structured to address these identified gaps and improve AMR response capabilities (p. 3, p. XXII). However, a situational analysis for a broader programmatic area like AMR, even if it includes some aspects of response, does not fit the criteria of an after-action review of a specific infectious disease response or a biological-threat focused exercise. ⁴¹⁰

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴¹¹

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴¹²⁴¹³

3.2.2a Evidence of national-level biological threat-focused exercise that includes private sector

Score: 0

There is no explicit evidence that the country has undergone a national-level biological threat-focused exercise that included private sector representatives within the past year.

While the country profile on the WHO website highlights various initiatives and achievements in public health, such as strengthening immunization, enhancing maternal and child health, and responding to the cholera epidemic (which began in February 2024), it does not mention any specific national-level exercises focused on biological threats that involved the private sector. It primarily reports on real-world responses and program implementations, as well as lessons learned from these activities, rather than planned or completed simulation exercises. For instance, the section "Responding strategically to the cholera epidemic in the Comoros" describes the rollout of the national preparedness and response plan for a real outbreak and the lessons learned from it, but not a simulated exercise. ⁴¹⁴

The National Multisectoral Action Plan for Antimicrobial Resistance 2022-2026 does establish a formal structure, the Multi-sectoral Coordination Body (OCM), which includes private sector representatives (p. 8). This indicates a mechanism for private sector engagement in AMR planning and response. However, the action plan outlines workshops for launch and implementation, but does not specifically detail a national-level biological threat exercise with private sector participation already conducted or planned. ⁴¹⁵

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴¹⁶

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴¹⁷⁴¹⁸

3.3.1a Existence of Emergency Operations Center (EOC)

Score: 0

The country does have an Emergency Operations Center (EOC) for general disaster management. However, for public health emergencies specifically, the dedicated center is currently non-operational.

The National Emergency Preparedness and Response Plan from 2007 and the Joint External Evaluation report from 2018 both confirm the existence of the Center for Rescue Operations and Civil Protection (COSEP). ⁴¹⁹⁴²⁰ COSEP functions as a national crisis management body under the Directorate-General of Civil Security (DGSC). Its responsibilities include monitoring, early warning, information centralization and analysis, prevention, resource management, and operational coordination for all state and non-state actors in disaster management (p. 12). ⁴²¹ The 2018 JEE notes that COSEP "disposes of a 24/7 monitoring and early warning unit that collects, processes, and analyzes information related to prevention and management of risks and disasters" and also has a "multisectoral operations room" (p. 1, p. 34). This structure serves as a general EOC for all hazards. ⁴²²

However, concerning a dedicated Public Health Emergency Operations Center (PHEOC), the situation is different. The 2018 Joint External Evaluation explicitly stated, "The country does not have a public health emergency operations center" and recommended, "Establish a Public Health Emergency Operations Center, with clearly defined missions and responsibilities" (p. 34). ⁴²³ More recently, in the context of the cholera epidemic managed since February 2024, the country profile for Comoros on the WHO website, under "Responding strategically to the cholera epidemic in the Comoros," highlights that "challenges such as the non-operational Public Health Emergency Operations Centre and weak regional coordination persist". ⁴²⁴

3.3.1b Requirement for EOC to conduct/evidence EOC conducts at least annual drills

Score: 0

While there is a general requirement for annual simulation exercises for the national contingency plan, there is no explicit evidence that the Emergency Operations Center (EOC) is required to conduct a drill for a public health emergency scenario at least once per year, nor is there evidence that they conducted such a drill in the past year.

The National Emergency Preparedness and Response Plan from 2007 and the 2018 Joint External Evaluation (JEE) report mention the existence of the Center for Rescue Operations and Civil Protection (COSEP), which functions as a general EOC for all-hazard disaster management under the Directorate-General of Civil Security (DGSC). The JEE states that the national contingency plan "annually provides for a simulation exercise," and the 2018 JEE confirms that "Simulation exercises are organized each year on emergency and disaster themes by DGSC" (p. 32, p. 34). These are general disaster exercises, which have, at times, included public health aspects, such as testing the IHR National Focal Point's notification system (p. 27). ⁴²⁵⁴²⁶

However, the 2018 JEE also critically identified a gap in dedicated public health emergency preparedness, stating that "the public health emergency aspect remains underdeveloped" (p. 2). It specifically recommended, "Establish a Public Health Emergency Operations Center… Organize simulation exercises by the health sector, involving other sectors to test the procedures and functions of the PHEOC" (p. 35). ⁴²⁷

More recently, the country profile for Comoros on the WHO website explicitly states that the dedicated Public Health Emergency Operations Centre (PHEOC) is still "non-operational". While the country has been responding to a real cholera epidemic since February 2024, this is a live response, not a simulated drill or exercise. ⁴²⁸

3.3.1c EOC activation within 120 minutes of identification of emergency/scenario

Score: 0

There is no public evidence to confirm that the Emergency Operations Center (EOC) in Comoros has, within the last year, conducted either a coordinated emergency response or an emergency response exercise activated within 120 minutes of the identification of a public health emergency or scenario.

The country has a general EOC, the Center for Rescue Operations and Civil Protection (COSEP), which is responsible for coordinating responses to various hazards. However, the dedicated Public Health Emergency Operations Centre (PHEOC) is noted as "non-operational" as of early 2024, as highlighted in the country profile on the WHO website: "challenges such as the non-operational Public Health Emergency Operations Centre and weak regional coordination persist". ⁴²⁹

The 2018 Joint External Evaluation (JEE) report sets a target for the capacity to activate emergency interventions, stating that personnel within the emergency operations center should be "able to activate a coordinated emergency intervention within 120 minutes of the identification of a public health emergency situation" (p. 34). However, the score for this indicator was 1, indicating "inexistent capacity" at that time (p. 3). There is no updated evidence to suggest this specific capacity has been achieved and demonstrated through a drill or response in the last year. ⁴³⁰

Comoros had been managing a real cholera epidemic since February 2, 2024, and a national preparedness and response plan was rolled out. This constitutes a "coordinated emergency response." However, while the plan was "rolled out," the evidence does not specify the timeframe of its activation relative to the identification of the emergency. ⁴³¹

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴³²

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴³³⁴³⁴

3.4.1a Joint exercise/procedures for potential deliberate biological events

Score: 0

There is no public evidence to indicate that the country meets either of the specified criteria regarding a potential deliberate biological event (bioterrorism attack).

The 2018 Joint External Evaluation (JEE) report, in the section "Link between public health and security authorities", notes that the country's penal and health codes contain provisions for managing biological events. It also mentions the involvement of security authorities (such as the Directorate-General of Civil Security, national police, and gendarmerie) in public order and protection during emergencies. Comoros's membership in Interpol provides a mechanism for requesting or offering assistance. However, the report explicitly identifies a lack of coordination between public health and security authorities in this area and, crucially, states a need to "Develop SOPs for the management of biological events, and validate them through periodic simulation exercises" (p. 37). ⁴³⁵

While the National Multisectoral Action Plan for Antimicrobial Resistance 2022-2026 establishes a Multisectoral Coordination Body (OCM) that includes "the main representatives of the private sector on medicines" (p. 8), this plan focuses on antimicrobial resistance in general and does not specifically address deliberate biological events (bioterrorism attacks) or outline MOUs/SOPs for inter-agency response to such attacks involving all the requested sectors. ⁴³⁶

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴³⁷

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴³⁸⁴³⁹

3.5.1a Risk communication plan for specific use during a public health emergency

Score: 100

The Union of Comoros has mechanisms and sections within its national emergency and health strategy documents that address communication and information dissemination during various crises, including public health events. However, the comprehensive nature of these provisions in terms of a dedicated "risk communication plan" for public health emergencies, as defined by international standards, has been a subject of identified gaps.

The National Plan for Emergency Preparedness and Response, dated November 2007, includes a section titled "Infomration/Early Warning" (p. 60). This section details activities intended to inform and sensitize the population before, during, and after an emergency. It specifically addresses the "Dissemination of early warning systems—cyclones, volcanic eruptions, epidemic crises—to all plan stakeholders and to the population" (p. 61). The plan outlines a "Schema for Transmission of Information to Competent Authorities" and defines four alert levels: Yellow, Orange, Red, and Alert Lifted, each with corresponding actions for information dissemination and engagement (p. 62-63). It emphasizes managing information to "avoid temporary panic among the population and its 'they said' so that we can be reassured by reliable information" (p. 61). This clearly indicates a framework for alerting and informing the public during epidemics, which constitutes a form of emergency communication. ⁴⁴⁰

The National Strategy for Disaster Risk Reduction 2024-2030 (SNRRC) further outlines a strategic commitment to communication and early warning systems within the broader disaster risk reduction framework, which explicitly includes biological/health risks. Strategic Axis 1 focuses on the "Development of knowledge, information, education, and communication systems on disaster risk prevention and management," with a specific action to "Develop awareness-raising and communication procedures on DRR" (p. 13). More crucially for emergency response, Strategic Axis 10 aims to "Strengthen institutional capacities on data collection and information management for early warning systems facilitating decision-making," including an action to "Develop a communication and coordination network for an effective EWS" (EWS = Early Warning System) (p. 17). The SNRRC also establishes a Technical Committee 4: Disaster Preparedness for Effective Response, whose mission includes to "Develop and maintain an early warning system" and "Ensure disaster preparedness, including contingency plans for emergencies… and communication procedures at the island and local levels" (p. 22). These provisions indicate a strategic intent to develop comprehensive risk communication infrastructure and procedures for all types of disasters, including public health emergencies, within the disaster management system. ⁴⁴¹

Despite these provisions, the "Joint External Evaluation of IHR Core Capacities of the Union of Comoros," conducted in August 2017, explicitly identified a deficiency. Under the "Risk Communication" section, the evaluation states the "Lack of a national risk communication plan" (p. 41) as a key challenge to be strengthened. It further recommends the "Develop and implement a national strategic risk communication plan, taking into account existing sectoral plans" (p. 40). This evaluation highlights that while the Directorate of Health Promotion (DPS) "ensures information, awareness and social mobilization of the community in the event of epidemics and/or natural disasters" (p.40) and various sectoral communication plans exist, a comprehensive national strategic risk communication plan was lacking in 2017. ⁴⁴²

More recently, the National Community Health Strategy 2024-2028, published in March 2024, references "CREC focal point (Communication Risk and Community Engagement)" roles at the peripheral level (p.26) and lists "Awareness by the CREC and the SBC" under promotional services (p.32). The acronym CREC translates to "Risk Communication and Community Engagement," indicating a conceptual understanding and integration of risk communication within community health activities. Strategic axis 6, “Community Engagement,” aims to “Promote accountability and social responsibility at the community level,” which involves strengthening collaboration with civil society actors and media (p.43). However, this strategy document does not itself detail an overarching, dedicated risk communication plan specifically intended for use during all public health emergencies, but rather focuses on community health promotion and engagement. ⁴⁴³

3.5.1b Inclusion of different population & sector needs in risk communication plan

Score: 100

The national public health response documents in the Union of Comoros comprehensively outline how messages are tailored and disseminated to reach diverse populations and sectors, acknowledging varying communication needs across different languages, geographical locations, media access, and the specific requirements of vulnerable and hard-to-reach groups.

The National Community Health Strategy 2024-2028 (SNSC), for instance, places a strong emphasis on localized engagement by leveraging "Community Relay" such as "Father Leader/Mother Leader, Influential Women, Influential Young People, Village Health Committees" (p. 15, 27, 56), who deliver messages through "home visits" and "door-to-door awareness raising" (p. 56), thus ensuring cultural and linguistic appropriateness at the community level, especially since Community Health Workers (ASC) are chosen from their respective localities and are expected to read and write in “Comorien ou Français” (p. 44). This strategy actively prioritizes vulnerable groups such as "children under five, pregnant women, people with disabilities, and the elderly" (pp. 10, 38), with specific interventions to "strengthen quality community health services for all, with a particular focus on vulnerable populations" (p. 39). To overcome geographical barriers, the SNSC acknowledges "difficult access areas" (p. 35) and outlines an approach to "strengthen community health for special populations" by developing a "specific approach" for such populations (p. 40). This document also advocates for diverse media engagement, utilizing "journalists" and "young reporters" for health-related spots, street interviews, and interviews (p. 57), alongside "local radio" for community-based sensitization (p. 34). ⁴⁴⁴

Similarly, the National Disaster Risk Reduction Strategy in the Comoros 2024-2030 explicitly calls for an "inclusive" communication strategy that is "gender-sensitive" (p. 13), underscoring the intent to address diverse communication needs across all levels—from decision-makers to hard-to-reach communities—and emphasizing a "(continuous) communication and community engagement program for better ownership of preparedness plans" (p. 16). It further specifies preparing "adequate tools for awareness-raising and communication with decision-makers, institutions, prefectures, town halls, and communities" (p. 25), indicating tailored messaging for different target groups and administrative tiers, while also aiming to strengthen multi-risk early warning systems to be "operational and accessible to communities" (p. 16). ⁴⁴⁵

The National Contingency Plan 2017-2018 details multi-level alert systems to ensure messages reach "the national level, the islands and the regions/districts/communes" (p. 15), through "Social Communication Bodies, communiqués, bulletins, conferences and other available means" (p. 13), with an explicit mandate for "radio and television stations" to "broadcast, in real time, warnings and self-protection measures for the population" during pre-emergency and emergency phases (p. 13). ⁴⁴⁶ Furthermore, the National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 articulates the need for a national communication plan that specifically targets "different targets (community, professionals, decision-makers, etc.)" (p. XIII), demonstrating a clear understanding that communication strategies must be differentiated and adapted to the specific needs and contexts of various population segments and stakeholders. ⁴⁴⁷

3.5.1c Designation of a specific government spokesperson during a public health emergency

Score: 100

During a public health emergency, a primary spokesperson is designated within the government to communicate with the public, though this role is typically assigned at the time of activation rather than being a specific, standing position.

