Joint external evaluation of the International Health Regulations (2005) core capacities of Nigeria: mission report, 14-18 August 2023

Joint external evaluation of the International Health Regulations (2005) core capacities of Nigeria Mission report: 14–18 August 2023

Joint external evaluation of the International Health Regulations (2005) core capacities of Nigeria Mission report: 14–18 August 2023 Joint external evaluation of the International Health Regulations (2005) core capacities of Nigeria: mission report, 14-18 August 2023 ISBN 978-92-4-010298-9 (electronic version) ISBN 978-92-4-010299-6 (print version) © World Health Organization 2024 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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Editing, design and layout by Genève Design iii Contents Acknowledgements . . . . . . . . . . . . . . . . . . . . v Acronyms and abbreviations . . . . . . . . . . . . . . . . . . vi Executive summary . . . . . . . . . . . . . . . . . . . . vii Nigeria: scores and priority actions . . . . . . . . . . . . . . . . 3 Prevent ————————————————————— 10 P1. Legal instruments . . . . . . . . . . . . . . . . . . . . 11 P2. Financing . . . . . . . . . . . . . . . . . . . . . . 13 P3. IHR coordination, national IHR focal point functions and advocacy . . . . . . 15 P4. Antimicrobial resistance (AMR) . . . . . . . . . . . . . . . . 18 P5. Zoonotic disease . . . . . . . . . . . . . . . . . . . . 22 P6. Food safety . . . . . . . . . . . . . . . . . . . . . 24 P7. Biosafety and biosecurity . . . . . . . . . . . . . . . . . . 26 Detect ————————————————————— 31 D1. National laboratory system . . . . . . . . . . . . . . . . . 32 D2. Surveillance . . . . . . . . . . . . . . . . . . . . . 36 D3. Human resources . . . . . . . . . . . . . . . . . . . . 39 Respond ———————————————————— 43 R1. Health emergency management . . . . . . . . . . . . . . . . 44 R2. Linking public health and security authorities . . . . . . . . . . . . 50 R3. Health services provision . . . . . . . . . . . . . . . . . . 52 R4. Infection prevention and control . . . . . . . . . . . . . . . . 55 IHR-related hazards, points of entry and border health —————————————————— 63 POE. Points of entry and border health . . . . . . . . . . . . . . . 64 CE. Chemical events . . . . . . . . . . . . . . . . . . . . 66 RE. Radiation emergencies . . . . . . . . . . . . . . . . . . 69 Annex: JEE Background ————————————— 72

v Acknowledgements The Joint External Evaluation (JEE) Secretariat of the World Health Organization (WHO) would like to sincerely appreciate the following, whose support and commitment to the principles of the International Health Regulations (2005) (IHR) have ensured efficacious outcomes for this JEE: • the Government and national experts of Nigeria for their work in preparing for the JEE mission; • the Governments of the Gambia, Kenya, the United States of America, and Zimbabwe for providing technical experts for the peer-review process; • the Global Health Security Agenda Initiative for its collaboration and support; • the Food and Agriculture Organization of the United Nations (FAO), the United States Centers for Disease Control and Prevention (US CDC), Resolve to Save Lives, and FHI 360 for their contribution of experts and technical staff; • the following WHO entities: WHO headquarters, the WHO Regional Office for Africa, and the WHO Country Office for Liberia which sent experts; and • the US CDC for their financial support to this mission. vi Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Acronyms and abbreviations AMR Antimicrobial Resistance AMS Antimicrobial Stewardship BHCPF Basic Health Care Provision Fund CBRN Chemical, Biological, Radiological and Nuclear COVID-19 Coronavirus disease DE Deliberate Event EHS Essential Health Services FAO Food and Agriculture Organization of the United Nations FETP Field Epidemiology Training Programme HCAI Healthcare-Associated Infections IAEA International Atomic Energy Agency IDSR Integrated Disease Surveillance and Response IHR International Health Regulations IMPACT Improving Public Health Management for Action IMS Incident Management System IPC Infection Prevention and Control JEE Joint External Evaluation MDAs Ministries, Departments and Agencies MDRO Multidrug-Resistant Organism M&E Monitoring and Evaluation MLSCN Medical Laboratory Science Council of Nigeria NADIS National Animal Disease Information and Surveillance NAFDAC National Agency for Food and Drug Control NAPHS National Action Plan for Health Security NCDC Nigeria Centre for Disease Control and Prevention NFELTP Nigeria Field Epidemiology and Laboratory Training Programme NFP National IHR Focal Point PHEOC Public Health Emergency Operations Centre POE Points of Entry RCCE Risk Communication and Community Engagement RRT Rapid Response Team SOP Standard Operating Procedure SORMAS Surveillance Outbreak Response Management Analysis System SURGE Strengthening and Utilizing Response Groups for Emergencies TWG Technical Working Group VHF Viral Haemorrhagic Fever WHO World Health Organization vii Executive summary The Joint External Evaluation (JEE) team acknowledges Nigeria for volunteering for a second JEE after holding its first in 2017 and an internal mid-term JEE in 2019. This JEE uses the third edition of the JEE tool. This revised third edition of the tool incorporates relevant lessons from the ongoing COVID-19 pandemic and other public health emergencies. Nigeria’s broad efforts to prepare for and respond to emergencies have clearly facilitated its whole-of- government response to the COVID-19 pandemic. The unprecedented nature, magnitude and wide societal impact of the pandemic has led to improvisation and innovation. As a result, emergency risk management stakeholders in Nigeria have been keen to combine the many lessons of the pandemic response – consolidated through intra-action reviews – and to address gaps in IHR core capacities identified through the JEE. The JEE team commends Nigeria for its efforts to monitor and improve health security with openness, transparency and goodwill. Findings from the joint external evaluation The JEE mission took place in Abuja from 14–18 August 2023. Nigeria’s capacities in 19 technical areas were evaluated through a peer-to-peer, consultative process that brought national subject matter experts and development partners together with the multinational, multidisciplinary expert JEE team for a week of discussion, interaction, and selected site visits. After a week of collaborative talks, this process led to consensus on scores and priority actions across the 19 technical areas, presented with the aim of improving implementation of the IHR (2005) to enhance health security and the resilience of the Nigeria health system in emergencies. While specific recommendations are made in the respective sections of this report, the evaluation also generated six wider, overarching recommendations. These recommendations, outlined below, address cross-cutting challenges affecting Nigeria’s capacities across many of the different technical areas that were explored in the JEE process. Five broader policy principles underpin these recommendations. The first is a need for strong governance mechanisms, facilitated by the highest levels of leadership, that ensure improved intra- and multisectoral and One Health coordination and collaboration (i.e. the horizontal harmonization of actions). These appear to be largely in place at the central level but not well established yet in many states. The second is the need to elaborate and endorse the legal and regulatory mechanisms, plans, standard operating procedures (SOPs), budgets, etc., that are needed to improve coordination and clarify roles across the three tiers of government in Nigeria’s federalized structure of governance and administration (i.e. the vertical integration of actions). Again, legal and regulatory status has greatly improved in recent years, but there is more to do, especially at the state level. Supporting both is the third principle: the need to strengthen the implementation of the statutes and guidance agreed upon nationally. To be sure, implementation has started, but when the JEE team probed what is being done, the first answer often provided was, ‘We have developed a plan for that’. Planning is a necessary start, but better plans will emerge as the Nigeria Centre for Disease Control and Prevention (NCDC) and its stakeholders learn from further implementation. viii Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria The fourth principle underpins all these efforts: the development and strengthening of an integrated, interoperable information management framework and architecture – supported by a strategy for optimal use of the right information and communication tools – that breaks down data and information silos and enables efficient sharing and analysis of data. This data can then be used to generate evidence that supports decision-making and action for health emergency risk management. This is a common problem in many countries, as many parts of an information system in public health have evolved independently, and their combination and use for analysis require additional advanced training, norms and technology. Finally, bringing these benefits to where they are most needed and supporting the Nigerian Constitution’s goal of universal access to health care, the fifth principle is to bridge gaps between authorities/service providers and communities. This can be done by planning and implementing actions that truly involve the whole of society and strengthening community protection mechanisms, including risk communication and community engagement (RCCE) that meets the needs and ensures the rights of the most vulnerable. Modern risk communication and engagement is a proactive activity requiring systems that reach people where they live and work. This is not yet well developed in Nigeria. Overarching recommendations of the JEE 1. Develop a five-year, risk-based, prioritized and costed National Action Plan for Health Security (NAPHS) based on the recommendations of the JEE report and after-action reviews – such a NAPHS should be very different from the country’s first NAPHS. New guidance from WHO rightly focuses on goal setting for five years, with detailed planning only for the next 1–2 years. No country can do all that is recommended, so priorities must be set with the specification of individuals responsible for each area and a plan and time frame for implementing and monitoring activities. Annual planning can occur in conjunction with annual State Party Self-Assessment Annual Reporting updates. Shortages of funds and staffing are limitations both here and around the world, but there are no excuses for complacency. International funding and technical support are available as never before, and these should be taken advantage of. While the current JEE shows significant progress, Nigeria has the potential to achieve much more. A NAPHS that emphasizes sustained, institutionalized funding aligned with national fiscal and budget processes, and that fosters intersectoral/One Health coordination while explicitly addressing staff incentives and retention, will strengthen the foundations of the health sector’s efforts to build and maintain core capacities under the IHR (2005). The NAPHS is not a stand-alone plan, and other sector-specific plans will be critical to its success: for example, a One Health Action Plan provides a framework for multisectoral information-sharing and coordinated cross-sectoral responses to outbreaks of endemic, emerging or re-emerging zoonotic diseases by the human health, animal health and environmental sectors. In addition to recommendations arising from the JEE, Nigeria has other robust recommendations for disaster and public health emergency preparedness, response and recovery. Every response should be evaluated, and every evaluation should help strengthen goal setting and planning in the NAPHS. As never before, you can see where you have come from, where you now are, and what you can aspire to achieve. ix Abbreviations 2. Update the national multihazard health emergency preparedness and response plan guided by the recently concluded strategic assessment of risks with multisectoral engagement and accountability, clearly aligned to the national disaster risk management architecture, strategy and plan. Ensure the rapid endorsement and implementation of this plan to enable national response readiness. Support provincial and local governments to develop similar plans contextualized to their risk profiles – but clearly aligned to the national plan to ensure vertical integration of preparedness and response actions. Then, all that remains is to carry out the plan and monitor its implementation. Nigeria has developed and uses several hazard-specific preparedness and response plans (including for earthquakes, monsoon floods, landslides and various infectious hazards). While some of these plans are multisectoral – assigning roles and responsibilities across all relevant sectors, including health – many are sector-specific and lack clear articulation of the intersectoral and intergovernmental coordination mechanisms needed for whole-of-government action. The development and implementation of multihazard health emergency preparedness and response plans at all tiers of government and administrative levels – whether federal, state, local government or wards – would lead to more harmonized and accountable action by all relevant stakeholders. These plans require a multisectoral/One Health approach that considers and aligns with the existing hazard- and sector-specific preparedness and response plans that have served the country so well. 3. Develop an accountability framework and SOPs for intra- and intersectoral coordination and communication, including the security apparatus, the private sector and civil society. This should be done with the goal of improving the outcomes of better prevention, quicker reporting and more effective response. Many relatively easy, cost-effective wins can be achieved quickly for health security in Nigeria if cross- sectoral working can be institutionalized. For example, valuable information is currently generated by human and animal health laboratories through the samples they process; health facilities generate clinical information; and a wide range of surveillance, outbreak response and epidemiological information is generated by different institutions according to their roles. Strengthened communication, coordination and effective sharing between these information streams will avoid duplication of information, enable comprehensive risk assessment and holistic decision-making, and leverage actions within different sectors to achieve a higher probability of the intended results being achieved. In another example, the food safety sector currently has some laboratory capacity to investigate the etiology of food poisoning and contamination, while laboratories in the human and animal health sectors have the capacity to investigate the etiology of foodborne outbreaks by identifying the causative pathogens. Developing and institutionalizing mechanisms for collaboration and joint investigation of foodborne outbreaks, with harmonized protocols and information-sharing through interoperable data platforms, would reduce the national burden of foodborne illnesses without requiring significant additional resources. xJoint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria 4. To empower and enable the implementation of actions to address the gaps in health security identified by the JEE and the lessons of the COVID-19 pandemic and other emergencies/disasters: a. map, review, and amend/update existing legal, regulatory and administrative instruments and develop new instruments that are critically needed; b. complete an assessment of current and potential financial resources and plan for the possibility of enhanced international support over the next five years; and c. map essential public health functions: assess the competencies needed; identify gaps in human resources; and develop, endorse, and implement (1) a national, multisectoral workforce plan, (2) a national human resources capacity-building strategy and action plan, and (3) a national partnerships platform to strengthen systems for One Health security, including for surge response during emergencies. Robust laws and regulations, adequate financing and sufficient human resources and capacities are essential for effective action. They are also essential to ensure the resilience of the health system and other critical systems during emergencies. Though it can be very challenging, due consideration and consistent attention are needed to ensure these enablers are sustained and the priority actions of the JEE can be transformed into the expected outcomes and impact. The COVID-19 pandemic showed the importance of engaging and empowering communities and co- creating interventions to mitigate the adverse consequences of disease and the infodemic that can accompany it. Neither compliance with public health and social measures nor the use of countermeasures and vaccines would have been possible without placing communities at the centre of planning, prioritization, implementation and course correction. Special attention needs to be given to the most vulnerable people in any community – those who are most impacted, both directly in terms of morbidity, mortality and mental health, and indirectly through loss of livelihoods, income and education, reduced prospects for progress and being pushed back into poverty. Whole-of-government efforts must expand to whole-of-society engagement, protecting the most vulnerable from future emergencies by engaging them in an equitable, inclusive, rights-enhancing manner throughout the emergency risk management cycle. 