Nigeria's Joint External Evaluation and National Action Plan for Health Security.

Nigeria is working to protect against and respond more effectively to disease outbreaks. Quick mobilization and control of the Ebola epidemic in 2014, at least 4 major domestic outbreaks each year, and significant progress toward polio eradication led to adoption of the World Health Organization's Global Health Security Joint External Evaluation (JEE) and National Action Plan for Health Security (NAPHS). The process required joint assessment and planning among many agencies, ministries, and sectors over the past 2 years. We carried out a JEE of 19 core programs in 2017 and launched a detailed NAPHS to improve prevention, detection, and response in December 2018, which required us to create topic-specific groups to document work to date and propose JEE scores. We then met with an international team for 5 days to review and revise scoring and recommendations, created a 5-year implementation plan, developed a management team to oversee implementation, drafted legislation to manage outbreaks, trained professionals at state and local levels of government, and set priorities among the many possible activities recommended. Management software and leadership skills were developed to monitor global health security programs. We learned to use international assistance strategically to strengthen planning and mentor national staff. Finally, a review of every major disease outbreak was used to prepare for the next challenge. Review and adaptation of this plan each year will be critical to ensure sustained momentum and progress. Many low-income countries are skilled at managing vertical disease control programs. Balancing and combining the 19 core activities of a country's public health system is a more demanding challenge.

Improving Cross-Border Preparedness and Response: Lessons Learned from 3 Lassa Fever Outbreaks Across Benin, Nigeria, and Togo, 2017-2019.

Long-standing cultural, economic, and political relationships among Benin, Nigeria, and Togo contribute to the complexity of their cross-border connectivity. The associated human movement increases the risk of international spread of communicable disease. The Benin and Togo ministries of health and the Nigeria Centre for Disease Control, in collaboration with the Abidjan Lagos Corridor Organization (a 5-country intergovernmental organization) and the US Centers for Disease Control and Prevention, sought to minimize the risk of cross-border outbreaks by defining and implementing procedures for binational and multinational public health collaboration. Through 2 multinational meetings, regular district-level binational meetings, and fieldwork to characterize population movement and connectivity patterns, the countries improved cross-border public health coordination. Across 3 sequential cross-border Lassa fever outbreaks identified in Benin or Togo between February 2017 and March 2019, the 3 countries improved their collection and sharing of patients' cross-border travel histories, shortened the time between case identification and cross-border information sharing, and streamlined multinational coordination during response efforts. Notably, they refined collaborative efforts using lessons learned from the January to March 2018 Benin outbreak, which had a 100% case fatality rate among the 5 laboratory-confirmed cases, 3 of whom migrated from Nigeria across porous borders when ill. Aligning countries' expectations for sharing public health information would assist in reducing the international spread of communicable diseases by facilitating coordinated preparedness and responses strategies. Additionally, these binational and multinational strategies could be made more effective by tailoring them to the unique cultural connections and population movement patterns in the region.

Performance of the Public Health System During a Full-Scale Yellow Fever Simulation Exercise in Lagos State, Nigeria, in 2018: How Prepared Are We for the Next Outbreak?

Recurring outbreaks of infectious diseases have characterized the West African region in the past 4 decades. There is a moderate to high risk of yellow fever in countries in the region, and the disease has reemerged in Nigeria after 21 years. A full-scale simulation exercise of the outbreak of yellow fever was conducted to assess preparedness and response in the event of a full-scale outbreak. The exercise was a multi-agency exercise conducted in Lagos, and it involved health facilities, points of entry, state and national public health emergency operation centers, and laboratories. An evaluation of the exercise assessed the capability of the system to identify, respond to, and recover from the emergency using adapted WHO tools. The majority of participants, observers, and evaluators agreed that the exercise was well-structured and organized. Participants also strongly agreed that the exercise helped them to identify strengths and gaps in their understanding of the emergency response systems and plans. Overall, the exercise identified existing gaps in the current capabilities of several thematic areas involved in a yellow fever response. The evaluation presented an opportunity to assess the response capabilities of multisectoral collaborations in the national public health system. It also demonstrated the usefulness of the exercise in understanding public health officials' roles and responsibilities; enabling knowledge transfer among these individuals and organizations; and identifying specific public health systems-level strengths, weaknesses, and challenges.