The National Emergency Preparedness and Response Plan (PNPU) from November 2007 is the most explicit on this matter. It states that upon the activation of the emergency response plan, the Minister of Defense, who acts as the principal coordinator, will proceed "from the first PC meeting to the designation of an operations coordinator, a sector coordinator and a spokesperson" (p. 18). This clearly outlines a process where a spokesperson ("spokesperson") is appointed by a high-ranking official at the onset of a crisis. This same document also describes an "Information and Public Relations Unit" whose mission is to "inform the public and the media according to the directives of the Operations Directorate" and includes representatives from the Ministry of Information and other relevant ministries (p. 19), which would be the team supporting the designated spokesperson. ⁴⁴⁸

Similarly, the National Contingency Plan 2017-2018 (PCN) indicates that the Director General of Civil Security (DGSC) holds significant responsibility for public communication during emergencies. Under the section "Information Management and Early Warning Systems," it states that the "DGSC will be responsible for the following tasks… Designate the person(s) authorized to speak to national and international media" (p. 13). Furthermore, the "Rapid Response Matrix" for press conferences specifies the "Lead: DG/DGSC" for "Holding a first press conference" (p. 17). This confirms that the DGSC (or a person delegated by them) is the central authority for managing public communication and leading press engagements during a crisis, aligning with the concept of a primary spokesperson, even if it's a role assumed for the duration of the emergency rather than a permanent title. ⁴⁴⁹

While other documents, such as the National Strategy for Disaster Risk Reduction in the Comoros 2024-2030 (SNRRC) and the National Community Health Strategy 2024-2028 (SNSC), detail mechanisms for broad communication, community engagement, and media involvement, they focus more on the overall communication strategy and channels rather than the specific designation of a singular primary government during an acute public health emergency. ⁴⁵⁰⁴⁵¹

3.5.2a Government use of media platforms to share info on public health emergencies

Score: 0

There is indirect evidence of the public health system's engagement in information dissemination and countering misinformation, often through traditional media and community channels; however, there is no direct evidence that confirms the active use of the public health system's own official online media platforms (such as dedicated social media accounts or a government health website) for these purposes in the past year.

Efforts to inform the public about health concerns and address misinformation are evident. The news "Mpox: Health actors made aware", dated September 5, 2024, describes a meeting where health actors were sensitized to Mpox and tasked with "relaying information in their localities but also avoiding misinformation and reassuring the population" (p.2). This clearly indicates an active measure by the public health system to inform the population about an ongoing public health concern (Mpox) and to prevent disinformation. ⁴⁵² Similarly, the country profile on the WHO website highlights that in response to the cholera epidemic since February 2, 2024, a national preparedness and response plan that included "risk communication" was rolled out, and these measures "have significantly reduced cholera cases". ⁴⁵³

Furthermore, the National Community Health Strategy 2024-2028, published in March 2024, emphasizes community engagement and risk communication, noting the role of "Point focal CREC" (Risk Communication and Community Engagement) (p.26) and "Awareness raising by CREC" (p.32) in health promotion, which inherently involves informing the public and potentially correcting misconceptions. ⁴⁵⁴ The "Professionals trained in risk communication" news, while dated December 7, 2021, quotes the Minister of Health acknowledging that the Union of the Comoros "has not escaped disinformation and fake news, which sometimes undermine our response policy" (p.2), indicating a recognized need to counter such issues. The document also mentions the intention to strengthen capacities for "crisis communication and risk communication" among various professionals, including journalists. ⁴⁵⁵

The 2018 Joint External Evaluation specifically identified the "Absence of website to communicate on health issues" (p.42) as a challenge. While information about the public health system's activities (such as the Mpox sensitization) is reported by online news outlets, these are reports about the system's actions rather than the system's direct use of its own official online platforms. ⁴⁵⁶

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴⁵⁷

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴⁵⁸⁴⁵⁹

3.5.2b Evidence that senior leaders have shared mis/disinformation on infectious diseases

Score: 100

There is no evidence to suggest that senior leaders, such as the President or ministers, have shared misinformation or disinformation on infectious diseases in the past two years. Instead, the available information indicates that these leaders and health officials have emphasized the importance of accurate information and vigilance regarding public health concerns.

For instance, in the news "Mpox: Health actors made aware," dated September 5, 2024, the Minister of Health, Dr. Nassuha Oussene Salim, clearly states the need to take the threat of Mpox seriously and highlights the government's preparedness with diagnostic kits and treatment. He stresses the importance of informing the population about prevention techniques. Similarly, the Director General of Health, Dr. Saindou Ben Ali Mbae, alerts the public to the ongoing vigilance required, despite no cases being identified in the country. ⁴⁶⁰

Furthermore, the document "Professionals trained in risk communication," from December 7, 2021, quotes the Minister of Health (unnamed in this specific instance) acknowledging that the Union of the Comoros has encountered "disinformation and fake news, which sometimes undermine our response policy". ⁴⁶¹

The country profile on the WHO website, which covers progress up to 2024, mentions the Comoros' strategic response to a cholera epidemic since February 2024, including "risk communication" efforts that contributed to a significant reduction in cases. ⁴⁶²

The National Community Health Strategy 2024-2028," published in March 2024, and the "National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026" are policy and strategic documents that reflect governmental priorities and plans in public health. While they mention the involvement of ministers in their forewords, they do not contain any public statements from senior leaders that could be categorized as misinformation or disinformation on infectious diseases. ⁴⁶³⁴⁶⁴

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴⁶⁵

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴⁶⁶⁴⁶⁷

3.6.1a Percentage of households with Internet

Score: 45.92

3.6.2a Mobile-cellular telephone subscriptions per 100 inhabitants

Score: 59.41

3.6.3a Gender gap in access to a mobile phone (percentage points)

Score: 63.33

3.6.4a Gender gap in access to the Internet (percentage points)

Score: 0

3.7.1a Restrictions on export/import of medical goods due to an infectious disease outbreak

Score: 100

There is no publicly available evidence indicating that Comoros has implemented restrictions on the export or import of medical goods (such as medicines, oxygen, medical supplies, or PPE) due to an infectious disease outbreak.

Reviews of national news outlets within the last year do not show a change in this stance or the implementation of new trade restrictions on medical goods. ⁴⁶⁸⁴⁶⁹

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴⁷⁰

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴⁷¹⁴⁷²

3.7.1b Restrictions on movement and/or exports/imports due to disease outbreak

Score: 100

There is no publicly available evidence indicating that Comoros has implemented restrictions on the export or import of non-medical goods (e.g., food, textiles) due to an infectious disease outbreak.

Subsequent checks of national news within the last year do not show indication of such restrictions being implemented. ⁴⁷³⁴⁷⁴

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴⁷⁵

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴⁷⁶⁴⁷⁷

3.7.2a Evidence of travel ban due to an infectious disease outbreak

Score: 100

There is no publicly available evidence indicating that Comoros has implemented widespread inbound or outbound travel restrictions due to an infectious disease outbreak within the past year.

Reviews of national news outlets within the last year do not show international travel bans linked to infectious diseases. ⁴⁷⁸⁴⁷⁹

While the "Mpox: Health actors made aware" news, dated September 5, 2024, mentions "health agents at our borders for health control", this indicates health checks rather than outright travel restrictions. Similarly, the country profile on the WHO website notes the presence of a cholera epidemic since February 2024, but no associated travel restrictions are described. ⁴⁸⁰⁴⁸¹

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁴⁸²

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁴⁸³⁴⁸⁴

3.7.2b Risk-based approach to international travel-related measures

Score: 100

There is evidence that the country employs a risk-based approach to international travel-related measures, especially during infectious disease outbreaks. While the specific phrase "risk-based approach" may not be explicitly used, the actions and stated intentions of the health authorities demonstrate this methodology.

The implementation of "health control" at borders by health agents in response to the Mpox concern, as mentioned in the "Mpox: Health stakeholders made aware" news (September 5, 2024), illustrates a reactive measure to a perceived external risk. The fact that these measures were put in place due to Mpox cases in other countries like the Democratic Republic of Congo and Kenya suggests an assessment of the risk of disease importation. ⁴⁸⁵

Furthermore, the "Joint External Evaluation of the IHR Core Capacities of the Union of the Comoros" from 2018 highlights the "Existence of health personnel at points of entry" and a "surveillance system to detect suspected cases at points of entry" (p. 28). ⁴⁸⁶

The "National Emergency Preparedness and Response Plan" (November 2007) also outlines a framework for "cross-border movement control" (p. 32) in response to health disasters such as epidemics. ⁴⁸⁷

Additionally, historical responses to major outbreaks further support this. During the onset of the COVID-19 pandemic, the country implemented stringent travel restrictions, suspending all flights and maritime links. This decision, as reported by Comoros Infos in April 2020, was made "in agreement with the decisions of the Council of Ministers and the opinions of scientific experts who accompany this pandemic". The reliance on "opinions of scientific experts" to inform such significant travel interventions demonstrates a decision mechanism involving scientific evidence and expert input. ⁴⁸⁸

4.1.1a Doctors per 100,000 people

Score: 5.88

4.1.1b Nurses and midwives per 100,000 people

Score: 20.39

4.1.1c Updated health workforce strategy to address human resource shortfalls

Score: 100

The country does have a health workforce strategy in place, and there is evidence of updates and continued focus on identifying and addressing workforce shortcomings within the past five years.

The National Health Development Plan 2015-2019 (PNDS), although its timeframe ended in 2019, comprehensively addressed health workforce issues. Under strategic orientation 3-1, "Development of Human Resources for Health," it explicitly identified problems such as "quantitative and qualitative insufficiency of the health workforce," "concentration of staff in urban areas," and "inadequate staff distribution" (pp. 49, 39). To address these, it outlined actions including: "Develop and implement a policy and management plan for human resources for health" (p. 61); "Redefine health professions training curricula… to the needs of the health system" (p. 62); and "Implement a human resources motivation policy" (p. 62). ⁴⁸⁹

More recently, the National Community Health Strategy 2024-2028, published in March 2024, effectively serves as an updated and specialized health workforce strategy for community health workers, falling well within the "past five years" criterion. This document dedicates "Objective 7: Have an equipped, competent, committed, motivated, equitably distributed, and well-paid community health workforce" (p. 43). It clearly identifies workforce insufficiency, noting that the "ratio of health personnel per 1,000 inhabitants in 2021 is 2.02 for doctors, 0.85 for nurses, and 0.73 for midwives," which is "relatively unsatisfactory by SADC standards" (pp. 17-18). It also points out shortcomings such as "Insufficient and poorly distributed number of CHWs" and "Lack of a common strategy for financially motivating Community Health Workers" (p. 34). ⁴⁹⁰

To address these shortcomings, the 2024-2028 strategy includes specific strategies: Strategy 7.1: "Improve comprehensive community health planning and programming," with interventions to "Organize CHW management by integrating it into the national human resources system" and "Ensure equitable distribution of CHWs" (p. 43); Strategy 7.2: "Ensure standardization of training and certification," by "Update integrated training modules for CHWs and trainers" (p. 43); Strategy 7.3: "Develop a CHW retention mechanism" (p. 43); Strategy 7.4: "Ensure CHW motivation" by establishing mechanisms for recognition and remuneration, and ensuring free healthcare for CHWs (p. 43). ⁴⁹¹

4.1.1d Health system capacity for essential health services

Score: 0

There is insufficient capacity within the Comorian health system to comprehensively deliver essential health services. Multiple documents highlight significant gaps across various pillars of the health system.

The Joint External Evaluation (JEE) gives the country a score of 1 – the lowest score possible – on this measure owing to the need to establish a plan defining criteria and standards for the deployment of healthcare personnel; strengthen regional/international agreements for personnel deployment; ensure the safety and financial resources of medical personnel during international deployments; and integrate security and animal health authorities into the plan for sending and receiving personnel during emergencies.⁴⁹²

The ratio of health personnel per 1,000 inhabitants is notably low. For instance, in 2021, the ratio was 2.02 for doctors, 0.85 for nurses, and 0.73 for midwives. This is deemed "relatively unsatisfactory" compared to the SADC (Southern African Development Community) norm of 4.45 health professionals per 1,000 inhabitants by 2030, indicating a clear deficit, as noted in the National Community Health Strategy 2024-2028 (p.17). ⁴⁹³

The utilization rate of health services is generally low and fluctuates, suggesting barriers to access or quality concerns. Between 2018 and 2020, the consultation rate per inhabitant per year was around 21.63 to 26.7, and critically, "the referral and counter-referral system is not functional" (p.18). Geographical accessibility remains a significant issue, with a national average of 37% of the population lacking access to health services within a 5 km radius (p.18). ⁴⁹⁴ The "Universal Health Coverage – Stacked indicator contributions" chart in the country profile on the WHO website even shows a negative net contribution for UHC in 2023 and 2024, indicating a decline in progress towards universal coverage. ⁴⁹⁵

There is an "insufficiency in the development of community health-related infrastructures and equipment" (p.41). ⁴⁹⁶ Furthermore, the WHO's "Output Prioritization" table shows very low utilization against planned costs for critical areas like "Service delivery" (1.63%) and "Health information systems" (0.49%), indicating that planned improvements are not being adequately implemented. ⁴⁹⁷

The government's financial contribution to health is explicitly stated as "insufficient" (p.29). As a result, households bear a disproportionately high burden, with "household health expenditures (47.57%) remaining higher than all other expenditures" (p.19). This high out-of-pocket spending creates financial barriers to accessing essential services. ⁴⁹⁸

Despite some progress in specific areas (e.g., neonatal mortality reduction, leprosy elimination efforts), the system faces persistent challenges such as the "mobility of trained personnel," "absence of maternal death audits," "inadequate ongoing staff training," "Internet access issues," "lack of financial resources to reach all affected areas," and a "non-operational Public Health Emergency Operations Centre". ⁴⁹⁹ The country continues to grapple with a high burden of maternal and infant mortality, high rates of chronic malnutrition (30% of children under 5), and persistent transmissible and non-communicable diseases (p.20-21), all of which suggest that essential services are not fully meeting the population's needs. ⁵⁰⁰

4.1.1e Essential health services continuity plan for public health emergencies

Score: 100

National plans and measures are in place in the Union of Comoros that aim to ensure the continuity of essential health services during public health emergencies, primarily through frameworks for preparedness, contingency updates, and emergency response. While a standalone, explicitly detailed "continuity of essential services" plan might not be articulated as such, existing strategic documents integrate mechanisms designed to maintain health service provision during crises.