1Nigeria: scores and priority actions Scores: 1=No capacity; 2=Limited capacity; 3=Developed capacity; 4=Demonstrated capacity; 5=Sustainable capacity. Technical areas Indicator number Indicator Score Priority actions Prevent P1. Legal instruments P1.1. Legal instruments 2 • Conduct subnational legal assessments of health laws in all states of the federation and develop and revise the necessary legal instruments for IHR implementation at these intermediate levels, where applicable. • Conduct a comprehensive gender assessment of legal instruments to identify and address gender- related considerations. • Establish a framework (legislative or administrative) for legal surveillance across ministries, departments and agencies (MDAs), ensuring periodic reviews of all health security-related legal instruments in the country. • Prioritize capacity-building initiatives for legal officers in the field of public health laws. • Prioritize securing adequate funding for legal activities related to public health laws, such as creating a dedicated budget line to support legal surveillance, periodic reviews and reforms, ensuring the effective implementation of public health legislation. P1.2. Gender equity and equality in health emergencies 1 P2. Financing P2.1. Financing for IHR implementation 2 • Develop a framework for monitoring and accountability mechanisms for IHR and NAPHS implementation across MDAs at national and subnational levels. • Elevate health security, IHR and NAPHS implementation into the Medium-Term Expenditure Framework and national budget processes. • Operationalize the health emergency financing mechanism of the Basic Health Care Provision Fund (BHCPF) at subnational level. • Develop a public health emergency fund within five years and streamline existing emergency funding mechanisms by international partners and private sectors into this fund. P2.2. Financing for public health emergency response 2 2Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Technical areas Indicator number Indicator Score Priority actions P3. IHR coordi- nation, National IHR focal point functions and advocacy P3.1. National IHR Focal Point functions 3 • Conduct a summative evaluation of the current NAPHS. • Develop a new five-year NAPHS for Nigeria. • Design and conduct subnational health security assessment exercises across states and develop the corresponding State Action Plan for Health Security. • Develop an evidence-informed advocacy strategy and disseminate it through the national and intermediate levels. • Review and update multihazard and contingency plans. P3.2. Multisectoral coordi- nation mechanisms 3 P3.3. Strategic planning for IHR, prepared- ness or health se- curity 3 P4. Antimi- crobial resistance (AMR) P4.1. Multisectoral coordi- nation on AMR 4 • Finalize the National Action Plan for AMR 2.0 and implement (including costed, budgeted operational and monitoring and evaluation (M&E) framework). • Develop an advocacy plan for the domestic dedicated budget. • Develop an integrated AMR surveillance system with priority pathogens (Conduct a One Health AMR prevalence survey). • Develop a standardized case definition of multidrug-resistant organism (MDRO) to be used in Nigeria by all healthcare facilities. • Map existing law for One Health (tripartite sectors) and review and update national legislation to cover all aspects including the implementation framework. P4.2. Surveillance of AMR 2 P4.3. Prevention of multidrug-resistant organisms (MDROs) 1 P4.4. Optimal use of anti- microbial medicines in human health 3 P4.5. Optimal use of anti- microbial medicines in animal health and agriculture 2 P5. Zoonotic disease P5.1. Surveillance of zoo- notic diseases 3 • Develop an interoperable surveillance and analysis platform at national and state levels. • Review outbreaks to develop and disseminate improved outbreak identification and reporting materials. • Above all implement animal identification practices P5.2. Response to zoo- notic diseases 3 P5.3. Sanitary animal pro- duction practices 1 P6. Food safety P6.1. Surveillance of food- borne diseases and contamination 3 • Develop self-study training materials with well- defined steps to investigate possible foodborne illness. • Integrate foodborne illness into the Integrated Disease Surveillance and Response (IDSR) database. • Work with health communications to prepare communication materials for foodborne and food safety materials. P6.2. Response and man- agement of food safety emergencies 3 3Nigeria: scores and priority actions Technical areas Indicator number Indicator Score Priority actions P7. Biosafety and bios- ecurity P7.1. Whole-of-govern- ment biosafety and biosecurity system is in place for human, animal, and agricul- ture facilities 2 • Develop a plan specifying the responsibility of key governmental MDAs with generic terms of reference for coordination of inventory and records for high-consequence pathogens in the country. • Work with the responsible MDAs to plan and operationalize the biosafety and biosecurity preservice training curriculum in institutions of higher learning. • Aim to create a four-fold increase in the number of laboratory professionals trained in biological risk management within the health system at national and subnational levels across all sectors. • Aim to plan and conduct defined periodic biological risk assessments in laboratories across all sectors at national and subnational levels. • Work with MDAs to develop a biosecurity framework specifying oversight responsibilities for dual use research of concern and a responsible code of conduct for life scientists in the country. P7.2. Biosafety and bios- ecurity training and practices in all rele- vant sectors (includ- ing human, animal and agriculture) 2 P8. Immuniza- tion P8.1. Vaccine coverage (measles) as part of national programme 2 • Aggressively develop and disseminate communications materials to combat vaccine misinformation. • Develop working relations with primary and secondary medical facilities to identify missed populations for priority vaccines. • Improve data management to mobilize vaccination efforts better. P8.2. National vaccine ac- cess and delivery 4 P8.3. Mass vaccination for epidemics of vaccine preventable diseases (VPDs) 4 Detect D1. National laboratory system D1.1. Specimen referral and transport sys- tem 2 • Aim to expand the national integrated sample transportation and referral system to cover all priority pathogens for the three tiers of laboratories and across all sectors (One Health). • Develop and implement a national diagnostic network optimization framework for all tiers of laboratories (including private and faith- based laboratories) and cross sectors for clinical diagnostics, detection and surveillance of priority pathogens. • Work with the relevant MDAs to increase by six-fold the number of trained and certified biomedical engineers in all three sectors of One Health. • Empower the accredited national reference laboratories to expand the external quality assurance and quality improvement implementation across all tiers of the national laboratory network to support AMR and infection prevention and control (IPC) core capacities. • Develop a plan to implement remote logging and interoperable laboratory information systems covering all priority pathogens at all tiers of laboratories across all sectors. D1.2. Laboratory quality system 3 D1.3. Laboratory testing capacity modalities 3 D1.4. Effective national diagnostic network 3 4Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Technical areas Indicator number Indicator Score Priority actions D2. Surveillance D2.1. Early warning sur- veillance function 3 • Integrate early warning surveillance functions in private and public sectors across all One Health sectors and levels. • Ensure full-scale deployment of surveillance outbreak response management analysis system (SORMAS) to health facilities (public and private). • Train and retrain staff on epidemiological investigations especially at subnational levels across all sectors. • Implement community-based surveillance across all 36 states and the Federal Capital Territory. • Establish interoperability between the different systems across the different sectors: environment (Integrated National Environmental Surveillance System), animal (National Animal Disease Information and Surveillance (NADIS)) and human health (SORMAS, District Health Information System 2). D2.2. Event verification and investigation 4 D2.3. Analysis and infor- mation sharing 3 D3. Human resources D3.1. Multisectoral work- force strategy 3 • Develop mechanisms for better retention of skilled professionals, including career paths for epidemiologists and other emergency responders. • Improve recruitment mechanisms for both additional long-term health workers and emergency short-term volunteers. • Update the public health multisectoral strategy to include the implementation plan, budgeting and funding mechanisms. • Develop a comprehensive sustainability plan for Nigeria field epidemiology and laboratory training programme (NFELTP), improving public Health management for action (IMPACT), strengthening and utilizing response groups for emergencies (SURGE), etc. • NCDC should align, collaborate and participate in the implementation of the national surge capacity- building in line with its mandate. D3.2. Human resources for implementation of IHR 3 D3.3. Workforce training 3 D3.4. Workforce surge during a public health event 2 5Nigeria: scores and priority actions Technical areas Indicator number Indicator Score Priority actions Respond R1. Health emergency manage- ment R1.1. Emergency risk as- sessment and readi- ness 3 • Increase the number of events to which the PHEOC responds. • Integrate Inter- and after-action reviews as a routine part of response, including 7-1-7. • Develop self-directed training materials for those staffing national and state emergency operations centre and rapid response team (RRT) staff. • Lead research with an applied, practical, research agenda. R1.2. Public health emer- gency operations centre (PHEOC) 4 R1.3. Management of health emergency response 4 R1.4. Activation and co- ordination of health personnel in a pub- lic health emergency 3 R1.5. Emergency logistic and supply chain management 3 R1.6. Research, develop- ment and innovation 2 R2. Linking public health and security authorities R2.1. Public health and security authorities (e.g. law enforce- ment, border con- trol, customs) are linked during a sus- pect or confirmed biological, chemical, or radiological event 2 • Empower the Office of National Security Advisor Focal Point with real-time data visualization capability (dashboards) at the Technical Working Group (TWG) Secretariat for monitoring, evaluation, review and timely decision making during deliberate events (DEs). • Aim to develop, validate, and implement a national protocol for joint investigations, incident reporting and information sharing between public health NFP and law enforcement (local and international). • Aim to create a five-fold increase in the number of public health and security personnel trained as front-line responders for ambiguous or DEs of chemical, biological, nuclear, radiation, explosives origin. • Review employment levels, set goals, identify conditions affecting retention and distribution of trained public health and security personnel, and improve training and staffing for trained first responders to DEs. • Develop a plan and work with the WHO country office to deepen the assessment of ambiguous or suspected DEs involving chemical, radiological, biological and nuclear (CBRN) hazards using the National Self-Assessment Tool and regularize simulation exercises/ tabletop exercises for DEs. 6Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Technical areas Indicator number Indicator Score Priority actions R3. Health services provision R3.1. Case management 1 • Develop a governance accountability and coordination framework with periodic (five-year) review for maintaining EHS during emergencies. • Develop a monitoring, evaluation, accountability and learning framework for implementing post- event improvement plans. • Establish telemedicine options for service delivery during emergencies. • Mobilze resources for increased frequency of simulation exercises and post-event reviews at all levels. R3.2. Utilization of health services 2 R3.3. Continuity of essen- tial health services (EHS) 2 R4. Infection prevention and control (IPC) R4.1. IPC programmes 3 • Institutionalize the IPC programme by getting approval for the revised national IPC policy, finalize the IPC legal framework development and implement a budget advocacy plan for IPC at subnational level. • Develop a national IPC (in-service) training plan and preservice curriculum. • Finalize and validate the updated healthcare- associated infections (HCAI) plan and incorporate secondary health facilities into the national HCAI surveillance network. • Revise and update the IPC M&E framework to include Infection Prevention and Control Assessment Framework – Minimum Requirements. • Develop national standards for safe environments in healthcare facilities. R4.2 HCAI surveillance 2 R4.3. Safe environment in health facilities 1 R5. Risk com- munication and com- munity en- gagement (RCCE) R5.1. RCCE systems for emergencies 3 • Empower the subnational level to promote ownership of sustained coordination, implementation, M&E of One Health RCCE activities at all levels. • Scale up infodemic management and other RCCE strategies/interventions at subnational level. • Sustain capacity-building for message co-creation and RCCE competencies at all levels. • Advocate for the creation of a dedicated budget line for RCCE and health promotion as well as the institutionalization of RCCE across relevant MDAs and at all administrative levels. • Scale up the use of participatory approaches, social behavioural research and feedback mechanisms (offline and online) for evidence based RCCE and health promotion intervention at all levels. R5.2. Risk communication 3 R5.3. Community engage- ment 3 7Nigeria: scores and priority actions Technical areas Indicator number Indicator Score Priority actions IHR-related hazards, Points of entry and Border health POE: Points of entry and border health POE1. Core capacity re- quirements at all times for POE (air- ports, ports and ground crossings) 4 • Integrate POE into radiological and chemical surveillance system. • Port Health Service to improve POE or exit RCCE among border communities of neighbouring countries using the One Health approach. • Improve cross-border collaboration and information sharing. • Review and update Port Health Service SOPs and guidelines. • Train Port Health Service staff and frontline agencies at POE using a multisectoral approach. • Develop diagnostics and testing capacities at designated POE. • Digitize and harmonize Port Health Service surveillance tools. POE2. Public health re- sponse at POE 4 POE3. Risk-based ap- proach to interna- tional travel-related measures 4 CE. Chemical events CE1. Mechanisms estab- lished and function- ing for detecting and responding to chemical events or emergencies 2 • Establish an effective policy, institutional and regulatory framework for chemical event management (policies, guidelines, SOPs, regulations). • Improve and harmonize existing public health surveillance systems to include chemical surveillance and integrate with poison information services. • Identify and describe priority chemical events. • Develop capacity for chemical event surveillance, alert and response at national and subnational levels. • Develop capacities for diagnosis and treatment of chemical poisonings and establish a poison information service. CE2. Enabling environ- ment in place for management of chemical event 2 RE. Radiation emergen- cies RE1. Mechanisms estab- lished and function- ing for detecting and responding to radiological and nuclear emergencies 3 • Collaborate with NCDC and the Federal Ministry of Health to train human health workers on medical response to nuclear and radiological safety and security-related emergencies at the six designated hospitals located in each of the six geopolitical zones. • Ensure budgetary provision for operationalization of the National Nuclear and Radiological Emergency Plan. • Improve collaboration between Nigerian Nuclear Regulatory Authority and health-related MDAs for planning and implementation of related activities (training of human health workers, first responders). • Create opportunities for testing relevant policies and plans (Nuclear and Radiological Emergency Preparedness and Response Plan) through simulation exercises (in the absence of real nuclear and radiological incidents). RE2. Enabling environ- ment in place for management of radiological and nuclear emergencies 3 8Prevent 9Prevent P1. Legal instruments Introduction The International Health Regulations (IHR) (2005) provide obligations and rights for States Parties. In some States Parties, implementation of the IHR (2005) may require new or modified legislation. Even if new or revised legislation may not be specifically required, States may still choose to revise some regulations or other instruments in order to facilitate IHR implementation and maintenance. Implementing legislation could serve to institutionalize and strengthen the role of IHR (2005) and operations within the State Party. It can also facilitate coordination among the different entities involved in their implementation. See detailed guidance on IHR (2005) implementation in national legislation. In addition, policies that identify national structures and responsibilities as well as the allocation of adequate financial resources are also important. Target Adequate legal instruments for States Parties to support and enable the implementation of all their obligations and rights created by the IHR. The development of new or modified legal instruments in some States Parties for the implementation of the Regulations. Where new or revised legal instruments may not be specifically required under a State Party’s legal system, the state may revise some laws, regulations, or other legal instruments in order to facilitate their implementation in a more efficient, effective or beneficial manner. Level of capabilities Following the 2017 JEE, Nigeria has strengthened its public health security legal framework. New laws were developed and enacted by the National Assembly to manage and prevent the spread of contagious, infectious and zoonotic diseases, i.e. the NCDC Act of 2018 and Animal Disease Control Act. These laws also enhanced national health security coordination and funding (see Section 30, Animal Disease Control Act). The "National Technical Guidelines for Integrated Disease Surveillance and Response" was approved by the National Council on Health in 2002 and reviewed to address surveillance and response requirements under the IHR (2005) in 2010 with a further review in 2019. A comprehensive assessment in 2020 analysed existing laws on disease surveillance, detection, response, port health, quarantine services and food safety. The identified gaps from the assessment led to the amended Nigeria Centre for Disease Control Bill of 2022 and Animal Disease (Control) Act of 2022 to address the prevention of the spread of infectious and zoonotic animal diseases as well as antimicrobial resistance (AMR). Additionally, Nigeria has carried out legal mappings and assessments at the subnational level, with pending legislation in several states. Indicators and scores P1.1. Legal instruments – Score 2 Nigeria has conducted a legal mapping and assessment of the legal instruments at the national level and in seven states at the intermediate level. Based on the recommendations contained in this mapping, new legislation was drafted including the NCDC Amendment Bill 2022, the Public Health Emergency Bill, the National Health Act, and the Quarantine Bill. The revised legislation contains provisions for the legal authorities for health emergency declaration, preparedness, operational readiness and response planning. At the time of writing, four states had passed their public health security bills, which are pending governors’ assent. Additionally, there are federal bills pending presidential assent. Given its size and federal system, Nigeria has not yet completed all subnational assessments, or developed and revised the necessary legal instruments for IHR implementation at the intermediate levels. 