The National Health Development Plan 2015-2019 (NHDP) addresses emergency situations under its strategic orientation "Strengthening Prevention and Health Promotion Interventions." One of its specific actions is to "Prepare the health sector to provide health services in response to emergencies and disasters" (p. 55). This includes actions such as "Annually update the health sector contingency plan" and "Prepare all inputs for DRM" (p. 55). These directives indicate a proactive approach to maintaining functionality. A health sector contingency plan, by its very nature, is intended to outline how critical health services will continue to operate under adverse conditions, thereby directly contributing to the continuity of essential services during emergencies. ⁵⁰¹

The 2018 Joint External Evaluation (JEE) also highlighted that "The Union of the Comoros has developed a national disaster risk management plan, but the public health emergency component remains underdeveloped" (p. 2). It recommended developing "a national multi-risk, multi-sectoral public health emergency preparedness and response plan" (p. 33). While the JEE also highlighted challenges such as the "lack of pre-positioned emergency medical supplies" (p. 32), these are recognized gaps within an established system geared towards preparing for and responding to emergencies, with the inherent goal of ensuring health services continue. ⁵⁰²

The more recent National Community Health Strategy 2024-2028 mentions that "The provision of services at the community level must integrate, in the basic package of CAs, aspects related to health security to prevent avoidable disasters at the community level, detect threats early and enable rapid and effective response at the community level" (p. 40). This community-level focus on health security, early detection, and rapid response is integral to ensuring that essential services are sustained or rapidly restored at the local level during emergencies, thereby contributing to overall system continuity. ⁵⁰³ Therefore, through these interconnected planning and response efforts, Comoros demonstrates a commitment to ensuring the ongoing provision of essential health services during public health emergencies, albeit with acknowledged areas for further development and explicit detailing.

4.1.2a Hospital beds per 100,000 people

Score: 55.9

4.1.2b In-country capacity to isolate patients with highly communicable diseases

Score: 0

Comoros possesses some fundamental infrastructure for isolating patients with communicable diseases, specifically noting the presence of isolation units in regional hospitals as an asset in the context of preventing and controlling healthcare-associated infections However, available documents reveals significant limitations and challenges that affect the country's full capacity to effectively isolate patients with highly communicable diseases, particularly in specialized biocontainment patient care units.

The Joint External Evaluation report explicitly states that, despite considerable efforts, "major challenges remain to strengthen the capacities required for prevention, detection, and response to public health events" (p.2). A crucial area for improvement is the readiness to respond to health emergencies. The report indicates that the country needs to "put in place appropriate resources in terms of transport, isolation rooms, and treatment centers to manage emergency situations envisioned by the IHR" (p.35). ⁵⁰⁴nFurthermore, the report scores the country's "capacity to activate emergency interventions as a 1, indicating non-existent capacity (p.4), which strongly implies a lack of operational readiness for comprehensive emergency responses that would include high-level patient isolation. The national multi-hazard public health emergency plan developed in 2007 is noted as needing updating, and "standardized operational procedures are also lacking" (p.32). These procedural gaps would inevitably impact the effective functioning of any existing or planned isolation facilities. ⁵⁰⁵ In terms of human resources, there is a recognized need to "Strengthen the capacities of personnel on the management of potentially infectious patients" (p.35), which is critical for operating biocontainment units. ⁵⁰⁶

The broader National Health Development Plan 2015-2019 points out deficiencies in equipment, stating "Equipment is insufficient, poorly maintained due to a lack of a maintenance system and qualified personnel" (p.41). Such general weaknesses would likely extend to specialized isolation facilities, hindering their effectiveness. ⁵⁰⁷

The National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 also identifies "insufficient qualified human resources, material, and financial resources" as a risk for strengthening prevention and control of infections (p.XVII). This reinforces the challenge in adequately staffing and equipping specialized isolation units. ⁵⁰⁸

4.1.2c Demonstrated capacity / evidence of plan to expand isolation capacity

Score: 0

While the country has been actively responding to an outbreak and implementing a preparedness plan, there is no specific evidence of a demonstrated expansion of isolation capacity.

While the country profile on the WHO website confirms that Comoros has been managing a cholera epidemic since February 2024, and that "key actions include strengthening local capacities, conducting two vaccination campaigns, and mobilizing additional resources," it does not provide specific details on the expansion of isolation facilities or beds. The statement "strengthening local capacities" is broad and could refer to various aspects of the response, not necessarily the physical expansion of isolation units. It also notes challenges such as a "non-operational Public Health Emergency Operations Centre". ⁵⁰⁹

In September 2025, the Comoros organized a table-top simulation exercise to test its new institutional arrangements and coordination mechanisms for disaster risk reduction. This simulation specifically included a scenario involving a cholera outbreak, alongside a tropical cyclone and volcanic turbulence. The exercise was designed to evaluate "operational capacities" and anticipatory actions outlined in the National Disaster Risk Reduction Law and the National DRR Strategy and Action Plan (2024-2030). While the documents do not explicitly detail the outcomes related to isolation capacity expansion during this test, the inclusion of a cholera outbreak scenario and the testing of "operational capacities" is mentioned. ⁵¹⁰

4.2.1a National procurement protocol for the acquisition of routine laboratory/medical supplies

Score: 0

The Union of Comoros has established a procurement system for essential medicines and vaccines, primarily through the Central Purchasing Office for Essential Medicines of the Union of Comoros (CAMUC), which was formed in 2012 by abrogating the previous law that created the Autonomous National Pharmacy of the Comoros (p.42). This entity functions as a central purchasing agency to ensure the supply, distribution, and accessibility of quality essential medicines. The existence of such a central purchasing agency is also noted in the 2018 Joint External Evaluation report, which mentions "Presence of a purchasing center (OCOPHARMA)" as an existing asset (p.39). However, this capacity is scored as "1," indicating non-existent capacity in the context of a system for sending and receiving medical supplies during a public health emergency, pointing to significant limitations even for this established mechanism (p.4). ⁵¹¹

Despite the presence of CAMUC for essential medicines, the documents indicate a lack of a comprehensive national or international procurement protocol or contract framework that can be fully utilized by both the Ministry of Health and the Ministry of Agriculture for the routine acquisition of a broader range of laboratory and medical supplies. For laboratory supplies, the Joint External Evaluation report explicitly identifies the need to "put in place a system for supplying quality laboratory reagents and consumables" (p.22). It further recommends to "develop and validate conventions for the purchasing procedures of laboratory diagnostic tests", implying such comprehensive conventions are not yet in place (p.22). ⁵¹²

The National Health Development Plan 2015-2019 also lists health products as a key area, noting that "the provision of medical imaging and laboratory services is insufficient and of poor quality in health facilities". It states that "the provision of equipment, staff training, and the regular supply system for reagents, films, and other consumables must be major concerns for the organization and management of services" (p.42). This indicates that a reliable and regular procurement and supply system for these critical items for routine needs is a significant challenge rather than a well-established framework. ⁵¹³

Furthermore, while CAMUC focuses on medicines and vaccines for human health, there is no explicit mention of a similar centralized or national procurement framework specifically catering to the routine needs of the Ministry of Agriculture for veterinary laboratory supplies, equipment, or personal protective equipment (PPE). The National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 highlights "insufficient human, material, and financial resources" as a risk for strengthening laboratory capacities for controlling antimicrobial resistance (p.XV, XVII), which would include procurement challenges. The document does not describe existing robust procurement frameworks for veterinary supplies. ⁵¹⁴

4.2.2a Stockpile of medical supplies for national use during a public health emergency

Score: 0

Comoros does not have a comprehensive, pre-positioned national stockpile of medical supplies for national use during a public health emergency, as indicated by the available documents.

The Joint External Evaluation clearly states that "With very limited logistical capacity, emergency stocks are not prepositioned in reference structures"(p.32). This assessment is reinforced by the low score of "1" for the indicator "System in place for sending and receiving medical supplies during a public health emergency", which corresponds to non-existent capacity (p.38). In fact, a recommended priority action is to "Implement pre-positioning activities for emergency medical kits before high-risk disaster seasons", further confirming the current absence of such a stockpile (p.38). ⁵¹⁵

The National Emergency Preparedness and Response Plan (PNPU) 2007, which serves as the overarching national public health emergency response plan, also highlights significant deficiencies in emergency supplies. In its "Monitoring of material/equipment needs" section for "Health and Nutrition" it lists numerous medical items such as Ringer lactate, perfusers, catheters, Oral Rehydration Solutions (SRO), antibiotics (Doxicicline, Bactrim, Flagyl), and PPE (gloves), indicating substantial deficit for these items. The proposed action to be taken for many of these is "Order for pre-positioning before end of March 2005" (p.43-44). This indicates that even as of the plan's update in 2007, these were needs to be addressed rather than existing stockpiles, and the JEE's later assessment confirms this continued gap. The plan also mentions a need to "Pre-position basic kits for different interventions (surgery, childbirth, guides, etc.)" as an activity to be undertaken before an emergency (p.42), signifying a lack of existing, ready-to-deploy kits. ⁵¹⁶

Furthermore, the National Health Development Plan 2015-2019 (PNDS) explicitly states that "The Ministry of Health does not have adequate storage structures for health products (vaccines, contraceptives, impregnated mosquito nets, donated materials…)" (p.42). This absence of appropriate storage facilities directly impedes the ability to maintain a functional national stockpile. The PNDS also lists "stockouts of medicines and vaccines" as a persistent problem (p.48), further underscoring the vulnerability of the supply chain. ⁵¹⁷

4.2.2b Stockpile of laboratory supplies for national use during a public health emergency

Score: 50

Comoros possess a national stockpile of laboratory supplies designated for use during public health emergencies, but there is limited evidence about what the stockpile contains.

The Joint External Evaluation (JEE) report from 2018 explicitly states that "laboratories face difficulties in supplying reagents and consumables" (p.21). As a key recommendation, the JEE advises the country to "put in place a system for supplying quality laboratory reagents and consumables" (p.22). This recommendation underscores that a reliable, routine supply system, which is foundational for maintaining any emergency stockpile, is currently inadequate. Furthermore, the JEE's broader assessment notes that "With very limited logistical capacity, emergency stocks are not prepositioned in reference structures" (p.32), a general observation that would encompass laboratory supplies. The recommendation to "Pre-position all inputs for Risk and Disaster Management" (p.55) indicates a planned future action rather than a current reality. ⁵¹⁸

The National Health Development Plan 2015-2019 (PNDS) reinforces this deficiency, noting that "The provision of medical imaging and laboratory services is insufficient and of poor quality in health facilities" and that a "regular supply system for reagents, films, and other consumables must be major concerns for the organization and management of services" (p.42). Additionally, the PNDS points out that "The Ministry of Health does not have adequate storage structures for health products" (p.42), which would inherently affect the viability of maintaining any stockpile, including laboratory reagents and media. ⁵¹⁹

More recent evidence from the National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 (PANM RAM) 2022-2026, while outlining strategies to strengthen laboratory capacities for Antimicrobial Resistance (AMR) surveillance, confirms the existing gaps. Under Objective Strategic 2, the plan aims to "Strengthen the capacities of the two structures (coordination and reference laboratories)" (p.XV). However, the identified risk for this intervention is "insufficient human, material, and financial resources" (p.XV), indicating that adequate material resources, such as laboratory supplies, are not currently available. The plan acknowledges the need for "the progressive reduction of numerous identified gaps" (p.2) and describes "The acquisition of financial resources constitutes a major challenge for the PANM" (p.viii). ⁵²⁰

The National Community Health Strategy (SNSC) 2024-2028, while focused on community health, also broadly mentions "an insufficiency in the development of infrastructure and equipment related to community health" (p.41) and aims to "Provide medicines, consumables, and equipment to improve the effectiveness of Community Health Workers" (p.42). While addressing consumables, this refers to community-level health worker kits, not a national strategic stockpile of specialized laboratory reagents and media. ⁵²¹

4.2.2c Annual review of national stockpile to ensure sufficient supply

Score: 0

There is no evidence to suggest that Comoros conducts or requires an annual review of a national stockpile to ensure its sufficiency for a public health emergency. This is primarily because a comprehensive national stockpile for public health emergencies, as described in terms of medical supplies, laboratory supplies, and personal protective equipment (PPE), is not established or robustly managed.