10 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Strengths • The executive and legislators maintain a cordial and positive working relationship for the review and reform of public health laws in the country. • All stakeholders have demonstrated high-level commitments to fully implement the IHR core capacities in Nigeria. • Public health ministries, departments and agencies (MDAs) have functional legal departments to support the legal implementation of IHR in Nigeria. • Health-related reforms are regularly included in Periodic Legislative Agendas of the National Assembly. • A Law Reform Commission of Nigeria has been established to oversee and promote the reform of laws (including health laws) in the country. Challenges • There is a lack of funding for legal activities to strengthen public health laws. The scarcity of funding impedes the timely review and update of obsolete public health laws and results in a lack of advocacy after the review of those laws. • There is a need for training of legal officers across agencies about public health legislation. • Bureaucratic arrangements in the law-making process delay the passage of bills. P1.2 Gender equity and equality in health emergencies – Score 1 At this time, no systematic assessment of gender gaps in any of the IHR capacities has been conducted. Currently, there is no funding allocated to activities under this indicator. Strengths • The 1999 Constitution as amended guarantees gender equality in Nigeria. Challenges • There is currently no funding available to conduct a gender assessment of all the legal instruments at the national and intermediate levels. Recommendations for priority actions • Conduct subnational legal assessments of health laws in all states of the federation and develop and revise the necessary legal instruments for IHR implementation at these intermediate levels, where applicable. • Conduct a comprehensive gender assessment of legal instruments to identify and address gender-related considerations. • Establish a framework (legislative or administrative) for legal surveillance across MDAs, ensuring periodic reviews of all health security-related legal instruments in the country. • Prioritize capacity-building initiatives for legal officers in the field of public health laws. • Prioritize securing adequate funding for legal activities related to public health laws, such as creating a dedicated budget line to support legal surveillance, periodic reviews and reforms, ensuring the effective implementation of public health legislation. 11 Prevent P2. Financing Introduction The implementation of the IHR, including the development of the core capacities, requires adequate financing. State Parties should ensure sufficient allocation of funds for IHR implementation. Target States Parties ensure provision of adequate funding for IHR implementation through the national budget or other mechanisms. The country has access to financial resources for the routine implementation of IHR capacities and financial resources that can be accessed on time and distributed for readiness and response to public health emergencies, is available. Level of capabilities Although funding of the health sector by the government has always been a weak factor in the state health system politics and reform efforts, the financing technical area has recorded progress. In collaboration with the NCDC, annual health financing workshops were conducted to orient National Action Plans for Health Security (NAPHS) technical leads on the national budgeting process. Resource mapping exercises were conducted to identify available domestic and external financing for health security implementation. Some attempts have been made to understand estimated resource needs. Statutory annual budgetary allocations to MDAs with key responsibilities for health security are in place but seem to be insufficient for the increasing needs of a fast-growing population. The country is also struggling with allocating enough earmarked funding for IHR implementation at the state level. There are ongoing efforts to secure legislative backing for sustainable financing for public health activities, but essential new legislation, like the Public Health Emergency Bill 2023 and the establishment of an Emergency Preparedness Fund (NCDC Act (amendment) Bill 2023) are awaiting presidential assent. Even though the NCDC Basic Health Care Provision Fund (BHCPF) gateway finances the Public Health Emergency Response Fund from 20% of the funds allocated to this gateway as approved by the Ministerial Oversight Committee, Nigeria still relies too much on external partners for funding essential health care. Ultimately, it will be more sustainable to develop its own responsibility for primary health care and IHR implementation as much as possible. Indicators and scores P2.1. Financing resources for IHR implementation – Score 2 Financial planning is based on some estimations of resource needs, mainly through workshops, organized by external partners. However, the funding is insufficient, particularly at the state and lower levels. Monitoring and evaluation (M&E) need to focus more on budget lines for health security activities and IHR implementation at the state and lower levels. It will help reach a higher score to dedicate a higher percentage of the national budget to IHR implementation as part of a national health system and to develop a framework for monitoring budget allocation to the NAPHS across the relevant technical areas. Strengths • Annual budgetary allocation for health security exists across most IHR-implementing MDAs. • Regular NAPHS resource mapping exercises are undertaken. • Substantial availability of external financing for implementing health security exists (the Global Fund, GAVI, the Vaccine Alliance, the World Bank, US CDC, the UK Health Security Agency, the Foreign, Commonwealth and Development Office, the Bill & Melinda Gates Foundation, etc.). 12 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria • There is collaboration with development partners and civil society organizations who advocate for more funding for health security. • An annual health security workshop is conducted along with re-skilling of NAPHS technical leads on the budgeting process. • There is availability of direct funding to states through the NCDC gateway of the BHCPF for IHR implementation. Challenges • The NAPHS and the other health security plans (e.g. the National Action Plan for Antimicrobial Resistance and the One Health Strategic Plan) are not fully financed. • There is limited awareness of the budgetary process among NAPHS technical area leads. • The NAPHS, IHR implementation and health security are not a priority in the national budgeting process. • There is insufficient budgetary provision for IHR at the subnational level. P2.2. Financing for public health emergency response – Score 2 A health emergency fund exists at the national level as part of the NCDC gateway of the BHCPF. Other partners including WHO, World Bank, US CDC, Resolve to Save Lives, FAO, etc., are providing external funding through the NCDC gateway. Funding for emergency response at state and lower levels is awaiting full implementation. The development of a Government Public Health Emergency Fund will contribute to reaching a higher score. Strengths • A health emergency fund exists at national and subnational levels as part of the NCDC gateway of BHCPF. • The Public Health Emergency Bill provides additional funding for health emergencies (awaiting presidential assent). • The Rapid Outbreak Investigation Fund can be employed as a flexible funding mechanism for timely response to outbreaks. • A health emergency fund was established by donor organizations (WHO, World Bank, REDISSE/ COPREP, Resolve to Save Lives-Revolving Outbreak Investigation Fund, US CDC, FAO etc.) to support the national response. Challenges • Competing national priorities and declining revenue sources present significant obstacles. • The federal government is over reliant on states for public health emergency response. • There is poor implementation of emergency funding mechanisms for public health response at the subnational level. Recommendations for priority actions • Develop a framework for monitoring and accountability mechanisms for IHR and NAPHS implementation across MDAs at national and subnational levels. • Elevate health security, IHR and NAPHS implementation into the Medium-Term Expenditure Framework and national budget processes. • Operationalize the health emergency financing mechanism of the BHCPF at subnational level. • Develop a public health emergency fund within five years and streamline existing emergency funding mechanisms by international partners and private sectors into this fund. 13 Prevent P3. IHR coordination, national IHR focal point functions and advocacy Introduction The effective implementation of the IHR requires multisectoral/multidisciplinary approaches through national partnerships for efficient alert and response systems. Coordination of nationwide resources, including the designation of a national IHR focal point (NFP), and adequate resources for IHR implementation and communication, is a key requisite for a functioning IHR mechanism at country level. Target Multisectoral/multidisciplinary approaches through national partnerships that allow efficient, alert and response systems for effective implementation of the IHR. Coordinate nation-wide resources, including sustainable functioning of a National IHR Focal Point – a national centre for IHR communications which is a key obligation of the IHR – that is accessible at all times. States Parties provide WHO with contact details of National IHR Focal Points, continuously update and annually confirm them. Timely and accurate reporting of notifiable diseases, including the reporting of any events of potential public health significance according to WHO requirements and consistent relay of information to FAO and OIE. Planning and capacity development are undertaken and supported through advocacy measures to ensure high-level support for implementation of IHR. Level of capabilities The NCDC is the designated NFP that coordinates the effective implementation of IHR across relevant MDAs. Within the jurisdiction of the NCDC Act 2018, the NFP has legal backing to obtain official clearance regarding emergency communications with WHO within the required time limits. The NFP is always accessible to communicate with WHO. Headed by a Director-General, the NCDC is composed of seven directorates. These are: (1) Surveillance and Epidemiology, (2) Public Health Laboratory Services, (3) Health Emergency Preparedness and Response, (4) Department of Planning, Research and Statistics, (5) Administration and Human Resources, (6) Finance and Accounts, and (7) Subnational Support. Within the Nigerian NFP, there is an IHR Technical Working Group (TWG), which is a multisectoral and multidisciplinary group constituted by the 19 IHR technical area leads drawn from the relevant MDAs. The national and subnational public health emergency operations centres (PHEOCs), IHR TWG and disease-specific TWGs are all functional mechanisms for multisectoral collaboration operating within the jurisdiction of the NCDC, as the NFP in Nigeria. The NFP also coordinates with relevant sectors through disease-specific TWGs, the National One Health Risk Surveillance and Information Sharing committee comprising stakeholders from the health, agriculture and environment sectors within a One Health governance structure. State Party Annual Reporting, a mandatory component of the IHR Monitoring and Evaluation Framework, is conducted yearly to give updates across the IHR core capacities and is coordinated by the NFP. The NAPHS is a five-year, multisectoral national strategic plan developed to address gaps from JEEs, simulation exercises and after-action/intra-action reviews conducted to strengthen health security. The NAPHS presents an annual operational plan for ease of implementation which is uploaded on the NAPHS tracker, ensuring transparency and accountability. Although there are no specific documents or guidelines that describe advocacy strategies used in strengthening IHR capacities in the country, advocacy approaches are used in most of the IHR activities implemented. 14 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Indicators and scores P3.1. National IHR Focal Point functions – Score 3 The NFP has a clear legal and governmental mandate: the NCDC Act (2018) provides the NFP with the authority to coordinate IHR functions. The country has clear NFP terms of reference describing its roles and responsibilities. Further, it maintains regular engagement with relevant MDAs and stakeholders using a whole-of-society approach. The NFP is always available (24/7/365) to communicate with WHO. Strengths • The establishment of the NFP under the jurisdiction of the NCDC Act 2018 provides a solid framework. • A structure is in place for communication and collaboration with other relevant sectors (SOPs, IHR TWG). • A functional process is in place for timely reporting to WHO through dedicated NFP email, WhatsApp, and phone calls. • A representative of the Nigerian Governors’ Forum is included in all IHR-related activities. Challenges • Despite having a structure in place for surveillance information sharing, the country faces challenges in terms of consolidation and sharing of surveillance information available from relevant sectors. There is a need for a strong feedback system from the relevant MDAs and states to the NFP and WHO. • There is a lack of interoperability between e-reporting platforms within the key sectors of One Health. • Suboptimal communication is evident from relevant MDAs to WHO through the NFP. P3.2. Multisectoral coordination mechanisms – Score 3 Nigeria possesses strong multisectoral platforms at the national level through mechanisms such as IHR TWGs, disease-specific TWGs, a One Health governance structure and a National One Health Risk Surveillance and Information Sharing committee. Procedures like signal monitoring on event-based surveillance platforms, daily meetings for public health information sharing, and SOPs for addressing unusual events are used to ensure timely detection and response to public health events. Updates on IHR progress are disseminated among relevant sectors via mechanisms like the NAPHS tracker and IHR TWG meetings. Strengths • There are clear SOPs available for communication and coordination with the relevant MDAs. • The Nigeria NFP organizes quarterly IHR TWG meetings. • The NAPHS tracker is used to track the implementation of activities. • A One Health governance structure has been constituted. • The provision for subnational health security assessments (State JEE) has reinforced multisectoral collaboration at the state level. • Functional grouping approaches ease communication and collaboration among the IHR technical areas with relevant functions. • The presence of an archival platform for IHR-relevant documentation demonstrates best practice record keeping. 15 Prevent Challenges • Multisectoral coordination mechanisms are suboptimal at the subnational level. • There is insufficient funding to strengthen the multisectoral coordination platforms at all levels. • Inconsistencies are apparent in representation from MDAs at IHR functions. P3.3. Strategic planning for IHR, preparedness or health security – Score 3 A comprehensive NAPHS has been established and implemented through a whole-of-society approach, involving collaboration across sectors. Regular monitoring and updates are conducted using the NAPHS tracker, with all technical area leads having access to the tracker and updates being shared regularly. Although advocacy is integrated into IHR-related activities, the guidelines and SOPs are still in development. Strengths • The development and implementation of the NAPHS and National Public Health Multihazard Emergency Preparedness and Response Plan are notable strengths. • Staff trained on rapid response are readily available for deployment to respond to emergencies or disease outbreaks. • Disease-specific contingency plans (e.g. for cholera, cerebrospinal meningitis, Lassa fever, etc.) are developed and implemented. • Lessons learned from simulation exercises, after-action reviews, intra-action reviews and strategic tool for assessing risks (STAR) assessments are translated into national planning (NAPHS Annual Operational Plan 2023). • The IHR Division/Secretariat routinely follows up with the other MDAs on the implementation of the NAPHS. Challenges • A lack of advocacy guidelines/SOPs is evident. • Updates of disease-specific contingency plans are irregular. • Intra- and after-action reviews as well as simulation exercises are irregularly conducted. Recommendations for priority actions • Conduct a summative evaluation of the current NAPHS. • Develop a new five-year NAPHS for Nigeria. • Design and conduct subnational health security assessment exercises across states and develop the corresponding State Action Plan for Health Security. • Develop an evidence-informed advocacy strategy and disseminate it through the national and intermediate levels. • Review and update multihazard and contingency plans. 16 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria P4. Antimicrobial resistance (AMR) Introduction Bacteria and other microbes evolve in response to their environment and inevitably develop mechanisms to resist being killed by antimicrobial agents. For many decades, the problem was manageable as the growth of resistance was slow and the pharmaceutical industry continued to create new antibiotics. Over the past decade, however, this problem has become a crisis. AMR is evolving at an alarming rate and is outpacing the development of new countermeasures capable of thwarting infections in humans. This situation threatens patient care, economic growth, public health, agriculture, economic and national security. Target A functional system in place for the national response to combat antimicrobial resistance (AMR) with a One Health approach, including: a). Multisectoral work spanning human, animal, crops, food safety and environmental aspects. This comprises developing and implementing a national action plan to combat AMR, consistent with the Global Action Plan on AMR. b). Surveillance capacity for AMR and antimicrobial use at the national level, following and using internationally agreed systems such as the WHO Global Antimicrobial Resistance Surveillance System (GLASS) and the WAOH global database on the use of antimicrobial agents in animals. c). Prevention of AMR in health care facilities, food production and the community through infection prevention and control measures. d). Ensuring appropriate use of antimicrobials, including assuring the quality of available medicines, conservation of existing treatments and access to appropriate antimicrobials when needed, while reducing inappropriate use. Level of capabilities As in most countries, AMR poses a critical One Health challenge in Nigeria. Given that human, animal and environmental health are closely linked, interventions targeted at reducing the spread of AMR and those promoting antimicrobial stewardship (AMS) must be conducted with all sectors in mind. Tackling this global slow-moving AMR pandemic also requires action and strong commitment from all countries. Like many other countries, Nigeria has made considerable progress in implementing the National Action Plan on Antimicrobial Resistance. The accomplishments and ongoing work led by the National TWG on AMR are commendable. Some strengths we identified in this area include: the subnational One Health AMR response being piloted in two states, the availability of partners and domestic funding, and the operational national One Health Technical Committee. However, gaps still exist in operationalizing One Health interventions for AMR, especially regarding rational antimicrobial use and stewardship. Moreover, the AMR governance manual is not operational at the subnational level and has limited National Action Plan for AMR implementation monitoring. Because of these limitations, there is a need to strengthen the One Health infrastructure. This includes building an operational workforce, implementing educational strategies to elevate AMR and rational antimicrobial use into public consciousness, and the use of improved data systems as countermeasures to the challenge of AMR. 17 Prevent Indicators and scores P4.1. Multisectoral coordination on AMR – Score 4 Nigeria has developed a multisectoral national AMR action plan and the multisectoral coordination mechanism is functional with clear terms of reference and regular meetings. Strengths • The multisectoral AMR governance manual is approved. • The multisectoral TWG exists and is chaired by NCDC, the Federal Ministry of Agriculture and Food Security and the Federal Ministry of Environment with defined terms of reference and meets quarterly, reporting to the National One Health Technical Committee. • Nigeria is currently implementing the National Action Plan for AMR 2017–2022. However, the country has started the process of updating this plan to AMR National Action Plan 2.0. Challenges • Limited domestic funding is available for AMR response coordination and National Action Plan implementation (more in the human sector). • The environment, food and agriculture response strategies were not well represented in the National Action Plan for AMR 2017–2022. • The AMR governance manual is not operational at the subnational level. • There is limited AMR National Action Plan implementation monitoring. P4.2. Surveillance of AMR – Score 2 The human health sector has mandated reporting of all pathogens retrieved from blood cultures from the AMR sentinel surveillance sites. AMR data is collated locally in hospitalized and community patients using a standard approach. There are guidelines for surveillance of resistant microorganisms in food animals (poultry and aquaculture) and the environment. Strengths • There is a One Health AMR surveillance network and an integrated information AMR system coordinated at the national level. Nigeria enrolled on GLASS in 2017 and has been reporting bloodstream infections. Challenges • Low health insurance coverage is evident in the human sector and access to veterinary services is limited. • Limited domestic funding is available for laboratory infrastructure and capacity maintenance. • AMR surveillance is yet to commence in the animal health, agriculture and environment sectors. P4.3. Prevention of multidrug-resistant organisms (MDROs) – Score 1 The national government has not identified the priority MDROs. Strengths • A national IPC manual exists that defines some MDROs and containment strategies in healthcare facilities. • A National Tuberculosis (TB) Programme and multidrug-resistant TB surveillance strategy exist. Challenges • There are no MDRO surveillance strategies in human or veterinary hospitals. 