The Joint External Evaluation 2018 highlights a critical gap in this area, stating that "With very limited logistical capacity, emergency stocks are not prepositioned in reference structures" (p.32). Furthermore, the report recommends "Implement pre-positioning activities for emergency medical kits before high-risk disaster seasons) (p.38), which underscores that the pre-positioning of emergency supplies is a future goal rather than a current, established practice with an ongoing review process. For the indicator related to a system for sending and receiving medical supplies during a public health emergency, the country was scored "1," indicating non-existent capacity (p.4, p.38), further confirming the absence of a functional system for managing such supplies. ⁵²²

The National Health Development Plan (PNDS) 2015-2019 also supports this finding, explicitly stating that "The Ministry of Health does not have adequate storage structures for health products (vaccines, contraceptives, impregnated mosquito nets, donated materials…)" (p.42). The plan also lists stockouts of medicines and vaccines as a persistent problem, indicating ongoing challenges with supply availability even for routine needs (p.48). ⁵²³

While the National Community Health Strategy (SNSC) 2024-2028 discusses the provision and management of essential medicines and small equipment for community health workers (p.41, p.47), it focuses on their immediate operational needs and does not describe a national stockpile for public health emergencies or any annual review mechanism for such a stockpile. ⁵²⁴ Similarly, the National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 details efforts to improve laboratory capacities and supply chains for reagents and consumables (p.XV, p.XIX), but these are aimed at building fundamental capabilities rather than reviewing an existing, comprehensive national stockpile for emergencies. The plan notes "insufficient human, material, and financial resources" as a risk (p.XV, XVII). ⁵²⁵

4.2.3a Plan/agreement to produce/procure medical supplies during a public health emergency

Score: 0

Comoros does not meet the criteria regarding plans or mechanisms for manufacturing, procuring, or expediting medical supplies for national use during a public health emergency.

The National Health Development Plan (PNDS) 2015-2019 mentions the Central Purchasing Office for Essential Medicines of the Union of the Comoros (CAMUC) as responsible for medicines supply (p.42), but this refers to purchasing rather than domestic manufacturing. The document also highlights issues with the private pharmaceutical sector being very disorganized (p.30), which would hinder leveraging any potential local manufacturing capacity. ⁵²⁶

While CAMUC exists for essential medicines and vaccines, its capacity is deemed insufficient for public health emergencies. The Joint External Evaluation report explicitly scores the system for sending and receiving medical supplies during a public health emergency as "1" (non-existent capacity) (p.4, p.38). The report further recommends "Conclude or strengthen regional/international agreements for the acquisition, sharing, distribution, and reception of medical supplies as well as for personnel deployment" (p.38). ⁵²⁷ The Joint External Evaluation report identifies "The identification and designation of points of entry as well as the strengthening of the essential capacities required under IHR (2005) also represent a challenge" (p.2). Specifically, the report notes "Absence of a national public health emergency response plan for responding to public health emergencies occurring at points of entry" (p.45). While the report mentions "Multisectoral coordination mechanism within the framework of the "Strategic Approach to International Chemicals Management (SAICM)" project" (p.47) for chemical events and "Control of consumer products (SPS Service)" (p.47), these are not equivalent to a plan or mechanism for expediting medical supplies during a public health emergency. ⁵²⁸

The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 also indicates that "The acquisition of financial resources constitutes a major challenge for the PANM" (p.viii), which directly impacts procurement capabilities. ⁵²⁹

4.2.3b Plan/agreement to produce/procure lab supplies during a public health emergency

Score: 0

Comoros does not meet the specified criteria regarding plans or mechanisms for manufacturing, procuring, or expediting laboratory supplies for national use during a public health emergency.

While there is a focus on strengthening laboratory capacities, as seen in the National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026, this plan discusses improving existing infrastructure and training, not establishing or leveraging domestic or regional manufacturing of laboratory supplies (p.XV). ⁵³⁰ The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 identifies "insufficient human, material, and financial resources" as a risk (p.XV, p.XVIII). ⁵³¹The National Health Development Plan (PNDS) 2015-2019 similarly highlights the "insufficiency of medical imaging and laboratory services" (p.42) and the need for a regular supply system, without mentioning manufacturing capacity. ⁵³²

The Joint External Evaluation 2018 report explicitly notes that "laboratories face difficulties in supplying reagents and consumables" (p.21). As a priority measure, the report recommends to "put in place a system for supplying quality laboratory reagents and consumables" and to "develop and validate conventions for the purchasing procedures of laboratory diagnostic tests" (p.22). The Joint External Evaluation also broadly states that "With very limited logistical capacity, emergency stocks are not prepositioned in reference structures" (p.32), which would include laboratory supplies, further indicating a lack of emergency procurement planning. ⁵³³

The Joint External Evaluation 2018 report highlights significant deficiencies at points of entry, noting "The identification and designation of points of entry as well as the strengthening of the essential capacities required under IHR (2005) also represent a challenge" (p.2). More critically, the report points to the "Absence of a national public health emergency response plan for responding to public health emergencies occurring at points of entry" (p.45). While general control mechanisms at points of entry exist, they are not framed as emergency expediting protocols (p.44-45). ⁵³⁴

4.2.3c Mechanism emergency logistics and supply chain management

Score: 0

There is no evidence of a fully established and operational system or mechanism for emergency logistics and supply chain management at national and subnational levels in Comoros.

Comoros does have a functioning cold chain for routine vaccination, with "a functional cold chain, with good vaccine storage capacity) at central and district levels" (p.19, p.20). However, challenges remain, including "some vaccine stock ruptures at the peripheral level" and a recommendation to "Develop and implement the maintenance plan for the cold chain" (p.19, p.20). ⁵³⁵ The Joint External Evaluation (JEE) explicitly states that "With very limited logistical capacity, emergency stocks are not prepositioned in reference structures" (p.32). Furthermore, the country scores "1" (non-existent capacity) for the indicator "System in place for sending and receiving medical supplies during a public health emergency" (p.4, p.38). Priority measures recommended include developing a plan for organizing the deployment of medical supplies and rapid response teams, and establishing an operational Public Health Emergency Operations Center (COUSP) with Standard Operating Procedures (SOPs) (p.34, p.38). ⁵³⁶ The JEE notes that "Simulation exercises are organized annually on emergency and disaster themes by the DGSC. However, SOPs for emergency response are not yet developed" (p.34). ⁵³⁷

The National Health Development Plan (PNDS) 2015-2019 also identifies "Insufficient logistics and lack of standardization of the fleet" and "Lack of human resources trained in logistics and supply systems" as persistent problems (p.49). The PNDS also notes that "The Ministry of Health does not have adequate storage structures for health products" (p.42). ⁵³⁸ The PNDS also indicates "Insufficient cold chain" as a problem and highlights the need to "increase storage and conservation capacities (cold chain)" for future needs (p.42, p.49). ⁵³⁹

While the underlying emergency preparedness plan (National Emergency Preparedness and Response Plan – PNPU), last published 2007, is subject to periodic review, and some simulation exercises are conducted, it is not clear if the nascent logistics and supply chain mechanisms are regularly exercised, reviewed, or evaluated for sufficiency. The PNPU itself states that its update will take place every 3 years (p.72), which is not on an annual basis. ⁵⁴⁰

4.3.1a Plan/program/guidelines for dispensing MCMs during a public health emergency

Score: 0

A comprehensive, overarching plan, program, or set of guidelines specifically for dispensing medical countermeasures (MCMs) for national use during a public health emergency (including antibiotics, vaccines, therapeutics, and diagnostics) is not fully in place or clearly detailed. The existing evidence points to significant gaps in preparedness, logistics, and specific operational plans for such a scenario.

The Joint External Evaluation (JEE) report identifies significant weaknesses in Comoros' emergency response capabilities. For instance, the indicator "System in place for sending and receiving medical supplies during a public health emergency" scores a "1", indicating non-existent capacity (p.4, p.38). The report also highlights that "With very limited logistical capacity, emergency stocks are not prepositioned in reference structures" (p.32), which is crucial for rapid MCM dispensing. A key priority action identified is to "Implement pre-positioning activities for emergency medical kits before high-risk disaster seasons" (p.38). ⁵⁴¹

The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 (PANM RAM) aims to "Optimize the use of antimicrobial agents" (p.13). It includes activities to "Develop a national reference framework (technical guides) for the judicious use of antibiotics in human health" (p.XLI). While these are critical for responsible antibiotic management, they focus on judicious use and combating resistance rather than a plan for mass emergency dispensing during a public health emergency. ⁵⁴²

The National Emergency Preparedness and Response Plan (PNPU) 2007 mentions an objective to "Ensure the vaccination of 12000 children aged 0 to 5 years among the displaced population" as part of emergency health response (p.40).The PNPU also lists "Vaccins VAR" (Measles vaccine) as a needed item with a deficit requiring pre-positioning (p.44). While there is a Programme Elargi de Vaccination (PEV) which is "effective and provides good vaccine coverage, especially for measles" (p.1), and it relies on a "functional cold chain" (p.19), this relates more to routine vaccination rather than a comprehensive emergency dispensing plan for a novel public health threat requiring mass vaccination campaigns. ⁵⁴³

The National Community Health Strategy (SNSC) 2024-2028 does outline an Intervention Package for community health workers, including dispensing "SRO, Zinc, amoxicilline, CTA" (Oral Rehydration Solutions, Zinc, amoxicillin, Artemisinin-based Combination Therapy) for conditions like simple malaria, diarrhea, and acute respiratory infections (p.52). While this indicates a framework for dispensing specific therapeutics and diagnostics (e.g., TDR for malaria) at the community level, particularly for routine or endemic diseases, it is not presented as a national emergency dispensing plan for a broader public health crisis. ⁵⁴⁴

4.3.2a Plan to receive foreign health personnel during a public health emergency

Score: 0

There is no explicit evidence of a comprehensive, public plan in place to facilitate a rapid workforce surge in an emergency. The available information indicates that this is an area where Comoros has identified significant gaps and has made recommendations for future development rather than having an existing, formalized system.

The Joint External Evaluation (JEE) directly addresses the capacity for deploying health personnel during emergencies. For the indicator R.4.2 "System in place for sending and receiving health personnel during a public health emergency", Comoros received a score of 1, meaning non-existent capacity (p.4). The report explicitly states: "The country, during many major disasters or health emergencies, has had to receive from abroad and deploy medical supplies and support personnel… However, no written mechanism in the form of a plan or integrated into an existing emergency preparedness plan has been developed" (p.38). It further recommends, as a priority measure, to "Put in place a plan defining criteria and standards for the deployment of health personnel" (p.38). This clearly indicates the absence of such a plan. ⁵⁴⁵

While the National Emergency Preparedness and Response Plan (PNPU) 2007 outlines general emergency response structures, it describes the composition of Evacuation team and Health team in terms of general categories of personnel (gendarmerie, army, police, health service, Red Crescent, medical center staff, NGOs) and notes that their "number depends on the scale of the situation" (p.20-21). The plan also lists minimal necessary human resources for health in an emergency (p.44), but it does not detail a strategy for surge beyond identifying these minimal needs. ⁵⁴⁶

The National Health Development Plan (PNDS) 2015-2019 identifies "Development of human resources for health" as a strategic orientation (p.51). It discusses persistent problems such as the "shortage of health personnel) and its uneven distribution" (p.39). It aims to "Develop and implement a policy and a plan for human resources management for health" (p.62), which is a general human resources development objective, not specifically an emergency workforce surge plan. ⁵⁴⁷

The National Community Health Strategy (SNSC) 2024-2028 focuses on the long-term integration, training, and motivation of Community Health Workers (ASC) into the health system (p.9, p.43). It outlines criteria for their selection and distribution for routine service delivery ("1 ASC pour 1000 habitants") (p.46). However, it does not describe a mechanism for rapidly increasing or deploying these or other health workers specifically for an emergency surge. ⁵⁴⁸

The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 (PANM RAM) addresses human resources in the context of specialized training for AMR control (p.XV, p.XVII, p.XXVII). While it aims to strengthen capacities, its focus is on specialized skills and roles related to AMR rather than a general emergency workforce surge plan. ⁵⁴⁹

4.3.2b Plan to facilitate workforce surge in an emergency

Score: 0

There is no evidence of a comprehensive, publicly available plan specifically designed to receive health personnel from other countries to respond to a public health emergency in Comoros. The available information strongly indicates that this is a significant gap in the country's emergency preparedness.

The Joint External Evaluation (JEE) report from 2018 provides the most direct evidence on this matter. For the indicator R.4.2 "System in place for sending and receiving health personnel during a public health emergency", Comoros received the lowest possible score of 1, indicating non-existent capacity (p.4). The report further elaborates on this: "The country, during many major disasters or major health emergencies, has received medical supplies and support personnel from abroad and deployed them in the field… However, no written mechanism in the form of a plan or integrated into an existing emergency preparedness plan has been developed" (p.38). Among the priority recommended measures is to "Put in place a plan defining criteria and standards for the deployment of health personnel" (p.38). Another recommendation is to "Conclude or strengthen regional/international agreements for the acquisition, sharing, distribution, and reception of medical supplies as well as for personnel deployment" (p.38). ⁵⁵⁰ While the JEE mentions as an asset/best practice that "The country participates in regional/international agreements for the deployment of personnel in case of an epidemic (SEGA/COI Network, CRCo)" (p.38), this refers to participation in networks for deployment, not a specific national plan for receiving personnel from other countries.⁵⁵¹

Other documents, such as the National Emergency Preparedness and Response Plan (PNPU) 2007 and the National Health Development Plan (PNDS) 2015-2019, discuss partnerships with international organizations for various forms of support (e.g., technical, financial, training), but do not detail a specific plan or mechanism for the reception and integration of health personnel from other countries during an emergency. The PNDS, for example, lists various international partners who provide support (p.31-33), but this doesn't equate to an operational plan for receiving personnel. ⁵⁵²⁵⁵³

4.3.2c Plan to redeploy existing health personnel within the country

Score: 0

There is no explicit evidence of a dedicated, public plan in place for the strategic redeployment of existing health personnel, either geographically or by role, during a public health emergency in Comoros.

The Joint External Evaluation (JEE) report scores Comoros a 1 (non-existent capacity) for the indicator R.4.2 "System in place for sending and receiving health personnel during a public health emergency" (p.4). This critical assessment directly implies the absence of a structured plan for internal redeployment. The report explicitly states: "The country, during many major disasters or major health emergencies, has received medical supplies and support personnel from abroad and deployed them in the field… However, no written mechanism in the form of a plan or integrated into an existing emergency preparedness plan has been developed" (p.38). The recommendation to "Put in place a plan defining criteria and standards for the deployment of health personnel" (p.38) further confirms this gap. ⁵⁵⁴

The National Health Development Plan (PNDS) 2015-2019 points to systemic issues in human resources management that would hinder effective emergency redeployment. "The problem of shortage of health personnel persists, and the few that exist are concentrated much more in urban areas than in rural areas. This situation, to the detriment of rural areas, is certainly among the causes of the poor performance of health structures at the district level" (p.39). The PNDS lists "Lack of human resources management tools", "Lack of job description sheets", "Lack of career plan", and "Lack of evaluation and rating mechanisms for health personnel" as main problems (p.48). "The positioning of agents is inadequate between the job profile and the assignment" (p.48), further complicating any emergency redeployment. ⁵⁵⁵

The National Emergency Preparedness and Response Plan (PNPU) 2007 outlines general emergency response structures, including a "Rescue and Logistics Cell" and a "Health Team" (p.19-20). The "Health Team" is generally composed of medical professionals, but the plan only states that their "number depends on the scale of the situation" (p.20). ⁵⁵⁶

The National Community Health Strategy (SNSC) 2024-2028 focuses on community health workers (ASC) and their long-term integration, training, and equitable distribution (p.43, p.46). It mentions "Ensure equitable distribution of ASCs" (p.43) as a strategic intervention, but this refers to routine, long-term distribution norms (1 ASC for 1000 inhabitants) rather than emergency redeployment. ⁵⁵⁷

The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 focuses on strengthening specialized human resources for AMR control through training and capacity building (p.XV, p.XVII), not on a national redeployment strategy for emergencies. ⁵⁵⁸

4.4.1a Constitutional guarantee of citizens’ right to medical care

Score: 25

The Constitution of the Union of Comoros explicitly guarantees the protection of specific groups, which implicitly includes access to medical care, but does not extend a universal right to medical care for all citizens.

Article 12 states: "The State ensures the protection of childhood and maternity". This provision mandates the state to safeguard the well-being of children and mothers, which inherently involves medical care and health services for these particular populations. However, the constitution does not contain a general clause guaranteeing a "right to health" or "right to medical care" for all citizens. ⁵⁵⁹

4.4.1b Access to skilled birth attendants (% of population)

Score: 95.59

4.4.1c Out-of-pocket health expenditures per capita, PPP (current international $)

Score: 80.54

4.4.1d Coverage of essential health services through universal health coverage

Score: 43.75

4.4.1e Total population pushed below a relative poverty line by household health expenditure (60% of media daily per capita consumption or income)

Score: 64.19

4.4.1f Rate of mortality amenable to health care

Score: 72.57

4.4.2a Guaranteed paid sick leave

Score: 66.67

Workers in Comoros are guaranteed paid leave for absence due to illness, though the specific amount of this payment is determined by a separate regulatory act.

According to the Comoros Labor Code (n°84-108), a worker's contract can be suspended for the duration of an absence due to illness, provided it is duly certified by an approved doctor, with this period limited to six months and extendable until the worker is replaced (Article 60, p.12). For such cases, Article 62 states that a decree, issued after consultation with the Superior Council of Labor and Employment, will determine the amount of the indemnity to be paid to the worker (Article 62, p.12). This indicates that compensation is provided during sick leave, although the Labor Code itself does not specify if it amounts to full salary. ⁵⁶⁰

Regarding the availability of sick leave for mental as well as physical health problems, the Labor Code refers to "maladie" (illness or sickness) in general terms, without explicitly differentiating between physical and mental conditions. However, the Public Health Code clearly establishes that mental health care is a responsibility of the State and constitutes a priority, with provisions for its integration into the national health system and emphasis on the prevention of mental illnesses (Article 138, p.27). ⁵⁶¹ Given this recognition of mental health as a public health priority, and the general term "maladie" in the Labor Code's sick leave provisions, it can be inferred that a mental health condition, when duly certified by an approved medical professional, would qualify a worker for sick leave under the existing regulations.

4.4.3a Government prioritisation of care for healthcare workers during response

Score: 0

There is no explicit evidence of a government-issued legislation, policy, or public statement committing to provide prioritized healthcare services specifically to healthcare workers who become sick as a result of responding to a public health emergency.

The National Health Development Plan (PNDS) 2015-2019 mentions, under its financing objectives, an intervention to "Ensure free healthcare for ASCs in their intervention district, including free consultations and a 50% reduction in hospitalization costs" (p.53). ⁵⁶² This same provision is reiterated in the more recent National Community Health Strategy (SNSC) 2024-2028 as Intervention 7.4.3 under Strategy 7.4: "Ensure ASC motivation" (p.43). ⁵⁶³

The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 (PANM RAM), in its strategic interventions, mentions "Systematize the protection of health personnel, recruitment, periodic assessment, particularly for exposed personnel, tuberculosis services, laboratory" (p.57). This points to protective measures for HCWs exposed to specific diseases like tuberculosis, but it does not constitute a comprehensive policy for prioritized healthcare for illness acquired during a general public health emergency response. ⁵⁶⁴

The Joint External Evaluation (JEE) report (p.29-31) and the PNDS 2015-2019 (p.48, p.62) highlight general deficiencies in human resource management for health, including a lack of motivation mechanisms and inadequate working conditions. The JEE also emphasizes the need to develop plans for the deployment of health personnel, but it does not address their specific healthcare entitlements if they become ill due to their emergency duties (p.38). ⁵⁶⁵⁵⁶⁶

4.5.1a Existence of system for communication during a public health emergency

Score: 0

There is no clear evidence of a fully functional and adapted system currently in place for public health officials and healthcare workers to effectively communicate during a public health emergency.

The National Health Development Plan (PNDS) 2015-2019 explicitly states a critical gap: "There is a lack of a suitable communication system between health services and facilities, which makes it difficult to share statistical information, conduct epidemiological surveillance, and report cases of potentially epidemic diseases, as well as call an on-call person in an emergency. This is due to a lack of culture in using new information and communication technologies." (p.41). ⁵⁶⁷

The Joint External Evaluation (JEE) 2018 corroborates this deficiency and recommends improvements. Under "Coordination, communication and promotion of the IHR", it suggests creating "an exchange platform to improve multi-sectoral and multidisciplinary coordination and communication between all stakeholders" (p.8) This implies that such a platform for effective multi-stakeholder communication is not yet adequately established. For "Real-Time Surveillance," indicator D.2.2 "Interoperable and Interconnected Real-Time Electronic Notification System" scores a 2 (limited capacity), with recommendations to "Establish an electronic notification system for notifiable diseases affecting human health." (p. 4, p. 25) This highlights that the digital infrastructure for real-time communication for urgent health events is not fully developed. For "Notification," indicator D.3.2 "Network and Notification Protocols in the Country" also scores a 2, recommending improvements to "SOPs" (Standard Operating Procedures) for risk evaluation and notification (p. 4, p. 28). ⁵⁶⁸

The National Emergency Preparedness and Response Plan (PNPU) 2007 describes a hierarchical structure with a Transmission Cell and a "Schema for Information Transmission to Competent Authorities" (p.19, p.62). ⁵⁶⁹ This plan predates the more critical assessments of the PNDS (2015-2019) and JEE (2017). Moreover, the JEE notes that for emergency interventions, “SOPs for emergency response are not yet developed” (p.34), which is essential for effective communication protocols. ⁵⁷⁰

More recent strategies, such as the National Community Health Strategy (SNSC) 2024-2028 and the National Multisectoral Action Plan to Combat Antimicrobial Resistance (PANM RAM) 2022-2026, emphasize improving information systems and communication, but these are framed as future goals. The SNSC aims to "Integrate the community health component into the digitalized national health information system" and "Equip and train CHWs in digital tools for data entry, reporting, and decision-making." (p. 42) These interventions indicate that digital tools for data collection and reporting, which are foundational for effective communication, are still being implemented or strengthened. The PANM RAM aims to "Ensure regular data collection and information sharing by establishing effective communication and coordination among all stakeholders" for AMR. (p.6-7) This is specific to AMR and highlights ongoing efforts to establish effective coordination. ⁵⁷¹⁵⁷²

4.5.1b Inclusion of public and private sector in healthcare communication system

Score: 0

The existing or planned communication systems for public health officials and healthcare workers during an emergency do not comprehensively encompass healthcare workers in both the public and private sectors. The evidence suggests a significant gap in the integration of the private sector into such communication and information-sharing mechanisms.

The National Health Development Plan (PNDS) 2015-2019 explicitly identifies a major deficiency in integrating the private sector into the national health information system (HIS): "When we add to this the mass of private sector activities for which no information is transmitted to the HIS, it is no longer necessary to say that the HIS needs support to be able to serve for progress assessment and decision-making." (p. 45) The PNDS also recommends "Defining the legal framework for the HIS, including the private sector in terms of collaboration" (p.66), confirming this legal gap. ⁵⁷³ The PNDS defines the national health system as comprising public, private (profitable, non-profitable), and traditional medicine sectors (p.27, p.30). It notes the growth of the private sector, especially in urban areas, but also states that its development is "neither controlled, nor structured, and does not operate in complementarity and synergy with the public healthcare system" (p.30). ⁵⁷⁴

The Joint External Evaluation (JEE) 2018 and other documents emphasize multisectoral coordination. For example, the JEE recommends a “exchange platform to improve coordination and multisectoral and multidisciplinary communication of all stakeholders” (p.8). While "multisectoral" and "all actors" could theoretically include the private healthcare sector, there is no explicit detail about how private healthcare workers specifically are integrated into emergency communication protocols or systems. ⁵⁷⁵

The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 (PANM RAM) does show an intention to involve specific private sector entities in coordination, particularly concerning pharmaceutical products. The composition of the "Multi-sectoral Coordination Body (OCM)" includes "The main representatives of the private sector on medicines" (p.8). This is a positive step towards private sector engagement, but it is specific to AMR initiatives and limited to "representatives of the private sector for medicines," not all private healthcare workers or facilities, nor for all types of public health emergencies. ⁵⁷⁶

The National Emergency Preparedness and Response Plan (PNPU) 2007 outlines communication flows during an emergency but does not specifically detail how private sector healthcare providers would be integrated into this system. Its structure primarily focuses on governmental and established non-governmental (Red Crescent, UN agencies) actors. ⁵⁷⁷

4.6.1a Evidence of national public health system monitoring and tracking of HCAIs

Score: 0

There is no evidence that the national public health system in Comoros is currently monitoring for and tracking the number of healthcare-associated infections (HCAI) that take place in healthcare facilities.

In the Joint External Evaluation (JEE) report from 2018 is very clear on this point, for indicator P.3.3 "Program for the prevention and control of healthcare-associated infections," Comoros received the lowest possible score of 1, indicating "non-existent capacity" (p. 4). The report's "Aspects to strengthen/challenges" section for this indicator further emphasizes the absence: "Define a policy for the prevention and control of healthcare-associated infections"; "Establish infection control committees at national, regional, and local levels"; "Prepare and disseminate a national guide for the prevention and control of healthcare-associated infections in hospitals"; “Train health personnel on infection prevention and control.” ⁵⁷⁸

The most recent National Multisectoral Action Plan to Combat Antimicrobial Resistance (PANM RAM) 2022-2026 acknowledges this gap and includes actions to address it, indicating that it is still a work in progress. Strategic Objective 3 is to “Establish an Infection Prevention and Control program” (p.XVII). Under this objective, Activity 3.1.1 is to "Develop and validate a national IPC action plan based on new international WHO recommendations" (p. XXXII) ⁵⁷⁹ The PANM RAM also includes future studies related to HCAIs, which implies a lack of ongoing systematic monitoring: "Conduct a study on healthcare-associated infections; in each pilot site and the reference hospital" (p. XV, Activity 2.1.6) and “Conduct punctual studies on the prevalence of healthcare-associated infections and the consumption of antimicrobials” (p.XVIII, Activity 2.2.2). ⁵⁸⁰

The National Health Development Plan (PNDS) 2015-2019 points to a general weakness in the health information system (SIS) in hospitals that would make granular tracking of HCAIs challenging: “However, it should be noted that there is a weakness in the health information system in hospitals.” (p.18). The section on the SIS (2.3.6) details issues such as a "completeness system is weak", information not being "organized or analyzed locally", and infrequent feedback, particularly from peripheral levels (p.45). ⁵⁸¹

4.6.1b Infection prevention and control programme

Score: 0

There is no clear evidence of a comprehensive, nationally established and fully operational Infection Prevention and Control (IPC) program in Comoros. Instead, the documents highlight significant gaps and outline plans for future development and implementation of such a program.