18 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria P4.4. Optimal use of antimicrobial medicines in human health – Score 3 In Nigeria, guidelines for the appropriate use of antimicrobials are available and AMS programmes are established in some healthcare facilities. Strengths • In 2022 the Honourable Minister of Health, on behalf of the three sectors (human, animal and environmental health), signed the Muscat Manifesto – committing to reducing the total amount of antimicrobials used in the agri-food system by at least 30–50%; ensuring zero use of medically important antimicrobials for human medicine in animals for non-veterinary medical purposes or in crop production and agri-food systems for non-phytosanitary purposes; and ensuring that Access Watch and Reserve (AWARE) group antibiotics comprise at least 60% of overall antibiotic consumption in humans by 2030. • The National Agency for Food and Drug Control (NAFDAC) assures access to quality antimicrobials across all sectors. • National drug policy has been updated to include AMR and AMS. • In total, 52 health care facilities have implemented AMS programmes, and 35 health care facilities have conducted antimicrobial use point prevalence surveys. • Human and animal treatment guidelines have been developed and an offline prescription companion app has been developed to ease access to the guidelines. Challenges • Gaps persist in monitoring the implementation of the AMS programme. • More hospitals should be supported to establish facility AMS programmes through subnational engagement. • There is limited engagement of the private sector in the AMS programme. P4.5. Optimal use of antimicrobial medicines in animal health and agriculture – Score 2 In Nigeria, the national legislation covers some aspects of national manufacturing, importation, marketing authorization, safety control, quality and efficacy, and distribution of antimicrobial products. Strengths • Policies and guidelines for the use of antimicrobials in humans and animals exist, such as the National Drug Policy, Standard Treatment Guidelines in humans and animals, and the Essential Medicines List. • A drug revolving fund exists in some human healthcare facilities and in few state veterinary hospitals. Some states have central medical stores where medical equipment and consumable are procured, stored and distributed to beneficiary human hospitals. This promotes access to antimicrobials. • Data has been submitted on animal antimicrobial consumption (imports) to the World Organisation for Animal Health for the past eight years. 19 Prevent Challenges • There is poor enforcement of laws ensuring antimicrobials are prescription only and banning their use as growth promoters. • Environmental protection is not adequately emphasized in the AMS strategy, for example in relation to disposal of unused or expired medicines. Recommendations for priority actions • Finalize the National Action Plan for AMR 2.0 and implement (including costed, budgeted operational and M&E framework). • Develop an advocacy plan for the domestic dedicated budget. • Develop an integrated AMR surveillance system with priority pathogens (conduct a One Health AMR prevalence survey). • Develop a standardized case definition of MDRO to be used in Nigeria by all healthcare facilities. • Map existing law for One Health (tripartite sectors) and review and update the national legislation to cover all aspects including the implementation framework. 20 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria P5. Zoonotic disease Introduction Zoonotic diseases are communicable diseases that can spread between animals and humans. These diseases are caused by viruses, bacteria, parasites and fungi carried by animals, insects or inanimate vectors that aid in its transmission. Approximately 75% of recently emerging infectious diseases affecting humans are of animal origin; and approximately 60% of all human pathogens are zoonotic. Target Functional multisectoral, multidisciplinary mechanisms, policies, systems, and practices are in place to minimize the transmission of zoonotic diseases from animals to human populations. Level of capabilities • There is a published agreed list of priority zoonotic diseases (2017), a reprioritized list (2022) and a National One Health Strategic Plan. • A National One Health Risk Surveillance and Information Sharing group exists. • Surveillance systems are in place in human and animal health, including wildlife and a wildlife surveillance committee, e.g. integrated disease surveillance and response (IDSR) and National Animal Disease Information and Surveillance (NADIS). • Horizon scanning of One Health threats is undertaken through event-based surveillance, risk surveillance and information-sharing systems, which are used for rabies, anthrax, Highly Pathogenic Avian Influenza and mpox. Indicators and scores P5.1. Surveillance of zoonotic diseases – Score 3 Meetings at the national level have established a high level of coordination in information systems for zoonotic disease, while local laboratories are able to diagnose priority diseases of animal origin along with those of human origin. The priority list of diseases and risk assessment was developed with a One Health approach. Strengths • Laboratory surveillance for priority zoonotic diseases/pathogens is undertaken across all relevant sectors at all levels. • An interoperable platform or information-sharing mechanism exists between relevant sectors. • There is capacity for surveillance and management of zoonotic diseases, including wildlife surveillance at subnational levels. • Surveillance data is analysed, disseminated and utilized for disease prevention and control. Challenges • The budget is inadequate. • There is attrition of the trained workforce. • The federal system of government makes enforcing national policies difficult at the subnational level. • Inaccessible or hard-to-reach areas pose obstacles to effective surveillance. 21 Prevent P5.2. Response to zoonotic diseases – Score 3 There are well-developed plans for major zoonotic diseases, but a coordinated response is still not in place and will take considerable effort to develop. Strengths • Joint training is conducted for the One Health workforce via the Nigeria Field Epidemiology and Laboratory Training Programme (NFELTP). • Joint rapid response teams (RRTs) are used for Lassa fever and mpox. • The National One Health Strategic Plan, Rabies Elimination Strategy, Lassa Fever Strategy, Anthrax Strategy, Brucellosis Strategy, mpox Strategy, and draft Bovine Tuberculosis Strategy are available. • The Report of the National Multisectoral Coordination Mechanism Operationalization Training is available. • Joint risk assessments are undertaken (national and subnational). • The National Veterinary Research Institute’s support in the diagnosis of COVID-19 in the heat of the pandemic shows multisectoral and multidisciplinary coordination, collaboration and communication in response to zoonotic diseases. Challenges • The related budget is inadequate and often delayed. • Attrition of the trained workforce is evident. • Documentation is poor. • Insecure areas impede the response. P5.3. Sanitary animal production practices – Score 1 There is a major lack of sanitary practices still, and norms are not yet established or implemented. Strengths • Some good sanitary practices in animal breeding are implemented. • Standard operating protocols exist for abattoir operations, meat inspection, artificial insemination, dairy hygiene policy, hatcheries, and feed production policies. • A functional food safety committee exists. • An AMR community of practice is in place to reduce use, abuse, and misuse of antibiotics in food animals as growth promoters. • A CODEX committee exists. • A National Aquaculture Strategy is in place. Challenges • Implementing standards for breeding and abattoir practices is difficult. • Animal identification for animal disease control and traceability is lacking. • Poor animal welfare practices are evident. • There is weak enforcement of biosecurity measures in farms, markets and abattoirs. Recommendations for priority actions • Develop an interoperable surveillance and analysis platform at the national and state levels. • Review outbreaks to develop and disseminate improved outbreak identification and reporting materials. • Above all implement animal identification practices. 22 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria P6. Food safety Introduction Food- and waterborne diarrhoeal diseases are leading causes of illness and death, particularly in less developed countries. The rapid globalization of food production and trade has increased the potential likelihood of international incidents involving contaminated food. It is estimated that one in ten people worldwide suffer from diarrhoeal foodborne diseases alone. The identification of the source of an outbreak and its containment are critical for control. Risk management capacity with regard to control throughout the food chain continuum must be developed. If epidemiological analysis identifies food as the source of an event, based on a risk assessment, suitable risk management options that ensure the prevention of human cases (or further cases) need to be put in place. Target A functional system is in place for surveillance and response capacity of States Parties for foodborne disease and food contamination risks or events with effective communication and collaboration among the sectors responsible for food safety. Level of capabilities • Foodborne diseases, outbreaks and food safety events are a substantial cause of preventable morbidity and mortality in Nigeria. • Foodborne disease outbreaks are under-recognized and under-reported, due to the inability to detect and investigate clusters of foodborne illness, which poses a significant challenge to improving the health security indices of the country. • Food safety benefits from regular meetings of the National Food Safety Management Committee. • The National Food Safety and Quality Bill has already passed the national legislative process and is awaiting assent by the President of Nigeria. • The National Integrated Guideline for Foodborne Disease Surveillance and Response has been developed and validated by stakeholders. The Guideline includes a list of prioritized foodborne diseases, protocols for collection and testing of clinical specimens and food samples, and data reporting protocols. It emphasizes leveraging existing functional surveillance systems for human, animal and environmental health. • The International Food Safety Authorities Network (INFOSAN) emergency contact point has been designated along with focal points in MDAs and Nigeria is in close contact, investigating and responding to alerts received from INFOSAN. Indicators and scores P6.1. Surveillance of foodborne diseases and contamination – Score 3 Both indicator-based surveillance and event-based surveillance systems exist. Both surveillance approaches can provide samples that are analysed at laboratories to determine the origin of foodborne diseases and contaminants. 23 Prevent Strengths • A defined structure exists for disease surveillance and notification at state and local government authorities levels within both the human and animal health sectors. • A national policy on food safety exists along with its implementation strategy. • Nigeria conducted a national assessment of the foodborne disease surveillance and response system. • The designated INFOSAN emergency contact point is in place along with focal points in relevant MDAs. • The list of priority foodborne diseases (biological and chemical) is in place. • Multisectoral food safety and laboratory personnel are routinely present during outbreak investigation. Challenges • Laboratory capacity is not sufficiently developed. • There is a need to build capacity of more food safety officers at subnational levels. P6.2. Response and management of food safety emergencies – Score 3 The country has a demonstrated coordination mechanism led by an INFOSAN-designated person, able to coordinate across sectors as needed for foodborne-related events. Strengths • Food safety stakeholder collaboration is established. • A National Food Safety Management Committee (NFSMC) exists. • A national assessment was undertaken of the foodborne disease surveillance and response system. • An active national focal point on animal health is present from World Organisation for Animal Health (food safety). • A National Food Safety Emergency Plan is in place along with definition of a food safety emergency. Challenges • There is a need for more trained food safety officers at the subnational level. • Funding support is insufficient. Recommendations for priority actions • Develop self-study training materials with well-defined steps to investigate possible foodborne illness. • Integrate foodborne illness into the IDSR database. • Work with health communications to prepare communications materials for foodborne and food safety materials. 24 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria P7. Biosafety and biosecurity Introduction It is vital to work with pathogens in the laboratory to ensure that the global community possesses a robust set of tools – such as drugs, diagnostics, and vaccines – to counter the ever-evolving threat of infectious diseases. Research with infectious agents is critical for the development and availability of public health and medical tools that are needed to detect, diagnose, recognize and respond to outbreaks of infectious diseases of both natural and deliberate origin. At the same time, the expansion of infrastructure and resources dedicated to work with infectious agents have raised concerns regarding the need to ensure proper biosafety and biosecurity to protect researchers and the community. Biosecurity is important in order to secure infectious agents against those who would deliberately misuse them to harm people, animals, plants or the environment. Target A whole-of-government multisectoral national biosafety and biosecurity system with high- consequence biological agents identified, held, secured and monitored in a minimal number of facilities according to best practices, biological risk management training and educational outreach conducted to promote a shared culture of responsibility, reduce dual-use risks, mitigate biological proliferation and deliberate use threats, and ensure safe transfer of biological agents; and country- specific biosafety and biosecurity legislation, laboratory licensing and pathogen control measures in place as appropriate. Level of capabilities National legislation and regulatory frameworks are in place including: the National Biosecurity Policy and Action Plan (2022–2026); the National Biosafety Emergency Response Strategy (2020); the National Biosafety Management Agency Act 2015 as amended; National guidelines on biosafety and biosecurity; National Biosafety Emergency Response Strategy (2020) and the Medical Laboratory Science Council of Nigeria (MLSCN) Guideline on Safe Transport of Infectious and Exceptional Substances. In addition, the country is currently developing legislation on the prohibition of chemical and biological weapons that will establish a National Authority for the effective implementation of the Chemical and Biological Weapons Convention in Nigeria and related matters. There is also a Confidence Building Measure initiative that is being coordinated by the National Authority on Chemical and Biological Weapons Convention. The country has just finalized the Nigerian universities’ biosafety and biosecurity curriculum that will be launched later in 2023 to augment biorisk training in academic institutions. Biosafety and biosecurity training is being undertaken in all facilities handling high-consequence agents with standardized biosafety and biosecurity risk assessment templates available in some facilities. Some facilities have standardized documentation (SOPs) in place with biosafety and biosecurity audits ongoing in some lab facilities. The country does not have a national mechanism for biosecurity oversight of dual-use research and a responsible code of conduct for life scientists. In addition, there is no comprehensive coordination of records and inventory of high-consequence pathogens in the country. The current biorisk training for laboratory personnel is siloed in human health with no evidence of joint training on biological risk management as well as joint biological risk assessments in all laboratories and across all sectors under One Health. 25 Prevent Indicators and scores P7.1. Whole-of-government biosafety and biosecurity system is in place for human, animal and agriculture facilities – Score 2 The country has some, but not all, elements of a comprehensive biosafety and biosecurity system in place. The country is also starting the process of monitoring and developing an updated record and inventory of pathogens within facilities that store or process dangerous pathogens and toxins. A comprehensive national biosafety and biosecurity regulatory framework to regulate the possession and use of priority pathogens has been developed. Strengths • A strong national legislation and regulatory framework exist to backstop the whole-of-government biosafety biosecurity system. • Confidence Building Measure is coordinated by the National Authority on Chemical and Biological Weapons Convention. • Initiatives are ongoing to develop legislation on the prohibition of chemical and biological weapons and thus establish the National Authority for effective implementation of the Biological Weapons Convention. Challenges • There is a need for better coordination of high-consequence pathogen inventory in specific locations across the country. • An urgent need exists for coordination of joint national biosafety/biosecurity risk assessments across all the sectors under One Health. • There is poor implementation of the national biosafety and biosecurity framework (National Biosafety Management Agency Act, work plan (2022–2026). • Support is required for MDAs, NCDC, MLSCN and the Veterinary Council of Nigeria to continuously monitor staff competence and standards of training at all laboratories. • There is an urgent need to develop a national framework for biosecurity oversight for dual-use research of concern and a responsible code of conduct for life scientists. • Limited dedicated budget line to support biosafety and biosecurity training by the relevant MDAs continues to hamper progress. P7.2. Biosafety and biosecurity training and practices in all relevant sectors (including human, animal, and agriculture) – Score 2 Nigeria has conducted a Training Needs Assessment and identified gaps in biosafety and biosecurity training but has not yet implemented comprehensive training that aligns with the incumbent roles and responsibilities. A general lack of awareness among the laboratory workforce of international biosafety and biosecurity best practices for safe, secure and responsible conduct was reported. Although personnel working with high-consequence pathogens are trained in biorisk management, the country does not yet have sustained academic training in institutions proportionate to the assessed risks. 26 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Strengths • A preservice biosafety and biosecurity curriculum has been finalized and at the time of writing was awaiting launch, targeting academia to complement the in-service biorisk management training for laboratory personnel. • Training for laboratory personnel on biosafety and biosecurity is undertaken in all high- containment facilities handling high-consequence agents. • Some laboratory personnel have international professional certification from the International Federation of Biosafety Associations (based in Canada) including biorisk management (84), biosecurity (4) and biological waste management (3). • The country also has certified master trainers in biorisk management as well as National Sanitation Foundation-certified biomedical engineers (11). • The country has conducted a Biosafety and Biosecurity Situation Analysis in 76 facilities from 12 states and the Federal Capital Territory in 2020 and produced a report to inform priority actions. Challenges • Sustainable funding for joint biosafety/biosecurity training and risk assessments at MDAs and institutional levels remains an area of concern. • There is a need to train more biomedical engineering personnel for biosafety cabinetry to meet the demand across all sectors. • There is a need to develop a biosafety/biosecurity refresher training programme package and roll out the same across all sectors at all levels. Recommendations for priority actions • Develop a plan specifying the responsibility of key governmental MDAs with generic terms of reference for the coordination of inventory and records for high-consequence pathogens in the country. • Work with the responsible MDAs to plan and operationalize the biosafety and biosecurity preservice training curriculum in institutions of higher learning. • Aim to create a four-fold increase in the number of laboratory professionals trained in biological risk management within the health system at national and subnational levels across all sectors. • Aim to plan and conduct defined periodic biological risk assessments in laboratories across all sectors at national and subnational levels. • Work with MDAs to develop a biosecurity framework specifying oversight responsibilities for dual use research of concern and a responsible code of conduct for life scientists in the country. 27 Prevent P8. Immunization Introduction Immunizations are estimated to prevent more than two million deaths a year globally. Immunization is one of the most successful global health interventions and cost-effective ways to save lives and prevent disease. Measles immunization is emphasized because it is widely recognized as a proxy indicator for overall immunization against vaccine-preventable diseases. Countries will also identify and target immunization to populations at risk of other epidemic-prone vaccine-preventable diseases of national importance (e.g. cholera, Japanese encephalitis, meningococcal disease, typhoid and yellow fever). Diseases that are transferable from cattle to humans, such as anthrax and rabies, are also included. Target A national vaccine delivery system – with nationwide reach, effective distribution, easy access for marginalized populations, adequate cold chain and ongoing quality control – that is able to respond to new disease threats. Level of capabilities The National Primary Health Care Development Agency is responsible for the country’s immunization services for the 774 local health areas. The Department of Disease Control and Immunization in the National Primary Health Care Development Agency is responsible for planning, supervision of routine immunization, supplemental immunization, outbreak response activities, developing guidelines, capacity-building at national and subnational levels and new vaccine introduction. Like other agencies of government, it has limitations in resources and staffing and the need to improve information management services. Indicators and scores P8.1. Vaccine coverage (measles) as part of national programme – Score 2 Vaccine coverage varies by year but has not exceeded 70% in any year. Strengths • The service provides a wide variety of vaccines and is up to date in its assessment of potential new vaccines to add to the national system. Challenges In 2021, Nigeria reported over 10 000 measles cases based on data from the IDSR. By 2022, this had declined to less than 1000. However, measles vaccination coverage remains suboptimal at 53% in 1990 and 54% in 2018. The COVID-19 pandemic interrupted routine immunization services, resulting in a decline in the first dose of measles-containing vaccine coverage from 73% (administrative coverage) in 2017 to 60% in 2021 (Multiple Indicator Cluster Surveys and National Immunization Coverage Surveys, 2021). Vaccine coverage rose in 2022, but these data were not available at the time of writing. P8.2. National vaccine access and delivery – Score 4 The system for vaccine delivery has advanced and is stable in its function in most parts of the country. When more fully implemented, this capacity will be reflected in a rising level of routine immunization. As the country still has inaccessible areas, is recovering capacity following the pandemic, and has weak administration and supply in some areas, the system has not yet shown the desired results. 28 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Strengths • The Government of Nigeria has been fulfilling its co-financing obligation in the procurement of routine immunization vaccines as well as counterpart funds for supplementary immunization activities. • The system has committed leadership, which harmonizes the work of many partner organizations. • Recent investments in the supply chain have established at least one warehouse facility for vaccines in each ward. • Advanced planning now focuses on the construction of three Hubs in Kano, Lagos and Abuja. • Annual vaccine forecasting has improved, with buffer stock sufficient to avoid stock outs at service delivery points. Challenges • There is a need to improve information management to establish real-time visibility into vaccine stock management at health facilities. • Effective vaccine management improvements are suboptimal at subnational levels with a well- developed plan but only 40% of states showed progress from the 2017–2020 plan. P8.3. Mass vaccination for epidemics of vaccine-preventable diseases (VPDs) – Score 4 Strengths • There is an existing National Measles Elimination Strategic Plan 2019–2028. • There is a measles outbreak response guideline and operational guidelines for vaccination teams. • A national coordination steering committee and subnational TWGs are functional. • Partnerships with international organizations provide significant financial and technical support. • State release of counterpart funds is a requirement before implementation of campaigns. • Institutionalization of traditional and religious leaders committees on primary health care delivery at subnational levels is important in low coverage areas. Challenges • High dependency on donor funds persists. • Vaccine hesitancy in evident in some communities. • Access to some areas is difficult due to security situations. • Financial management is weak at the subnational level. Recommendations for priority actions • Aggressively develop and disseminate communications materials to combat vaccine misinformation. • Develop working relations with primary and secondary medical facilities to identify missed populations for priority vaccines. • Improve data management to mobilize vaccination efforts better. 29 Detect 30 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria D1. National laboratory system Introduction Public health laboratories provide essential services including disease and outbreak detection, emergency response, environmental monitoring and disease surveillance. State and local public health laboratories can serve as a focal point for a national system, through their core functions for human, veterinary and food safety including disease prevention, control and surveillance; integrated data management; reference and specialized testing; laboratory oversight; emergency response; public health research; training and education; and partnerships and communication. Target Surveillance with a national laboratory system, including all relevant sectors, particularly human and animal health, and effective modern point-of-care and laboratory-based diagnostics. Level of capabilities Nigeria is testing for all priority diseases in country within a tiered laboratory system that includes public, clinical, animal and research laboratories. Some national clinical laboratories are accredited to ISO 15189 standard, such as National Veterinary Laboratory in Vom (the National Veterinary Research Institute), while National External Quality Assurance and National External Quality Assurance Laboratory in Zaria are accredited to ISO 17025. Other national labs (the National Reference Laboratory, Central Public Health Laboratory, Lagos University Teaching Hospital) are implementing a quality management system and are currently on WHO Guidelines for the Stepwise Laboratory Improvement Process Towards Accreditation in the Africa Region rating four and five stars. The laboratory results are sent within the defined turnaround time ranging from 3–7 days, depending on the disease syndrome. Nigerian national laboratory system reporting guidance on laboratory data includes demographic data, sex and age, among others, while the information on socio-economic status is captured on surveillance reporting tools. Personal protective equipment is available for laboratory staff to carry out their routine functions. The national stockpile system is in place to track the supply of commodities. There are also training modules on the appropriate use of personal protective equipment, including donning and doffing, use of hand gloves, nose mask, face shield, etc. The animal and human sector laboratory data sharing platforms require strengthening, while sample referrals for vertical disease programmes are partners/donors-driven and are not sustainable. Currently, remote logging of samples for referral does not exist, while integration of sample transport and referral system is weak. 31 Detect Indicators and scores D1.1. Specimen referral and transport system – Score 2 The sample referral and transport are organized at the national level for all priority diseases, with the National Integrated Sample Referral Network policy being implemented for some priority diseases as well. The animal and environment sectors still rely on ad-hoc sample transport mechanisms, although agreements and contracts are in place with third-party logistics for sample transport. Strengths • There is availability of in-country third party logistics that are trained on shipment of biological specimens. • A system is in place for transporting priority infectious samples from intermediate to national labs. • Capacity-building is undertaken (including IATA certification) for laboratory personnel and courier (transporters) staff on sample shipment/packaging. • A National Integrated Sample Referral Network policy and implementation framework is available for sample referral and shipment for vertical disease programmes. • Third party logistics are engaged for sample movement at the intermediate and national levels. Challenges • The country lacks an effective real-time tracking system or remote logging for sample transport. • Integration of sample referral systems in the context of One Health is not in place. • Limited support is available for subnational sample transportation and referral mechanisms. • Sample referrals are partners/donors-driven and require dedicated budget lines from government. • In-country manufacturing capacity is inadequate for sample collection materials (e.g. isolates shipment containers). D1.2. Laboratory quality system – Score 3 A regulatory agency responsible for licensing of laboratories in the human health sector at the national level and in some states is in place. A national laboratory quality manual has been developed and quality management systems implementation is ongoing in many laboratories. Up to 14 laboratories are currently accredited to national and international (ISO) standards for testing and detecting priority pathogens. Strengths • Implementation of national quality standards in line with ISO 15189, ISO 17O43 (external quality assurance) and 17025 (animal) is ongoing. • Regulatory agencies responsible for the accreditation of laboratories (the MLSCN, Nigeria National Accreditation System) are in place. • There are accredited laboratories (national and international) across public and private sectors of human and animal health laboratories (14 national, 15 international and 2 animal). • The National Laboratory Quality Management System document has been developed and rolled out but is at infancy. • National external quality assurance programme is in place for some priority diseases (COVID-19, yellow fever, measles, influenza, cerebrospinal meningitis, cholera). • Guidelines, quality manuals, SOPs, testing algorithms and job aids are available in laboratories. 32 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Challenges • Resource allocation is inadequate for improving laboratory diagnostic and quality system activities in laboratories across the tiered network. • The number of Strengthening Laboratory System towards Accreditation mentors is inadequate to support quality management system implementation across all the sectors and tiers of the laboratory network. • The number of certified biomedical engineers available to support regular preventive service and maintenance of equipment in the network of laboratories is limited. Quality management system implementation is limited and slow across all levels of the tiered laboratory network to attain accreditation. D1.3. Laboratory testing capacity modalities – Score 3 A National Reference Laboratory has been designated and is functional to support national and subnational laboratory systems on quality and testing. Testing capacity is available in public health laboratories for point-of-care and advanced laboratory testing (microbiology, antimicrobial sensitivity testing, molecular and sequencing). Testing capacity for priority diseases on the IDSR is available in selected laboratories across the country. External quality assurance/proficiency testing programmes are in place for most priority diseases in human and animal health laboratories. Strengths • Critical diagnostic equipment and trained personnel are available in the testing laboratories. • Expanded testing capacity for the IDSR priority diseases (e.g. cerebrospinal meningitis, cholera, viral haemorrhagic fevers, mpox, measles, rubella, anthrax, diphtheria, rabies) and AMR pathogens for both human and animal sectors are in place. • In-country capacity is available for calibration of laboratory equipment. • The country has the ability to conduct advanced diagnostic testing (polymerase chain reaction and genomic sequencing). • Point-of-care testing capacity is available in the human sector. • Specimen archiving and bio banking with biosafety and biosecurity considerations exist at national level. • Testing algorithms for priority pathogens are in use and conform to international testing best practices. • Sequencing data for priority pathogens is regularly shared on the Global Initiative on Sharing All Influenza Data platform, as well as other platforms. Challenges • No multi-disease testing initiatives are in place to optimize the use of diagnostic equipment. • Private sector laboratories are not integrated into public health on testing for priority diseases. • Strengthening of equipment harmonization and standardization is needed. • There is a lack of equipment platform harmonization. • Most laboratories are not mapped with geospatial technology, although the polymerase chain reaction laboratories supported by the President’s Emergency Plan for Aids Relief (PEPFAR) are geo-mapped. • Limited in-country manufacturing capacity exists for diagnostic reagents and consumables. 