The Joint External Evaluation (JEE) 2018 explicitly states that Comoros's capacity for a program of prevention and control of healthcare-associated infections (P.3.3) is Score 1, meaning non-existent capacity (p.4). As a priority measure, the JEE recommends: "Define a policy for the prevention and control of healthcare-associated infections. Establish infection control committees at national, regional, and local levels. Prepare and disseminate a national guide for the prevention and control of healthcare-associated infections in the hospital setting. Train health personnel on infection prevention and control" (p.10). These recommendations clearly indicate that a national IPC policy and program were not yet in place in 2017. ⁵⁸²

The more recent National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 (PANM RAM) includes "Establish an Infection Prevention and Control Program" as one of its strategic objectives (p. XVII). Under this objective, strategic intervention 3.1 is to "Develop and implement the national IPC policy in human healthcare settings." This explicitly lists the development and implementation of an IPC policy as a future action (p. XVII). Activity 3.1.1 is to "Develop and validate a national IPC action plan based on new international WHO recommendations", again indicating a future-oriented action rather than an existing program (p.XXXII). The term “Energize/revitalize the national IPC policy in healthcare settings” is used in the situational analysis of the PANM RAM (p.3). ⁵⁸³

The National Health Development Plan (PNDS) 2015-2019 mentions issues with hygiene and sanitation, and the management of biomedical waste, noting "poor management of biomedical waste" and "insufficient incinerators" (p.23). Instead, it lists “Absence of a biomedical waste management policy” as a problem to be addressed (p.49). ⁵⁸⁴

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁵⁸⁵

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁵⁸⁶⁵⁸⁷

4.6.1c National plan to ensure a safe environment in health facilities

Score: 0

There is no clear evidence of a comprehensive, nationally established plan currently in place to ensure a safe environment in health facilities.

The Joint External Evaluation (JEE) 2018 explicitly scores Comoros a 1 (non-existent capacity) for indicator P.3.3 "Program for prevention and control of healthcare-associated infections" (p.4). The JEE recommends "Defining a policy for the prevention and control of healthcare-associated infections" as a priority, and to "Establish infection control committees at national, regional, and local levels. Prepare and disseminate a national guide for the prevention and control of healthcare-associated infections in the hospital setting. Train health personnel on infection prevention and control" (p. 10). ⁵⁸⁸ The JEE 2017 also recommends "Develop a national biomedical waste management plan" (p. 18), explicitly stating the absence of such a plan. ⁵⁸⁹

The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 (PANM RAM) lists "Establish an Infection Prevention and Control Program" as a strategic objective (p. XVII). Strategic intervention 3.1 is to "Develop and implement the national IPC policy in human healthcare settings" (p. XVII). This plan is still in the phase of developing and implementing this policy. ⁵⁹⁰

The JEE also scores Comoros a 1 (non-existent capacity) for P.6.1 "Existence of a biosafety and biosecurity system involving the entire government for human, animal, and agricultural structures" (p. 4). Priority recommendations include "Develop and implement national legislation and regulation in the field of biosafety and biosecurity" and "Establish a multidisciplinary and multisectoral technical group on biosafety and biosecurity" (p. 18). This confirms the lack of an existing national plan for biosafety in health facilities. ⁵⁹¹

The National Health Development Plan (PNDS) 2015-2019 points out that "poor management of biomedical waste, which is often mixed with household waste and ends up in illegal dumps within large cities. This poor management is explained by the lack of incinerators in health facilities and the lack of training for health personnel in this area" (p. 23). The PNDS further lists "Absence of a biomedical waste management policy" as a priority problem for infrastructure, equipment, and health products (p. 49). ⁵⁹²

The PNDS 2015-2019 highlights "numerous infrastructures are in a state of total dilapidation and are obsolete" and "Infrastructures not compliant with safety standards for personnel and users" (p. 40, p. 49). While the plan aims to "Rehabilitate and upgrade at least 85% of hospitals" (p.63), this is an objective for future improvement, not evidence of an existing plan ensuring a safe environment. ⁵⁹³

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁵⁹⁴

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁵⁹⁵⁵⁹⁶

4.7.1a Requirement for ethical review before beginning a clinical trial

Score: 100

There is evidence of a national requirement for ethical review before beginning research in the medical and health fields, which would encompass clinical trials.

The National Health Development Plan 2015-2019 (PNDS) explicitly states: "A National Ethics Committee for Life and Health Sciences (CNESS) was established in 2014 by Decree No. 14-11/PR of 10/01/2014. Its primary mission is to provide opinions on ethical issues arising from advances in knowledge in the fields of biology, medicine, and health, and to publish recommendations on these topics" (p. 47). This indicates that a National Ethics Committee for Life and Health Sciences (CNESS) was established in 2014, and its primary mission is to provide opinions on ethical issues arising from advances in knowledge in biology, medicine, and health. Clinical trials, as a form of research contributing to progress in medicine and health, would fall directly under the purview of this committee for ethical review. ⁵⁹⁷

However, the same document also points to a broader challenge in the research domain: “There is no national policy or guidelines on health research and few people at the national level have received training in this area” (p.50). While the CNESS exists with the mandate for ethical review, the absence of comprehensive national policies or guidelines on health research (including the specific processes for ethical review) suggests that the operational framework for this requirement might still be developing or may not be as detailed as in other countries. Nevertheless, the establishment of the CNESS and its stated mission confirm a national requirement for ethical consideration and review in the context of medical and health advancements. ⁵⁹⁸

4.7.1b Expedited approval for clinical trials of unregistered MCMs during epidemics

Score: 0

There is no explicit evidence of an expedited process for approving clinical trials for unregistered medical countermeasures (MCMs) or for mutual recognition of clinical trial results taking place elsewhere to treat ongoing pandemics or epidemics in Comoros.

The National Health Development Plan 2015-2019 (PNDS) mentions the establishment of a "National Ethics Committee for Life and Health Sciences (CNESS)" in 2014. Its mission is to "provide opinions on ethical issues raised by advances in knowledge in the fields of biology, medicine, and health" (p. 47). The PNDS also states: “There is neither a national policy nor national guidelines on health research, and few people at the national level have received training in this field” (p.50). ⁵⁹⁹

The Joint External Evaluation (JEE) 2018 identifies numerous weaknesses in the Comorian health system's capacity to detect, prevent, and respond to public health events. While it covers various aspects of health security, it does not mention any existing mechanisms for expedited clinical trial approval or mutual recognition of results. ⁶⁰⁰

The National Emergency Preparedness and Response Plan (PNPU) 2007 focuses on general emergency coordination and response for various hazards (geophysical, biological, hydrometeorological, classical), but it does not delve into specific regulatory processes for medical products or clinical trials during emergencies. ⁶⁰¹

The National Multisectoral Action Plan to Combat Antimicrobial Resistance 2022-2026 (PANM RAM) focuses on strategies to combat AMR, including operational research, but not on expedited clinical trial approval processes for unregistered MCMs. ⁶⁰²

The National Quality Policy (PNQ) 2020 deals with standardization, metrology, and conformity assessment for products in general, but not with emergency regulatory pathways for experimental medical products. ⁶⁰³

4.7.2a Existence of agency responsible for approving new human MCMs

Score: 100

There is evidence of a government agency responsible for approving new medical countermeasures (MCM) for humans in Comoros.

The National Quality Policy (PNQ) 2020 explicitly identifies the National Agency for Medicines and Health Evacuations (ANAMEV). Its responsibilities include: "Decision on approval for the importation, wholesale or retail distribution, storage, export, and marketing of medicines and pharmaceutical specialties." (p. 22)⁶⁰⁴

Furthermore, the Joint External Evaluation (JEE) report also highlights the "Existence of a national medicines agency and the pharmacy office that implement mechanisms for the control and regulation of medicines." (p. 11) ⁶⁰⁵

The Central Purchasing Agency for Essential Medicines of the Union of the Comoros (CAMUC), transformed from the former PNAC in 2012, primarily serves as the central procurement agency for essential medicines, as noted in the National Health Development Plan 2015-2019 (p. 41). Its function is to acquire medicines, not to grant market authorization for new ones. ⁶⁰⁶

The Directorate of Public and Private Healthcare Establishments (DESPP), within the Ministry of Health, "Ensures the availability of effective, safe, high-quality, and accessible health products to the entire population; coordinates the development and dissemination of legislative and regulatory texts, and standards relating to pharmacy, health services, health products, medicines, medical biology, medicine, and traditional pharmacopoeia." (p. 22). ⁶⁰⁷

4.7.2b Expedited approval for human MCMs during public health emergencies

Score: 0

There is no explicit evidence of an expedited process for approving medical countermeasures (MCMs) for human use or for mutual recognition of approval decisions taking place elsewhere during public health emergencies in Comoros.

The 2020 National Quality Policy (PNQ) specifies that the National Agency for Medicines and Health Evacuations (ANAMEV) is responsible for the "Decision to approve the importation… and placing on the market of medicines and pharmaceutical specialties" (p. 22). ⁶⁰⁸ The 2018 Joint External Evaluation (JEE) also references a "national drug agency" involved in mechanisms for the control and regulation of medicines (p. 11). ⁶⁰⁹

None of the documents explicitly mention terms such as "expedited process", "fast-track", "emergency use authorization – EUA", or "mutual recognition" in the context of approving MCMs during public health emergencies. The description of ANAMEV's mandate in the PNQ is general regarding market authorization. The National Health Development Plan (PNDS) 2015-2019 notes a significant gap: “There is neither a national policy nor national guidelines on health research, and few people at the national level have received training in this field” (p.50). ⁶¹⁰ A comprehensive and agile regulatory framework for MCM approval during emergencies would typically fall under such a national research or health product policy, the absence of which suggests limitations in advanced regulatory mechanisms. The PNQ 2020 also points out that "the majority of these legal texts are inconsistent, whereas their synergies and complementarities are necessary to be more effective" (p.16). ⁶¹¹ Such inconsistencies in the general legal framework could hinder the smooth operation of any specialized expedited process, even if one were implicitly intended.

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁶¹²

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁶¹³⁶¹⁴

5.1.1a Submission of IHR reports to the WHO in past year

Score: 100

Comoros has submitted an IHR Self-Assessment Annual Report (SPAR) to the WHO for the last calendar year, with the latest submission in 2024.⁶¹⁵

5.1.2a Existence of specific risk reduction strategies for epidemics and pandemics

Score: 100

Epidemics and pandemics are integrated into the national risk reduction strategies in Comoros, rather than existing as entirely standalone frameworks, though the depth of this integration has been noted as an area needing development.

The National Plan for Emergency Preparedness and Response from November 2007 explicitly states that sectoral plans related to the preparation and management of emergencies, including epidemics, are an integral part of this national plan (p.4). This document categorizes biological emergencies, such as epidemics and avian flu, among the various types of emergencies the country faces, detailing their historical impact and outlining specific goals and planning assumptions for such events within its broader framework (p.10, p.11, p.15). ⁶¹⁶

Similarly, the National Contingency Plan 2017-2018 identifies epidemiological risks as one of its three primary hazards, alongside hydrometeorological and geological/geophysical risks (p.1, p.4). This plan was developed to align with the National Strategy for Disaster Risk Reduction (SNRRC) formulated in 2014, which itself established a comprehensive disaster risk management framework through the National Platform for Disaster Risk Prevention and Reduction (PNPRRC) (p.2). The National Contingency Plan elaborates on scenarios for epidemics like cholera, dengue, and H1N1, detailing potential impacts and required responses (p.6). Its objectives include clarifying responsibilities, facilitating coordination among humanitarian actors, and ensuring monitoring of operations, all within a multisectoral approach that organizes activities into various sectors, including health and nutrition (p.10, p.12). ⁶¹⁷

However, the Joint External Evaluation Report from 2018 provides a critical assessment of this integration, highlighting deficiencies. While acknowledging that Comoros has a disaster risk and management framework and a national contingency plan that incorporates health, it notes that "the public health emergency component remains underdeveloped" (p.2). The report specifically recommends the development of "a multi-hazard operational national public health emergency plan" (p.2). Furthermore, it states that "there is no national multisectoral multi-hazard operational plan for preparing and responding to major pandemics and epidemics that details all coordination and communication mechanisms" between the relevant ministries and partners (p.7). It also points out that the 2007 national plan for public health emergency preparedness and response has not been updated, and standardized operational procedures are lacking (p.32). ⁶¹⁸

The National Multisectoral Action Plan to Combat Antimicrobial Resistance, validated in 2022, serves as a specific standalone plan addressing antimicrobial resistance (RAM), a significant biological threat. This plan aims to strengthen the health system's resilience against epidemic threats and contributes to broader public health goals (p.2). ⁶¹⁹

5.2.1a Existence of public health emergency agreements with regional neighbors

Score: 100

The Union of Comoros has cross-border agreements, protocols, and Memoranda of Understanding (MOUs) with neighboring countries and as part of regional groups concerning public health emergencies.