33 Detect D1.4. Effective national diagnostic network – Score 3 A national tiered laboratory network system exists, and a National Essential Diagnostics List has been developed in line with the tiered laboratory system. Implementation of tiered diagnostic strategies exists within parallel programmes and in the human and animal sectors. Strengths • A functional tiered laboratory network exists for diseases of public health importance. • There is timely detection (within turnaround time) of priority (infectious) pathogens for informed decisions (cerebrospinal meningitis, cholera, Viral Haemorrhagic Fevers (VHFs), mpox, measles, rubella, anthrax, diphtheria, rabies) and AMR pathogens for both human and animal sectors. • Collaboration took place between the parallel disease programmes, private sector and public health laboratories for laboratory testing during the COVID-19 pandemic. • The National Essential Diagnostics List has been developed in line with the tiered laboratory system. • Some national laboratories have been designated as regional reference laboratories for diagnosis of priority diseases for the West Africa region (National Reference Laboratory for Influenza and other respiratory diseases as well as genomics, Lagos University Teaching Hospital for VHFs, Central Public Health Laboratory for cholera and National Veterinary Research Institute for zoonotic diseases and AMR). • Capacity exists to rapidly expand the laboratory network to provide adequate coverage for the population in emergencies. Challenges • The implementation of a real-time national laboratory data management and reporting system that is interoperable with other health reporting systems or platforms across the sectors is not in place. • Subnational implementation of the Nigeria Essential Diagnostics List to support tiered network testing capabilities is suboptimal. • Expansion of point-of-care diagnostics to cover more priority diseases is needed. • Lab services are fragmented along vertical disease programmes at different levels of the healthcare system. • Diagnostic network optimization to cover national, subnational and cross sector needs is not in place. Recommendations for priority actions • Aim to expand the national integrated sample transportation and referral system to cover all priority pathogens for the three tiers of laboratories and across all sectors (One Health). • Develop and implement a national diagnostic network optimization framework for all tiers of laboratories (including private and faith-based laboratories) and cross sectors for clinical diagnostics, detection and surveillance of priority pathogens. • Work with the relevant MDAs to increase by six-fold the number of trained and certified biomedical engineers in all three sectors of One Health. • Empower the accredited national reference laboratories to expand the external quality assurance and quality improvement implementation across all tiers of the national laboratory network to support AMR and IPC core capacities. • Develop a plan to implement remote logging and interoperable laboratory information systems covering all priority pathogens at all tiers of laboratories across all sectors. 34 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria D2. Surveillance Introduction The purpose of real-time surveillance is to advance the safety, security and resilience of the nation by leading an integrated surveillance effort that facilitates early warning and situational awareness of all IHR hazard-related events. Target Strengthened early warning surveillance systems that can detect events of significance for public health and health security; (2) improved communication and collaboration across sectors and between national, intermediate and primary public health response levels of authority regarding surveillance of events of public health significance; and (3) improved national and intermediate level capacity to analyse data. This could include epidemiological, clinical, laboratory, environmental testing, product safety and quality, and bioinformatics data; and advancement in fulfilling the core capacity requirements for surveillance in accordance with the IHR. Level of capabilities Nigeria's surveillance system has been consistently growing, allowing the country to monitor the occurrence of public health priority diseases and detect outbreaks early for prompt and effective response. The NADIS Service serves as the surveillance system for reporting transboundary animal diseases and zoonosis through the Animal Resources Information System platform. The IDSR strategy has had three reviews, is widely disseminated and used by surveillance and response staff, and forms the bedrock of IHR implementation in accordance with the policy within the WHO Regional Office for Africa. The country needs to improve on its subnational level implementation of indicator and events-based surveillance as well as ensure integration of surveillance activities to other sectors such as animal health, agriculture, communities, etc. The country should improve on interoperability. Indicators and scores D2.1. Early warning surveillance function – Score 3 National strategy, guidelines and SOPs for surveillance have been developed and are being implemented at the national, state and local government authorities levels. Immediate and weekly reporting of events are available at all levels. Laboratory results are integrated with surveillance data on SORMAS. Functional event-based surveillance systems, Epidemic Intelligence from Open Sources, Tatafo, Phone Calls, WhatsApp, SMS platforms exist. Strengths • National guidelines are available (IDSR Guidelines). • SOPs are available (Yellow fever, cerebro spinal meningitis, mpox, Lassa fever, COVID-19, Ebola virus disease, diphtheria, measles). 35 Detect • The health workforce is skilled. Examples of training programmes include: IDSR haemorrhagic fever training, Integrated Training of Surveillance officers in Nigeria, field epidemiology training programme (FETP) (intermediate and advanced graduates) and In-Service Applied Veterinary Epidemiology Training. • There is availability of reference and disease-specific laboratories. • The integration of a One Health approach in early warning is a strength. • There are electronic tools in place used to detect and report events, e.g. SORMAS and Auto Visual Alert Detection and Reporting of Multi Disease. • A National Community-Based Surveillance Strategic Plan is in place. • IDSR health facilities training has been rolled-out in all local government authorities in 36 States and the Federal Capital Territory. • e-IDSR is used for surveillance reporting (SORMAS for immediate reporting and a mobile Strengthening Epidemic Response System (mSERS) for weekly reporting). Challenges • Staff attrition is evident. • There is a lack of effective interconnectivity between the human, animal and environmental sectors, particularly at the community level. • Limited electronic reporting is undertaken at health facilities, especially the primary health facilities. • There is a lack of sufficient funding for surveillance at the subnational level, which includes M&E. D2.2. Event verification and investigation – Score 4 Mechanisms for verifying, investigating and risk assessing detected events have been developed and are being implemented at the national and intermediate levels. There is availability of trained personnel for event verification, investigation and risk assessments from multiple sectors – human, animal and environment. Guidance and methodology for event risk assessment are available and in use. Information in risk assessment is disseminated to all stakeholders via emails. Strengths • A strategic plan to enhance event-based surveillance and community-based surveillance is available. • A multidisciplinary approach is in place for verification and investigation of events (One Health Approach). • World Organisation for Animal Health reports are regularly disseminated. • A functional event management system is available, called SitAware (Situation Awareness). • SORMAS is functional across the country. • SOPs and technical guidelines are available. • Functional IDSR structures are in place and consist of well-trained personnel. • Effective data management capacities are evident across all levels. • Regular analysis and dissemination of event-based surveillance reports takes place. • Daily epidemic intelligence meetings are held and information is shared with all stakeholders. • Regular sharing of SPOTREPs/SITREPs (situation reports). • Signals and events are logged in SitAware and followed up until closed. • An event-based surveillance module is available in SORMAS to track event verification and investigation. 36 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Challenges • Inadequate funding is available for surveillance activities particularly for event verification and investigation at the subnational levels. • Workforce at subnational levels is inadequate to support event verification and investigation. D2.3. Analysis and information sharing – Score 3 Surveillance data is received and analysed on most priority diseases and unusual events. Advanced analysis of surveillance data available, such as geospatial modelling and time series, especially at the national level. Mechanisms are in place to link epidemiological and laboratory data through SORMAS. Plans are ongoing for interoperability of surveillance systems across the different sectors – human, animal and environment. There are, however, limited data management capacities at the subnational levels, with delays in data sharing from these levels. Strengths • Weekly epidemiological bulletins are regularly disseminated across the country and internationally. • Daily and weekly situation reports (SITREPS) are disseminated. • Electronic tools for data analysis are available (SORMAS). • Data sharing frameworks/agreements are available at the national level. • There is availability of a data analytics and visualization tool that pulls data from all surveillance data sources for data-driven decision-making. • Surveillance data quality management meetings are held routinely to review data at national and subnational levels. Challenges • There is limited capacity for predictive modelling. • Currently, there is no interoperability between the different systems across the different sectors (environment, animal and human health). Recommendations for priority actions • Integrate early warning surveillance functions in private and public sectors across all One Health sectors and levels. • Ensure full-scale deployment of SORMAS to health facilities (public and private). • Train and retrain staff on epidemiological investigations especially at subnational levels across all sectors. • Implement community-based surveillance across all 36 states and the Federal Capital Territory. • Establish interoperability between the different systems across the different sectors: environment (Integrated National Environmental Surveillance System), animal (NADIS) and human health (SORMAS, DHIS2). 37 Detect D3. Human resources Introduction Human resources are important in order to develop a sustainable public health system over time by developing and maintaining a highly qualified public health workforce with appropriate technical training, scientific skills, and subject-matter expertise. Human resources include nurses and midwives, physicians, public health and environmental specialists, social scientists, communication, occupational health, laboratory scientists/technicians, biostatisticians, IT specialists and biomedical technicians and a corresponding workforce in the animal sector: veterinarians, animal health professionals, para- veterinarians, epidemiologists, IT specialists etc. The recommended density of doctors, nurses, and midwives per 1000 populations for operational routine services is 4.45 plus 30% surge capacity. The optimal target for surveillance is one trained (field) epidemiologist (or equivalent) per 200 000 populations who can systematically cooperate to meet relevant IHR and performance of veterinary services core competencies. One trained epidemiologist is needed per RRT. Target States Parties with skilled and competent health personnel for sustainable and functional public health surveillance and response at all levels of the health system and the effective implementation of the IHR (2005). Level of capabilities Developing a functional and sustainable public health system requires a highly qualified and well- motivated public health workforce; a particular challenge in a country of over 200 million people. Nigeria has dedicated, well-trained public health professionals supporting public health across the health care system at all levels. The hundreds of trained field epidemiologists trained by the NFELTP serve in diverse roles across the various MDAs. They were notable for successfully interrupting the transmission of the Ebola virus and leading successful eradication of poliomyelitis (polio). They remain a huge resource for Nigeria’s surge capacity in responding to public health events in the country. Despite these accomplishments, the Nigerian public health workforce is still moving toward the goal of one trained field epidemiologist (or equivalent) per 200 000 population and at least one trained FETP frontline field epidemiologist in every district. A comprehensive workforce strategy that ensures continuous training and even distribution of healthcare workers as well as establishing an incentivized career path for the public health workforce, remains a priority. The NCDC has successfully advocated for the incorporation of the health security workforce in the National Workforce Strategy. Improving both recruitment and retention of a specialized public health workforce should be expedited to address attrition and ensure sustainability. There are also ongoing efforts to map the human resources for health security at national and subnational levels. This technical area had reduced scoring during the midterm assessment due to the stoppage of the frontline FETP training. This has been restored with the addition of the intermediate FETP training and the recommencement of the Integrated Training of Surveillance Officers in Nigeria. Finally, the disproportionate distribution of human resources between the national and subnational levels remains an issue. 38 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Indicators and scores D3.1. Multisectoral workforce strategy – Score 3 A comprehensive workforce strategy that ensures continuous training and even distribution of healthcare workers as well as establishing an incentivized career path for the public health workforce, remains a priority. The NCDC has successfully advocated for the incorporation of the health security workforce in the National Workforce Strategy; however, implementation and budget remain a challenge. Additionally, coordination across human, animal, and environmental health sectors is poor. Improving this coordination and focusing on the recruitment and retention of a specialized public health workforce should be expedited to address attrition and ensure sustainability. Strengths • A multisectoral strategy has been developed, which includes a broad range of professionals required in public health. • A TWG focusing on the development and implementation of the workforce strategy has been established. • The workforce strategy is supplemented by other documents focusing on specific professions and cadres. • A health workforce profile is available through the electronic workforce database established in the Federal Ministry of Health (Human Resources for Health). Challenges • The strategy does not include a detailed implementation plan, budget or funding mechanism. • There is poor collaboration with the animal health and environment sectors. • There is no clear career path for epidemiologists. • Overall, there is weak implementation of human resources for health policies and plans. • The workforce database needs a mechanism for regular updates. D3.2. Human resources for implementation of IHR – Score 3 There are ongoing efforts to map the human resources for health security at national and subnational levels. The technical area had reduced scoring during the midterm assessment due to the stoppage of the frontline FETP training. This has been restored with addition of the intermediate FETP training and the recommencement of the Integrated Training of Surveillance Officers in Nigeria. The disproportionate distribution of human resources between the national and subnational levels remains an issue. Strengths • There is availability of appropriate human resources at the national, state and local government authority levels. • There is availability of personnel across disciplines and sectors. • Implementation of FETPs is carried out appropriate to the functions of each administrative level (advanced, intermediate and frontline). Challenges • There is a need to develop and implement a policy to address the retention of skilled professionals at all levels for IHR implementation. • There is a need to collaborate with partners to identify volunteers to help augment the workforce during emergencies (short-term). • There are inadequate numbers and distribution of public health personnel. • There is poor retention of highly skilled personnel. 39 Detect D3.3. Workforce training – Score 3 Nigeria has established or utilized several trainings and institutions to support workforce training across the country. However, challenges include weak retention, a lack of sustainable budgets and funding mechanisms, and lack of coordination between agencies. Strengths • The country has established all the tiers of the NFELTP. • There are many public health tertiary institutions in Nigeria and well-established public health trainings and institutes. • NCDC serves as a platform for building competency for public health trainees. • IMPACT seeks to build the capacity of public health managers to be able to translate science into efficient and effective action. • National onboarding training for the African Volunteers Health Corps (AVoHC), SURGE was carried out in November 2022. • Successes include the institutionalization of the FETP in the National Public Health Institute and of In-Service Applied Veterinary Epidemiology Training in the Federal Ministry of Agriculture and Food Safety. • The One Health approach to training is integrated. • Competency-based, mentor-supported training exists. • Surge training at both national and subnational levels exists. Challenges • Funding mechanisms still need to be developed to sustain all the levels of training in the country, e.g. IMPACT, FETP, SURGE, Integrated Surveillance and Veterinary Education Training, etc. • No career path exists yet for specialized public health professionals within the Nigeria Civil Service Commission. • The NFETLP/IMPACT/SURGE are largely donor-financed, which undermines sustainability. • There is poor retention of highly trained personnel for maintaining the training programmes as mentors and instructors. • Weak Inter-agency synergy and collaboration undermines capacity-building efforts. D3.4. Workforce surge during a public health event – Score 2 Nigeria has developed a two-year national implementation roadmap based on scoping and mapping of workforce requirements and capacity and is beginning to develop a similar roadmap at the subnational level. The Federal Ministry of Health coordinates relevant MDAs and should develop clear funding mechanisms/create budget lines for the roll-out of the National SURGE flagship initiative to the subnational level beyond the initial phase 1 selected states. Relevant MDAs should align, collaborate, and participate in the rollout of the SURGE flagship initiative-workforce SURGE during a public health event. However, support, implementation and funding for implementation of all these roadmaps remain a challenge. Strengths • A two-year national implementation roadmap has been developed and costed; this was based on scoping and mapping of workforce requirements and capacity. • A two-year implementation roadmap is being developed for six states at the subnational level. • The roadmap is multidisciplinary and multisectoral. 40 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Challenges • Subnational plans still need to be developed for the 36 states and the Federal City Territory. • NCDC's active participation in the initiative and implementation roadmap is required in line with its mandate. • There has been a decline in the participation of the NCDC in the national SURGE initiative. • No clear funding mechanism has been identified – the initiative is being catalysed by WHO. Recommendations for priority actions • Develop mechanisms for better retention of skilled professionals, including career paths for epidemiologists and other emergency responders. • Improve recruitment mechanisms for both additional long-term health workers and emergency short-term volunteers. • Update the public health multisectoral strategy to include the implementation plan, budgeting and funding mechanisms. • Develop a comprehensive sustainability plan for NFELTP, IMPACT, SURGE, etc. • NCDC should align, collaborate and participate in the implementation of the national surge capacity-building in line with its mandate. 