One key regional collaboration is through the Indian Ocean Commission (COI), specifically its epidemiological surveillance and alert management network (SEGA) under the "One Health" approach. This network aims to enhance coordination in detecting and responding to public health events, including zoonoses (p.7). The Joint External Evaluation (JEE) report from 2018 notes that the surveillance of specific zoonoses like Rift Valley Fever (FVR) and Q Fever has been operational since 2016 through the SEGA project (p.13). The country has also developed collaboration with neighboring countries, particularly through the COI's health surveillance unit in the sub-region (p.13). The ability to call upon resources from COI countries for infectious zoonoses is mentioned as a functional mechanism (p.14). Regular simulation exercises are conducted, including at the sub-regional level within the COI, to test the country's capacity to identify and notify Public Health Emergencies of International Concern (PHEIC) (p.27). In the context of personnel deployment during epidemics, the country participates in regional and international agreements, citing the SEGA/COI network and the Comoros Red Crescent (CRCo) (p.39). ⁶²⁰

Despite these existing frameworks, the JEE report from 2018 points to significant gaps in implementation and coordination. It highlights that mechanisms for intersectoral collaboration for detecting and responding to public health events, including zoonoses, exist but are "activated only during crisis periods" (p.1). This indicates a reactive rather than consistently proactive approach. The report emphasizes the need for better analytical capabilities and regular information exchange, and calls for clearer procedures for coordination between sectors to improve notification modalities to the World Health Organization (WHO) and the World Organization for Animal Health (OIE) (p.1). Regarding notification protocols, the JEE notes that while standardized operating procedures (SOPs) exist for reporting events that could constitute a PHEIC, their use is "not always effective due to a lack of training" (p.27). ⁶²¹

In the context of the National Contingency Plan 2017-2018, its introduction section highlights that past experiences in disaster management have revealed "challenges related to resource mobilization" and "weaknesses in coordination mechanisms" (p.2). The document further lists "Challenges for the Implementation of the Response," which include a "lack of clear terms of reference," "insufficient appropriate training," and mechanisms for mobilizing actors that "need to be reviewed" (p.26). It also points out an "inadequate inter-sectoral and sectoral coordination process" as a major constraint ( p.9, p.26). ⁶²²

5.2.1b Existence of animal health emergency agreements with regional neighbors

Score: 50

The Union of Comoros has established cross-border agreements and participates in regional groups concerning animal health emergencies, including mechanisms for mutual support during such events. However, there are recognized gaps in the implementation and effective functioning of these frameworks.

Comoros is actively involved in regional collaboration for animal health emergencies, primarily through the Indian Ocean Commission (COI). This is evidenced by its integration into the SEGA "One Health" network, which is co-financed by the French Development Agency (AFD) and focuses on the epidemiological surveillance and alert management of zoonoses, as noted in the Joint External Evaluation (p.12). This directly indicates a cross-border agreement among COI member states to support each other during animal health emergencies, particularly those related to zoonoses. The country has identified priority zoonoses, including Rift Valley Fever (FVR), Q Fever, and Salmonellosis (p.12). Surveillance activities for FVR and Q Fever have been operational since 2016 through the COI's SEGA project, demonstrating a concrete regional mechanism for addressing animal health threats that can impact humans (p.13). Joint investigations of disease outbreaks are conducted between veterinary services and human health services, and the SEGA network supported the National Institute for Research in Agriculture, Fisheries, and Environment (INRAPE) in evaluating the prevalence of salmonella in meat during 2013-2014 (p.13). The country has also developed broader collaboration with neighboring nations, particularly through the sub-regional health surveillance unit of the COI (p.13). ⁶²³

Furthermore, Comoros participates in the World Organization for Animal Health (OIE) framework. A functional OIE Focal Point exists, regularly communicating animal disease information to the OIE via the World Animal Health Information System (WAHIS) platform (p.28). ⁶²⁴ This signifies a formal international protocol for notification regarding animal health emergencies. The country's National Multisectoral Action Plan to Combat Antimicrobial Resistance (PANM RAM) also highlights involvement with international bodies like the OMSA (OIE) and FAO, noting their role in supporting the country's efforts (p.v). The PANM RAM includes the National Livestock Directorate (DNE) and INRAPE in its national steering committee composition, signifying a multisectoral approach that explicitly includes animal health authorities in addressing a key animal health challenge (p.5). Interventions within this plan include strengthening animal vaccine coverage for diseases like PPR (Peste des Petits Ruminants), symptomatic anthrax, rabies, FVR, foot-and-mouth disease, Newcastle disease, avian cholera, and avian pox (p.XXXV). ⁶²⁵

Despite these agreements and collaborations, several gaps in implementation and capacity have been identified. The 2018 JEE report states that the "One Health" approach, though officially launched in 2014, is "difficult to implement due to a lack of resources and human resources in animal health" (p.12). It also notes that the SEGA project's surveillance of major zoonoses "does not cover 80% of the territory due to deficiencies in the animal health surveillance network" (p.13). The JEE recommends strengthening national financing for zoonoses activities, which are currently largely co-funded by the AFD (p.13), and highlights an insufficient number of veterinary personnel to carry out their missions effectively (p.14). There is also a lack of national control plans for priority zoonoses and insufficient budgets to implement them (p.14). The country's laboratories have limited capacity for microbiological and toxicological analysis related to food safety, affecting animal health aspects, and a lack of clear attribution between veterinary services and INRAPE for analyses and certification needs clarification (p.15). The JEE specifically recommends elaborating and implementing national biosafety guidelines for animal husbandry (p.18). ⁶²⁶

The PANM RAM, while outlining a strategic plan for 2022-2026, emphasizes that achieving its objectives requires significant financial resources, with "mobilisation of additional funds" being crucial (p.58). ⁶²⁷ This suggests that despite the existence of a detailed plan, funding for its implementation, especially for animal health components, remains a challenge. The JEE also pointed out that while a Point Focal OIE exists and communicates regularly, the overall mechanisms for responding to infectious zoonoses remain limited, with a score of 1 out of 5, indicating very low capacity (p.14). This limitation points to a significant gap between communication of data and the actual functional mechanisms for response. ⁶²⁸

5.3.1a Biological and Toxin Weapons Convention status

Score: 100

Comoros is fully a State Party to the Biological Weapons Convention (BWC) with the same legal effect as ratification. ⁶²⁹

Signing the BWC was only possible before its entry into force on March 26, 1975. Comoros did not sign before that date (it was established as independent only on July 6, 1975). It therefore acceded (which has the same legal effect as ratification for states that didn't originally sign the treaty) on February 14, 2025. ⁶³⁰

5.3.1b Submission of CBMs to the Biological and Toxin Weapons Convention

Score: 0

Comoros has not submitted confidence building measures for the Biological Weapons Convention in the past three years. ⁶³¹

5.3.1c Submission of UNSCR 1540 reports

Score: 100

In 2018, Comoros provided the required United Nations Security Council Resolution (UNSCR) 1540 report to the Security Council Committee established pursuant to resolution 1540 (1540 Committee).

5.3.1d Extent of UNSCR 1540 implementation on public health emergencies

Score: 0

5.3.2a Membership in global health security and/or biological weapons agreements

Score: 0

Comoros is not a member of the Global Partnership Against the Spread of Weapons and Materials of Mass Destruction (GP), the Australia Group (AG), nor the Proliferation Security Initiative (PSI). ^632633634

5.4.1a Completion and publication of JEE (or GHSA pilot external assessment) report

Score: 0

Comoros conducted a Joint External Evaluation (JEE) in 2017 and released a comprehensive report in 2018. No subsequent evaluations have been published since then. ⁶³⁵

5.4.2a Completion and publication of PVS report (past five years)

Score: 0

Comoros has not completed and published a Performance of Veterinary Services (PVS) assessment in the last five years. ⁶³⁶

5.4.2b Completion and publication of PVS gap analysis (past five years)

Score: 0

Comoros has not completed and published a Performance of Veterinary Services (PVS) gap analysis in the last five years. ⁶³⁷

5.5.1a Evidence of allocated national funds to improve capacity to address epidemic threats

Score: 100

There is evidence that the Union of Comoros has allocated national funds to improve capacity to address pandemic or epidemic threats within the past three years, covering various initiatives and frameworks.

The National Multisectoral Action Plan to Combat Antimicrobial Resistance (PANM RAM) 2022-2026 explicitly details financial allocations, partly from the national budget, for activities addressing antimicrobial resistance, which is a significant epidemic threat. The government of Comoros has committed to providing "financial resources" for the implementation of this plan (p.v). The budget for this plan (Annexe 5) indicates that "State Budget" (BE) alongside Technical and Financial Partners (PTFs) are funding sources for various activities from 2022 to 2026 (p.XLVII). For instance, the functioning of the National Executive Secretariat for RAM (SNE RAM), a core coordination body, is budgeted with 61,140,000 KMF (around 143,859 USD) in 2023, with a progressive and sustainable relay by state resources planned for the long term (P.XLVII, p.viii, p.15). ⁶³⁸

Furthermore, the National Community Health Strategy 2024-2028 outlines an objective to establish a diversified financing mechanism that is "budgeted and integrated into the State budget" (p.40). This strategy, active from 2024, clearly states that community health services will benefit from "direct subsidies from the State" (p.40). ⁶³⁹

Additionally, within the broader disaster risk reduction framework, the country adopted a new Disaster Risk Reduction (DRR) Law in June 2024, which established the National Emergency and Resilience Fund (FNUR). Its creation through national law within the past three years signifies a structural commitment and mechanism for allocating funds to address various risks, including epidemics. ⁶⁴⁰ The earlier Joint External Evaluation (JEE) report from 2018 had noted the existence of an emergency fund equating to "5% of the state budget" for disasters, and recommended developing a financing plan for the International Health Regulations (IHR) implementation, including a "specific budget line that is funded to allow for timely, effective and efficient disbursement of funds" (p.6, p.38). ⁶⁴¹

5.5.2a National budget to address gaps identified in JEE, NAPHS or GHSA roadmap

Score: 0

There is no evidence that the latest Joint External Evaluation (JEE) report, National Action Plan for Health Security (NAPHS), and/or national GHSA roadmap allocate or describe specific funding from the national budget (covering a time-period either in the future or within the past five years) to address the identified gaps.

The Joint External Evaluation (JEE) report for Comoros describes specific funding from the national budget to address identified gaps related to emergency response and preparedness. Under the "Preparedness" section, the JEE report states: "Financially, 5% of the DGSC budget represents the emergency fund whose disbursement mechanisms are not known" (p. 32). This statement directly indicates an allocation from the national budget for an emergency fund, which is intended to address preparedness and response gaps, and was current at the time of the JEE in 2017. While the report itself identifies a challenge regarding the unknown disbursement mechanisms for these funds, its explicit mention of this budgetary allocation confirms that specific national budget funding is described for addressing identified gaps. ⁶⁴²

The National Contingency Plan 2017-2018 states that the Government of the Union of Comoros will allocate special financial resources to support entities involved in providing aid and assistance to disaster victims (p.24). This plan specifies the establishment of an emergency fund consisting of 5% of the national budget (p.24). However, the same document also identifies challenges such as "no budget chapter for emergencies at the ministerial level" and difficulties with mechanisms for the immediate release of emergency funds (p.26), indicating implementation issues despite the allocated fund. ⁶⁴³

Furthermore, the National Multisectoral Action Plan to Combat Antimicrobial Resistance (PANM RAM) 2022-2026 provides a detailed budget for its interventions. In its budget table, "BE/PTFs" (State Budget / Technical and Financial Partners) is listed as a source of financing across the years 2022 to 2026 (p.XLVII). While it often lumps the state budget with external partners, it explicitly budgets for several activities from 2022 through 2026, totaling, for instance, 27,576,497 Comorian Francs (KMF) for 2023 (approximately 56,125 USD at the time of budget validation) and significantly larger amounts for subsequent years (p.XLVII). The plan's summary mentions that "the acquisition of financial resources constitutes a major challenge" and that external partner support will be crucial, "followed by a progressive but sustainable relay by state resources" (p.vii). ⁶⁴⁴

The National Community Health Strategy 2024-2028 explicitly outlines an objective to "Establish a diversified financing mechanism aligned with a unique plan, budgeted and integrated into the State budget" (p.40). It states that community health services will benefit from "direct subsidies from the State" (p.40). The document's introduction to its financing section confirms that "The financing of the national community health strategy 2024-2028 will be ensured by the community, the state budget, the financing of programs and projects as well as by the contribution of bilateral and multilateral partners" (p.58). However, it also acknowledges a current limitation, stating that "the financial contribution of the Government is insufficient. This means that community health is essentially borne by the PTF (Technical and Financial Partners)" (p.58). ⁶⁴⁵

5.5.2b National budget to address gaps identified in PVS assessment or gap analysis

Score: 0

Comoros has not completed and published a Performance of Veterinary Services (PVS) assessment or gap analysis in the last five years. ⁶⁴⁶

5.5.3a Emergency public financing during a public health emergency

Score: 100

The Union of Comoros has publicly identified special emergency public financing mechanisms and funds that it can access in the face of a public health emergency, though challenges related to their operationalization and disbursement have been noted.