41 Respond 42 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria R1. Health emergency management Introduction This capacity focuses on management of health emergency and systems for enabling countries to be prepared and operationally ready for response to any public health event, including emergencies, as per the all-hazard requirement of IHR. Ensuring risk-based plans for emergency preparedness, readiness and response, robust emergency management structures and mobilization of resources during an emergency is critical for a timely response to public health emergencies. Target (1) Existence of national strategic multi hazard emergency assessments (risk profiles) and resource mapping. (2) Existence of emergency readiness assessment (3) Development of national health emergency operations centre plans and procedures. (4) Establishment of an emergency response coordination mechanism or incident management system. (5) Evidence of at least one response to a public health emergency within the previous year that demonstrates that the country sent or received medical countermeasures and personnel according to written national or international protocols. (6) Existence of an emergency logistic and supply chain management system/mechanism. (7) Existence of policies and procedures for research, development and innovation for emergency preparedness and response. Level of capabilities In line with the IHR, Nigeria recognizes the significance of establishing robust systems for emergency preparedness, readiness and response. These systems encompass a range of activities, from risk assessment and emergency operations to the coordination of health personnel, research and logistics during crises. A collaborative approach is key to successful health emergency management, involving multisectoral actors across national, state and local levels. By prioritizing health emergency management, Nigeria aims to enhance its overall public health preparedness, bolster its response capabilities and protect the health and well-being of its population. Having developed capable rapid response and emergency management practices at the national level, the major challenge for Nigeria is to establish them well in each state. This process has been progressing for the last five years. Indicators and scores R1.1. Emergency risk and readiness assessment – Score 3 Nigeria has in place a multihazard risk assessment, updated in the last year as well as risk assessments and mobilization plans for priority diseases. This is a notable advancement in recent years. Strengths • An experienced and resilient workforce with demonstrated capacity in emergency risk assessment and readiness exists at the national and, in some cases, at the state level. • Emergency Management Framework: Nigeria has developed a National Public Health Multihazard Emergency Preparedness and Response Plan and hazard-specific contingency plans. 43 Respond • Technological software is in use to track, monitor and visualize readiness status at the national and state level. • Partnerships and Alliances: strategic partnerships and alliances exist with government, non- governmental and private sector organizations for preparedness. • A multihazard risk assessment was conducted using the WHO Strategic Tool for Assessing Risks (STAR) in 2018 and updated in 2022. Prior to this, Nigeria developed a National Public Health Multihazard Emergency Preparedness and Response Plan in 2021 with wide participation from relevant sectors. • A risk matrix has been generated which shows the risk of various hazards and a seasonal calendar of likely events. • A multihazard risk assessment was conducted at selected intermediate levels in four states: the Federal Capital Territory, Kano, Rivers and Ondo. • Vulnerability assessment and risk mapping were conducted at the national and state levels but are yet to be commenced at the community level. • Nigeria is the first country to pilot the Readiness Intelligence Tool. The country has conducted the National Readiness Assessment in 2022 using a validated checklist. Challenges • The country needs to further embrace technological advancements such as remote sensing and GIS, to enhance data collection, analysis and real-time for decision-making. • Improving coordination and collaboration among different stakeholders and international partners is always needed. • Providing training programmes for emergency frontline health workers will enhance their skills in disaster preparedness and response. • Fostering partnerships between the public and private sectors would leverage resources and expertise in emergency preparedness. • Staff attrition is creating gaps in capacity for emergency preparedness and response in relevant government agencies. • Gathering accurate and up-to-date data on hazards, vulnerabilities and potential impacts can be challenging. Incomplete or unreliable data can lead to inadequate risk assessments and preparedness plans. • Weak human resources capacity exists at the state level to conduct strategic risk assessment and inadequate resources at the national level. R1.2. Public health emergency operations centre (PHEOC) – Score 4 The permanent designated PHEOC facility has been occupied and in use continuously for at least four years with an operating budget and core permanent staffing. It has shown its ability to respond to new outbreaks rapidly at the national level and has corresponding units established in some form in every state. Strengths • In terms of readiness to act, the national PHEOC has capabilities for activating a coordinated response to public health events within two hours of notification. • The national PHEOC has a streamlined multisectoral structure for effectively coordinating concurrent incidents. • The capacity to initiate public health response actions such as incident investigation and reporting exists from local and intermediate levels up to national level. • Regarding digitization of PHEOC operations, data collection, analysis and visualization have been automated and digitized to enhance rapid decision-making and to maintain a common operating picture. 44 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria • The national PHEOC was operationalized in 2017 and by the end of 2020, 37 subnational PHEOCs had been established in every state in Nigeria, enabling stronger coordination of emergency preparedness and response activities at the subnational level. • The SitAware event management platform has been deployed nationwide as a key tool for epidemic intelligence gathering, tracking of disease outbreak evolution and documentation of response actions. • The PHEOC conducts after-action reviews and intra-action reviews to thoroughly evaluate and identify strengths, weaknesses and areas for improvement. This learning process enhances future response efforts and fosters a culture of continuous improvement. • The national PHEOC has trained personnel guided by comprehensive emergency response plans and SOPs such as the Incident Activation Plan, Infectious Disease Outbreak Response Plan, Viral Haemorrhagic Fever Preparedness and Response Plan and national guidelines for mpox, acute watery diarrhoea outbreaks, etc. • The daily epidemic intelligence review meetings approach facilitates real-time monitoring and assessment of the evolving situation that enables timely and informed decision-making. • Over the last five years, the national PHEOC has activated the Incident Management System (IMS) in response to 23 incidents. • A multilevel public health emergency management training programme is in place for continuous capacity-building of public health workforce at national and state levels. • Simulation exercises to test coordination and communication during emergencies have been conducted across 22 states. • A PHEOC network, made up of national and state PHEOCs was established to promote collaboration and coordination during emergencies. Challenges • Harmonization of digital tools for epidemic intelligence gathering would help achieve interoperability and reduce duplication of efforts. • Subnational PHEOCs need strengthening. It is critical to ensure that all the key functions of a PHEOC as stipulated in WHO’s Framework for a PHEOC are adapted to context and implemented at the subnational level. • In terms of physical infrastructure, the national PHEOC and a number of other subnational PHEOCs have inadequate office space and furniture to adequately support key PHEOC operations. • Information technology and communication systems deployed at the PHEOCs are outdated or inadequate, which hampers real-time data sharing and coordination during emergencies. • The workforce is overstretched. There are declining numbers of trained workforce as a result of brain drain, and the remaining health personnel are hard-pressed to respond to concurrent emergencies. R1.3. Management of health emergency response – Score 4 IMS training has been conducted and the IMS is used nationally in coordination with PHEOC units at the state level. Strengths • The IMS has been institutionalized and integrated at the national PHEOC. • The Incident Activation Plan and the national PHEOC Handbook were developed to provide clear guidance on IMS activation, de-escalation and deactivation. • Priority epidemic-prone diseases have disease-specific TWGs that mirror the structure and functional pillars of an IMS. • National Outbreak Review Meetings have been held. 45 Respond Challenges • All PHEOC staff need regular training and retraining. • A culture of continuous improvement needs to be established through conducting regular exercises and programme reviews to ensure everyone understands their responsibilities and can effectively work together during a crisis, which is essential for successful IMS implementation. • There is a need to expand the 7-1-7 system for managing and coordinating response activities to monitor the efficiency and effectiveness of outbreak response using timeliness measures. The aim of this strategy is to detect an outbreak within 7 days, report it within 1 day, and respond effectively within the following 7 days to contain the spread of infectious diseases. • Capacity is lacking at subnational level. Individuals with adequate knowledge and experience of the IMS, especially at the subnational level, are very limited, which impedes the full integration of the IMS at that level. R1.4. Activation and coordination of health personnel in a public health emergency – Score 3 Well-developed plans are in place, and surge teams have been activated repeatedly from the national level to areas of response for the 23 events which the national PHEOC has responded to and for many more regional and local events. Strengths • The Rapid Response Team Guidebook is in place to guide pre-deployment, deployment and post- deployment actions. • There is availability of online modules for RRT training to facilitate continuous learning and enhanced scalability across the health workforce. • The deployment roster enables a coordinated personnel deployment process that ensures balance and promotes effectiveness of RRT members. • Team members deployed to the field make use of a reporting template that captures key outbreak response indicators and documents response actions. • The debriefing session that follows deployment helps in identifying successes and challenges. • National First Responders has been set up and is available for deployment during emergencies. • Rapid response training has been conducted for frontline health workers at both national and state levels. • Surge capacity exists at national level. • The deployment of surge capacity is facilitated by membership of regional and global networks, e.g. African Volunteer Health Corps and the Global Outbreak and Alert Response Network. Challenges • The emergency management team should be expanded and trained. • The response structure at subnational level is weak. Often, the outbreak response and investigation are delayed at the subnational level. • Health emergencies usually strain healthcare systems, leading to shortages of medical supplies, equipment and facilities. 46 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria R1.5. Emergency logistic and supply chain management – Score 3 The system of supply, while needing improvement and modernization, is in place and provides support to the majority of PHEOC events. Strengths • Capacity building is undertaken through training of logistics officers at national and state level. • The workforce is experienced, with demonstrated capacity in emergency supply chain management. • A National Medical Counter Measure Plan is in place to guide the activation and deployment of response commodities. • There is availability of Import Duty Exemption Certificate. • Pre-positioning of response commodities is aligned with the national risk seasonal calendar. • Third-party logistics companies are used to move response commodities to point-of-care. • A clearing agent is engaged to speed up clearance. • Private sector companies are engaged to leverage their resources and expertise in emergency logistics. • The National Medical Counter Measures Plan was tested in a tabletop exercise and is utilized during disease outbreaks. • The NCDC maintains a strategic stockpile for emergency supplies. • The country has the capacity to produce antibiotics, personal protective equipment and some lab consumables. However, no human vaccines are currently manufactured in-country. • There are no standing regional agreements on the procurement, sharing and distribution of countermeasures; however, commodities are often shared with needy countries in times of emergency. • Plans are in place for the procurement and distribution of animal health countermeasures. Challenges • Warehousing capacity needs to be improved both in terms of capacity and storage capability. • Logistics management information systems need updating. • Training and capacity-building needs investment. • Resource acquisition and management needs adequate funding. R1.6. Research, development and innovation – Score 2 Research and relevant publications have been produced by the system, many of which are available online and many of which have been published in international journals. While the national research agenda exists, it is not tailored specifically for the needs of the NCDC and its PHEOC, and procedures for research and development are not yet regularized. Strengths • A National Research Agenda has been developed. • A National Research Consortium exists to guide the development and implementation of research priorities. • The country has identified a few institutions with research capacity within the country. • Research findings are disseminated on NCDC social media pages. • To promote research ethics and integrity, measures are in place to ensure research conducted adheres to ethical guidelines. 47 Respond Challenges • Brain drain reduces the pool of skilled researchers and health professionals in the organization and hinders the sustainability of research and innovation efforts. • Health system weaknesses including inefficient procurement, etc., can impede the implementation of research findings into practice. • Partnership and collaboration challenges: international organizations and funding agencies sometimes prioritize their own agendas, leading to an imbalance in the research direction. • Insufficient emphasis on capacity-building and education hinders the development of local expertise in research and innovation. Recommendations for priority actions • Increase the number of events to which the PHEOC responds. • Integrate intra- and after-action reviews as a routine part of response, including 7-1-7. • Develop self-directed training materials for those staffing national and state emergency operations centre and RRT staff. • Lead research with an applied, practical, research agenda. 48 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria R2. Linking public health and security authorities Introduction Public health emergencies pose special challenges for law enforcement, whether the threat is manmade or naturally occurring. In a public health emergency, law enforcement will need to quickly coordinate its response with public health and medical officials. Target Country conducts a rapid, multisectoral response for any event of suspected or confirmed deliberate origin, including the capacity to link public health and law enforcement, and to provide timely international assistance. Level of capabilities Nigeria has established a national TWG for linking public health and security authorities which is domiciled in the Office of National Security Advisor. Training on public health emergency preparedness has been conducted with joint capacity-building using tabletop/full-scale operational simulation exercises on public health emergencies and DEs involving 28 MDAs. The country has developed unique protocols and memoranda of understanding for security agencies and public health departments with specific roles and clear terms as part of the National Crisis Management Doctrine (2022). In addition, Nigeria has a Medical Incident Commander course for medical emergencies during DEs of chemical, biological, radiological and nuclear (CBRN) origin. Through a collaborative process led by the Office of National Security Advisor, the country has developed the National Public Health Emergency Response Committee for Point of Entry. Chemical, biological, nuclear, radiation, explosives elements have also been integrated into counter terrorism simulation exercises. There is still a need to develop and validate the protocol for joint investigations, incident reporting and information sharing between public health NFP and law enforcement (local and international). There should be a focus on developing an annual plan for simulation exercises (full-scale simulation and table-top). No clear plan exists to define the roles and responsibilities as well as the frequency of simulation exercises that should involve law enforcement and public health authorities. Due to the complex command and control hierarchical structure and nature of the security environment, there is underutilization of systematic information exchange. There is also no plan for highly skilled personnel retention, leading to unpredictable attrition of trained personnel in the sector. 