An emergency fund, constituting 5% of the national budget, has been established by the Government for disasters and other emergencies. This is explicitly stated in the National Contingency Plan 2017-2018 (p.24). ⁶⁴⁷ The Joint External Evaluation (JEE) report from 2018 further confirms the existence of this "emergency fund for disasters and other emergencies (5% of the state budget)" (p.38). This fund serves as a dedicated national reserve for emergency response, including public health crises. ⁶⁴⁸

In terms of accessing multilateral funding, the Directorate General of Civil Security (DGSC) is designated as the focal point for mobilizing external resources, which includes responding to United Nations (UN) appeals and engaging with bilateral partners (p.24). ⁶⁴⁹ Additionally, the Comorian Red Crescent (CRCo) has access to the Disaster Relief Emergency Fund (DREFF) for emergencies (p.38). This indicates established pathways for leveraging international and multilateral emergency funding mechanisms. The JEE also recommends establishing or strengthening regional and international agreements for acquiring, sharing, and receiving medical supplies and deploying personnel, which indirectly points to frameworks for accessing related financial support (p.38). ⁶⁵⁰

Despite the identification of these mechanisms, the functionality and immediate accessibility of the funds present significant gaps. The National Contingency Plan highlights "mechanism for immediate release of emergency funds" as a challenge for implementation (p.26). ⁶⁵¹ Moreover, the JEE report notes that while an emergency fund (5% of the national budget) exists, "the disbursement mechanisms are not known" (p.32). The JEE also identifies a "problem of disbursement/funding of the existing budget line" within the national legislation, policy, and financing framework (p.6). ⁶⁵² Another critical challenge cited in the National Contingency Plan is the absence of a dedicated "budget chapter for emergencies at the ministerial level", which could impede direct ministerial access to these funds (p.26). ⁶⁵³

The National Multisectoral Action Plan to Combat Antimicrobial Resistance (PANM RAM) 2022-2026 acknowledges that "the acquisition of financial resources constitutes one of the major challenges for the PANM" and relies heavily on external partners for initial funding, with a "progressive but sustainable relay by state resources" planned for the long term (p.vii, p.15). ⁶⁵⁴ The National Community Health Strategy 2024-2028 states that "the financial contribution of the Government is insufficient" for community health, with Technical and Financial Partners (PTF) bearing the primary financial burden (p.29, p.58). ⁶⁵⁵

5.5.4a Commitments to improve domestic or foreign capacity for epidemic threats

Score: 100

Within the past three years, senior leaders in the Union of Comoros have indeed made significant public commitments to bolster the nation's domestic capacity to counter pandemic and epidemic threats, both through expanded financing and active requests for external support. However, public evidence of commitments to provide financial or technical assistance to other countries for this purpose during the same period remains absent.

A key commitment to enhancing domestic resilience was demonstrated on September 14, 2025, when His Excellency Azali Assoumani, the President of the Union of the Comoros, publicly validated the National Disaster Risk Reduction Strategy and its Action Plan for 2024-2030. This comprehensive strategy explicitly addresses "biological and health risks," aiming to establish a cohesive, flexible, and sustainable system for overall risk reduction, thereby signifying a high-level strategic focus on preparedness for diverse threats, including epidemics, as outlined in "Comoros: New disaster risk reduction strategy | UNDRR" (October 2, 2025) and the National Strategy for Disaster Risk Reduction 2024-2030 (p. 12). ⁶⁵⁶⁶⁵⁷ Concurrently, a robust ministerial commitment to combat antimicrobial resistance (AMR), a recognized major global public health threat, was made in 2022. The preface of the National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 (p. v) details the public pledge from the Minister of Health, the Minister of Agriculture, and the Minister of Energy, Water, and Hydrocarbons to provide consistent leadership, administrative, technical, and financial backing for the implementation of the multisectoral action plan against AMR. ⁶⁵⁸ Further reinforcing this dedication to domestic capacity, the National Community Health Strategy 2024-2028 (p. 8, 40), with its preface endorsed by the Minister of Health, Solidarity, Social Protection, and Gender Promotion, articulates an objective to establish a diversified financing mechanism that is both budgeted and integrated into the State budget to support community health services. ⁶⁵⁹

The Union of Comoros has also actively pursued and secured substantial international financing and technical expertise to fortify its internal capabilities against epidemic threats. For instance, the nation benefited from the support of the World Health Organization (WHO) and the World Bank through the COMPASS project during the development of its PANM RAM, and it planned a donors' roundtable in the fourth quarter of 2022 to attract further funding for its operational blueprint, as noted in the National Multisectoral Action Plan to Combat Antimicrobial Resistance in the Union of the Comoros 2022-2026 (p. v, viii). ⁶⁶⁰ In response to the cholera epidemic that emerged in February 2024, a national preparedness and response plan was deployed with assistance from WHO, focusing on local capacity building and resource mobilization, as noted in the country profile on the WHO website. Similarly, technical and financial aid from partners, including the WHO Country Office, was instrumental in building capacity for leprosy elimination in 2024, a significant step in addressing neglected tropical diseases. ⁶⁶¹

Conversely, no direct public evidence within the national documents suggests that senior leaders of the Union of Comoros have, over the past three years, publicly committed to furnishing financial or technical assistance to other countries to strengthen their capacities against pandemic or epidemic threats. While the National Strategy for Disaster Risk Reduction 2024-2030 (p. 15) mentions promoting "South-South and triangular cooperation" to share disaster risk reduction practices, this remains a general cooperative ambition rather than a specific commitment to provide financial or direct technical support to other nations concerning epidemic threats within the specified timeframe. ⁶⁶²

5.5.4b Investments to improve domestic or foreign capacity for epidemic threats

Score: 100

There is no direct evidence in the national documents that the Union of Comoros has, in the past three years, provided other countries with financing or technical support to improve capacity to address epidemic threats. However, there is strong evidence that the Union of Comoros has, in the past three years, requested and received financing or technical support from donors to improve its domestic capacity to address epidemic threats.

While the Joint External Evaluation (JEE) report from 2018 mentions that Comoros had previously "sent agents to provide support abroad, as during the Ebola epidemic in Guinea" (p.38), this falls outside the specified three-year timeframe. ⁶⁶³ The National Strategy for Disaster Risk Reduction aux Comores 2024-2030 includes promoting "South-South and triangular cooperation" as a strategic action (p.15). ⁶⁶⁴

In the National Multisectoral Action Plan to Combat Antimicrobial Resistance (PANM RAM) 2022-2026 preface, it explicitly states: "In its commitment to fighting AMR, the Union of Comoros benefited from the support of WHO and the World Bank through the COMPASS project for the development of its PANM" (p.v). The plan outlines its intention to "Organize a donors' roundtable in the 4th quarter of 2022… for the financing of the 2023 operational action plan and the development of financing projects will be considered" (p.viii, p.14). The budget tables throughout the PANM RAM consistently list "BE/PTFs" (State Budget / Technical and Financial Partners) as funding sources for numerous activities from 2022 to 2026 (e.g., p.XLVII, p.XXII-XLVI), indicating ongoing reliance on donor support. ⁶⁶⁵

The country profile on the WHO website highlights recent support provided to Comoros. For the Cholera Epidemic Response (since February 2024): "The national preparedness and response plan encompassing prevention, vaccination, risk communication and surveillance has been rolled out with WHO assistance. Key actions include strengthening local capacities, conducting two vaccination campaigns, and mobilizing additional resources". For Leprosy Elimination (2024): "the Comoros received technical and financial assistance from partners, including the WHO Country Office, to build the capacity of Ministry of Health personnel". For the Health Data Management (DHIS2): "Since its launch in August 2022, DHIS2 has been supported by WHO and other partners, who have provided essential hardware and trained over 150 health care professionals". ⁶⁶⁶

The National Community Health Strategy (SNSC) 2024-2028 acknowledges significant reliance on external partners, stating that it seeks to respond to challenges "with significant support from technical and financial partners" (p.9). It also notes that "community health is essentially borne by the PTF [Technical and Financial Partners]" (p.58), indicating a current need for and reliance on external financing. ⁶⁶⁷

5.5.4c Evidence that the country has fulfilled its full WHO contribution within the past two years

Score: 100

There is evidence that the Union of Comoros has fulfilled its full contribution to the World Health Organization (WHO) within the past two years. The "Statement of Account" for Comoros, current as of 31 May 2025, indicates that the assessed contributions for both 2023 and 2024 have been fully paid. ⁶⁶⁸

For the year 2023, the assessed contribution was 4,780 CHF (Swiss Francs), and a receipt application for this exact amount was recorded on 5 May 2025. Similarly, for the year 2024, the assessed contribution was 5,740 CHF, and a corresponding receipt application for 5,740 CHF was also recorded on 5 May 2025. These receipt dates fall within the past two years from the perspective of the current system date, and the amounts precisely match the assessed contributions for those years, indicating full fulfillment (p.1). ⁶⁶⁹

5.6.1a Sharing of genetic/biological data and materials beyond influenza

Score: 0

There is no publicly available comprehensive plan or policy identified in the national documents for the Union of Comoros that specifically outlines the sharing of genetic data, clinical specimens, and/or isolated specimens (biological materials) along with associated epidemiological data with international organizations and/or other countries, extending beyond influenza.

The Joint External Evaluation (JEE) report from 2018 notes the "existence of procedures with external laboratories for tests not performable nationally" (p.22). It also mentions "a structured circuit of transport and transfer of samples to the WHO collaborating laboratory abroad" for poliovirus, as well as a "system for sample transfer and transport within the framework of surveillance of diseases with epidemic potential" (p.17, p.23). However, these instances describe practices of sending samples for diagnostic purposes or within specific disease programs (like polio), rather than a publicly available overarching policy for genetic data or biological materials sharing across various pathogens with international entities. ⁶⁷⁰ The JEE report highlights a general deficiency in documented procedures, stating that "the lack of documentation and written procedures for a large number of activities is one of the challenges" (p.2). ⁶⁷¹

The National Multisectoral Action Plan to Combat Antimicrobial Resistance (PANM RAM) 2022-2026 mentions enrolling the country in the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS), which involves sharing surveillance data (p.XXIX). However, GLASS primarily involves epidemiological and aggregate resistance data, not typically raw genetic data or clinical specimens. The PANM RAM emphasizes internal data collection and information sharing among national stakeholders (p.6) and aims to strengthen laboratory capacities for detecting resistant pathogens internally (p.10). ⁶⁷²

The National Community Health Strategy 2024-2028 and the National Contingency Plan 2017-2018 focus on internal health system organization, emergency response coordination, and information sharing within the country and with humanitarian partners, without detailing policies for sharing biological materials or genetic data internationally. ⁶⁷³⁶⁷⁴

5.6.1b Evidence of non-compliance with sample sharing element of PIP framework

Score: 100

Publicly available evidence indicating that Comoros has not shared samples in accordance with the Pandemic Influenza Preparedness (PIP) Framework in the past two years is not available.

A review of general public health reports from Comoros and WHO communications does not reveal any explicit public statements or reports of non-compliance by Comoros regarding sample sharing under the PIP Framework in the specified timeframe. ⁶⁷⁵

No relevant evidence was found on the website of the Presidency of the Union of Comoros. ⁶⁷⁶

The Ministry of Health, Solidarity, Social Protection and Gender Promotion and the Ministry of Agriculture, Fisheries and Crafts do not have official websites. They only have online presence on Facebook. ⁶⁷⁷⁶⁷⁸

5.6.1c Evidence of non-sharing of pandemic pathogen samples during an outbreak

Score: 100

There is no public evidence that the Union of Comoros has not shared pandemic pathogen samples during an outbreak in the past two years.

The country profile on the WHO website notes a significant public health event within this timeframe. For Cholera Epidemic, "Since 2 February 2024, the Comoros has been managing a cholera epidemic. The national preparedness and response plan encompassing prevention, vaccination, risk communication and surveillance has been rolled out with WHO assistance." While this confirms a major outbreak, it does not provide any information about whether samples related to this cholera epidemic were shared (or not shared) with international partners or organizations. It focuses on the response, WHO assistance, and challenges, but does not touch upon the specific act of pathogen sample sharing for this or any other outbreak. ⁶⁷⁹

6.1.1a Policy formation

Score: 0

6.1.1b Quality of bureaucracy

Score: 0

6.1.1c Excessive bureaucracy/red tape

Score: 0

6.1.1d Vested interests/cronyism

Score: 0

6.1.1e Corruption

Score: 21

6.1.1f Accountability of public officials

Score: 0

6.1.1g Human rights risk

Score: 0

6.1.2a Orderly transfers of power

Score: 0

6.1.3a Risk of social unrest

Score: 0

6.1.4a Risk of terrorism

Score: 0

6.1.4b Level of illicit arms flows within the country

Score: 50

6.1.4c Risk of organized criminal activity

Score: 0

6.1.5a Presence or risk of armed conflict

Score: 0

6.1.6a Government territorial control

Score: 100

6.1.7a International tensions

Score: 0

6.2.1a Adult literacy rate (15+ years old, both sexes)

Score: 80.29

6.2.2a UNDP Gender Inequality Index score

Score: 40.09

6.2.3a Poverty gap at $1.90 a day (2011 PPP) (%)

Score: 76.75

6.2.3b Share of employment in the informal sector

Score: 0

6.2.3c Coverage of social insurance programs (% of population)

Score: 0

6.2.4a Public confidence in government

Score: 0

6.2.5a Robust, open, diverse local media and reporting

Score: 50

6.2.6a Gini coefficient

Score: 54.7

6.3.1a Adequacy of road network

Score: 0

6.3.2a Adequacy of airports

Score: 0

6.3.3a Adequacy of power network

Score: 0

6.4.1a Urban population (% of total population)

Score: 79.96

6.4.2a Change in forest area (percentage points)

Score: 48.49

6.4.3a Natural disaster risk

Score: 0

6.5.1a Total life expectancy (years)

Score: 55.86

6.5.1b NCD mortality rate

Score: 70.08

6.5.1c Population aged 65+

Score: 78.19

6.5.1d Tobacco use (% of adults)

Score: 35.93

6.5.1e Level of adult obesity (%)

Score: 70.57

6.5.1f Age-standardised prevalence of mental health disorders (per 100 000 people)

Score: 73.9

6.5.2a Access to potable water

Score: 84.98

6.5.2b Access to at least basic sanitation facilities

Score: 56.94

6.5.2c Percentage of health-care facilities with no access to any electricity supply

Score: 0

6.5.3a Domestic general government health expenditure per capita (PPP)

Score: 2.6

6.5.4a Trust medical and health advice from the government

Score: 0

6.5.4b Trust medical and health advice from medical workers

Score: 0