49 Respond Indicators and scores R2.1. Public health and security authorities, (e.g. law enforcement, border control, customs) are involved during a suspect or confirmed biological, chemical or radiological event – Score 2 Agreement and protocols, including at least roles, responsibilities, SOPs, and information to be shared, exist between public health and authorities within the country and have been formally accepted to address some hazards. Strengths • Both law enforcement and public health leadership are involved in health security issues with good collaboration with relevant MDAs including Points of Entry (POE) as guided by relevant agreements, policies and SOPs. • Protocols and memoranda of understanding for security agencies and public health departments that elaborate specific roles as part of the National Crisis Management Doctrine are in place. • There are capacity-building efforts for public health and security personnel on the medical incident commander course. • Joint simulation exercises (public health and security sectors) on public health emergencies and DEs of chemical and biological origin are conducted, albeit irregularly. • A TWG for health and security domiciled in the Office of National Security Advisor has been established. Challenges • The unique command and control hierarchical structure of the security environment is complex and bureaucratic. • The retention rate is low for trained personnel in the public health security sector for DEs. • There is a need to strengthen the information-sharing mechanism between public health, local security authorities and international security authorities for DEs. • A standard protocol is lacking for public health security joint investigations, incident reporting and information sharing with law enforcement in CBRN DEs. • There is a need to establish a real-time data visualization capacity (dashboards) at TWG Secretariat for ease of monitoring, evaluation and timely decision-making during DEs. • An annual plan needs to be developed for joint public health-security simulation exercises (full-scale simulation and table-top). Recommendations for priority actions • Empower the Office of National Security Advisor Focal Point with real-time data visualisation capability (dashboards) at TWG Secretariat for monitoring, evaluation, review and timely decision-making during DEs. • Aim to develop, validate and implement a national protocol for joint investigations, incident reporting and information sharing between public health NFP and law enforcement (local and international). • Aim to create a five-fold increase in the number of trained public health and security front- line responders for ambiguous or DEs of CBRN origin. • Review employment levels, set goals, identify conditions affecting retention and distribution of trained public health and security personnel, and improve training and staffing for trained first responders to DEs. • Develop a plan and work with the WHO country office to deepen the assessment of ambiguous or suspected deliberate events (DEs) involving CBRN hazards using the National Self-Assessment Tool and regularize simulation exercises/tabletop exercises for DEs. 50 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria R3. Health services provision Introduction Resilient national health systems are essential for countries to prevent, detect, respond to and recover from public health events, while ensuring the maintenance of health systems functions, including the continued delivery of essential health services (EHS) at all levels. Particularly in emergencies, health services provision for both event-related case management and routine health services are equally as important. Moreover, ensuring minimal disruption in health service utilization before, during and beyond an emergency and across the varied contexts within a country is also a critical aspect of a resilient health system. Target (1) Evidence of demonstrated application of case management procedures for events caused by IHR relevant hazards. (2) Optimal utilization of health services, including during emergencies. (3) Ensuring continuity of essential health services in emergencies. Level of capabilities The health system of Nigeria is three-tiered: primary, secondary, and tertiary. Health is on the concurrent list in the Nigerian Constitution across all administrative levels of governance. Yet, attention during emergencies has always been focused on the ‘disease of interest’ with resulting unintended neglect of other EHS, owing to resource constraints. These include a shortage of skilled human resources due to a high rate of attrition and budgetary provisions. Routinely, assessments of health facilities are conducted at the national and subnational levels at intervals. In addition, specific disease programmes conduct assessments for specific priority diseases. Nigeria has limited integrated or alignment mechanisms in place for health information systems, particularly data on surveillance, health service delivery and health services utilization, to provide streamlined, quality data flow and reporting (from facility to national level public and private health service providers) to inform effective policy and decision-making. In addition, the Federal Ministry of Health has adopted the District Health Information System (DHIS2) as the national reporting system for health data, including service utilization across all sectors and regions using disaggregated variables. Assessments of health facilities are the responsibility of the government at all levels and reports inform policy review and efforts towards health strengthening. However, there is currently no strategic tool available for assessing the risks or vulnerability risk analysis and mapping. As part of emergency preparedness and response efforts, the Federal Ministry of Health has designated treatment centres for health emergencies with multi-disciplinary capacities, and various capacities at other facilities. To strengthen health delivery at all levels, a referral system is in place. However, there are gaps in implementation and sustainability across the board, given different leadership priorities and available funding. The current scope of the case management programme is limited to the management of some priority diseases rather than to managing priority health events. Accordingly, specific guidelines and protocols have been developed, disseminated, and are being implemented for some priority diseases such as Lassa fever, mpox, COVID-19, cerebrospinal meningitis, cholera and yellow fever, and others are under development. Moreover, strategic coordination for implementation is also in place for some of the priority diseases. However, there has been sub-optimal implementation of case management of priority health events at the state level because of inadequate resources such as infrastructure, limited human capacities (upskilling of frontline healthcare workers) and funding to procure commodities, medicines, and consumables. 51 Respond Indicators and scores R3.1. Case management – Score 1 The national case management guidelines for priority health events are not currently available. Strengths • Guidelines for some priority diseases have been developed, disseminated and implemented at all administrative levels. • Protocols and SOPs for some priority diseases have been developed. • Strategic coordination for implementation is currently in place for some of the priority diseases. • There has been a community of practice for case managers. Fellowship programmes were developed to strengthen expertise in case management of priority diseases such as viral haemorrhagic fever. Challenges • There needs to be a routine periodic (five-year, or as necessary) review of guidelines, given the increasing findings on the management of cases. • Capacities need to be increased for the case managers to collect, analyse and use data for informed decision-making and conducting scientific reviews, and update of the available guidelines. • Strengthening stakeholder engagement is necessary for resource mobilization for case management. • A clinical data repository (e.g. databank) is unavailable. • Resources are inadequate for scale-up of training to operationalize case management guidelines. • Development and institutionalization of a framework is needed for monitoring, evaluation, accountability and learning for implementing the guidelines and protocols. R3.2. Utilization of health services – Score 2 Available information suggests low levels of service utilization with a rate of less than two outpatient department visits per person per year across the country approximately, noting a possibility of under-reporting. Strengths • A functional mechanism is available to monitor and report health services utilization, albeit in a limited capacity. • Trained personnel are available for the use of the DHIS2 reporting system. • Legislation (National Health Act 2014) which backs data management systems is available. Challenges • There is massive attrition of skilled health workforce. • The health workforce overstretched. • Inadequate funding is available for health infrastructure, manpower and equipment. • Distribution of functional health facilities within urban and rural areas is inadequate. • There is low public trust in the healthcare system. • The security situation is unstable. • Medical tourism is taking place. 52 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria R3.3. Continuity of essential health services (EHS) – Score 2 Nigeria has a nationally defined package of essential or critical health services. However, there are no strategic or operational plans or guidelines available that detail the mechanism for the continuity of EHS during times of emergency. Strengths • A nationally defined package of EHS is available. • There is availability of joint inter-agency crisis management documents. • A strong collaboration mechanism involving health and other sectors is in place. Challenges • There is a need for the development and dissemination of working plans and advisories on the continuity of EHS during emergencies. • Disruptions in EHS have occurred during times of emergencies, insecurity and elections in recent crises including COVID-19 pandemic. • Frequency of simulation exercises and post-event reviews to evaluate EHS performance are not regular. • Post-event reviews do not always inform improvement of EHS measures. Recommendations for priority actions • Develop a governance accountability and coordination framework with periodic (five-year) review for maintaining EHS during emergencies. • Develop a monitoring, evaluation, accountability and learning framework for implementing post-event improvement plans. • Establish telemedicine options for service delivery during emergencies. • Mobilize resources for increased frequency of simulation exercises and post-event reviews at all levels. 53 Respond R4. Infection prevention and control Introduction To have strong, effective infection prevention and control (IPC) programmes that enables safe health care and essential services delivery and prevention and control of healthcare-associated infections (HCAI). It is critical to initially ensure that at least the minimum requirements for IPC are in place, both at the national and facility level and to gradually progress to the full achievement of all requirements within the WHO IPC core components recommendations. Target (1) National IPC programme strategy has been developed and disseminated. (2) Implementation of the national IPC programme plans, with monitoring and reporting of HCAI. (3) Established national standards and resources for safe health facilities. Level of capabilities Nigeria recognizes the threat that infectious diseases pose globally and has developed the National IPC Strategic Plan to provide a framework for implementing the recommendations of the national IPC policy and the National Action Plan on AMR according to WHO recommendations to achieve quality care, patient safety, health security and the reduction of HCAI and AMR. As a best practice, in 2019 Nigeria established a National IPC programme called the Turn Nigeria Orange. The programme is built on the philosophy of one nation, one plan with an implementation strategy that focuses on building a peer-network of healthcare facilities across secondary and tertiary healthcare facilities. The National IPC programme is anchored on the WHO core components of IPC implemented using a stepwise approach across a network of healthcare facilities called Orange Network. The idea is to learn and refine while scaling-up to other healthcare facilities at all levels. A key identified strength from the Orange Network is the establishment of IPC programmes led by trained and certified IPC focal persons supported by a team and committee that will continuously work towards the implementation of facility- specific IPC priorities using an annual work plan with budgetary support from the healthcare facilities. Through collaborations with academic and professional institutions like the College of Medicine University of Lagos and Infection Control Africa Network, the National IPC programme had trained over 100 IPC professionals (basic, intermediate and advanced levels), who continue to lead IPC programmes across health facilities and institutions in Nigeria. This in-service training programme is guided by a curriculum co-developed by the NCDC and Centre for Infection Control and Patient Safety. Further, the National IPC programme had also developed a manual (a compendium of guidelines) to guide healthcare workers on safe provision of healthcare services across facilities. In addition, all IPC activities implemented at national and facility level are contained and guided by a National IPC strategic plan (2022–2027), developed following national and facility-level risk assessments. The country also has an active national HCAI surveillance programme implemented across the Orange Network that employs both retrospective and prospective methodologies guided by a national HCAI surveillance strategic plan (2023–2028) to ensure methodical implementation of HCAI surveillance activities linked to the national AMR programme. Recently, the national IPC programme concluded a pilot implementation of surgical site infections surveillance from September 2022 to March 2023 before scaling-up to other Orange Network healthcare facilities. Another point prevalence survey for HCAI is also 54 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria being implemented across two Orange Network facilities in collaboration with WHO and Robert Koch Institute. The aim is to establish a network of facilities (Naija HAINet) conducting quality HCAI surveillance and providing data for policy-level decision making. Indicators and scores R4.1. IPC programmes – Score 3 Strengths • Nigeria has a budgeted IPC operational plan and IPC guidelines, as well as a national IPC manual and other disease-specific guidelines available and disseminated, e.g. for VHF, mpox and cholera. • An active national IPC programme “Turn Nigeria Orange” exists. • Linkages to other relevant programmes are present, such as AMR. • The implementation approach is multimodal. • The national database of certified IPC professionals is growing. • Relevant guidelines and tools are available including the Infection Prevention and Control Assessment Framework and Hand Hygiene Self-Assessment Framework. • Strong partnerships exist with academic institutions and relevant organizations critical for synergy and IPC expertise development. Challenges • Funding is inadequate for IPC activities and consumables including trainings, surveillance, audit and feedback. • Overall health care staffing is inadequate at the facility level to consistently implement good IPC practices. R4.2. HCAI surveillance – Score 2 Nigeria has a National HCAI Surveillance Strategic Plan (2023–2028) with a list of priority pathogens linked to the National AMR surveillance guidelines. Strengths • Prevalence surveys are undertaken. • Trained professionals in the Orange Network conduct HCAI surveillance activities at healthcare facility level. Challenges • Insufficient laboratory capacity exists to detect multidrug-resistant pathogens. R4.3. Safe environment in health facilities – Score 1 Nigeria does not have standards for safe environment in health facilities. Strengths • The national IPC strategic plan includes built environment (water, sanitation and hygiene are incorporated in this component). • Relevant guidelines and tools are available and disseminated to health care facilities, e.g. IPC manual and water, sanitation and hygiene. • A water, sanitation and hygiene assessment report is available and costed. • Close collaboration takes place with other MDAs relevant to safe environment in health facilities. 55 Respond Challenges • Knee-jerk reactions to IPC following outbreaks are not sustainable. • The absence of a legal framework is a challenge. • There is suboptimal buy-in and support by subnational entities. • No career path is evident for IPC professionals. • There are no dedicated personnel to manage IPC programmes at the facility level (state and private health facilities). • There are built environment challenges at the facility level. Recommendations for priority actions • Institutionalize IPC programme by getting approval for the revised national IPC policy, finalize the IPC legal framework development and implement a budget advocacy plan for IPC at subnational level. • Develop a national IPC (in-service) training plan and preservice curriculum. • Finalize and validate the updated HCAI plan and incorporate secondary health facilities into the national HCAI surveillance network. • Revise and update the IPC M&E framework to include Infection Prevention and Control Assessment Framework – Minimum Requirements. • Develop national standards for safe environments in healthcare facilities. 56 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria R5. Risk communication and community engagement Introduction Risk communication should be a multilevel and multifaceted process that aims at helping stakeholders define risks, identify hazards, assess vulnerabilities, and promote community resilience, thereby promoting the capacity to cope with an unfolding public health emergency. An essential part of risk communication is the dissemination of information to the public about health risks and events, such as disease outbreaks. For any communication about risk caused by a specific event to be effective, the social, religious, cultural, political and economic aspects associated with the event should be considered, including the voice of the affected population. Target States Parties use multilevel, multisectoral and multifaceted risk communication and community engagement (RCCE) capacity for public health emergencies. Real-time exchange of information, advice and opinions during unusual and unexpected events or emergencies so that informed decisions to mitigate the effects of threats, and protective and preventive action can be made. This includes a mix of communication and engagement strategies, such as media and social media communications, mass awareness campaigns, health promotion, social mobilisation, stakeholder engagement, community engagement and infodemic management. Level of capabilities Nigeria's RCCE strategy is a comprehensive approach that is multihazard, science-informed, data-driven and context-sensitive which enables it to be effective in complex public health emergencies. It utilizes social science methodologies and participatory engagement to enhance public health emergency prevention, preparedness, detection, response and mitigation. This approach involves two-way communication, rumour management, and community involvement to effectively address public health emergencies and minimize or mitigate their impact. Nigeria's RCCE capacity has evolved through extensive multisectoral coordination, collaboration, and communication at both national and subnational levels, creating a robust system that can adapt and align various mechanisms, models and management of resources for meeting predetermined and emerging needs in any crisis. Nigeria's RCCE interventions also adopt a comprehensive One Health approach, considering the interconnectedness of human, animal and environmental health and leveraging the strengths of the One Health approach to address existing and emerging threats before, during and after outbreaks/ events of public health importance. This holistic approach ensures a thorough understanding of disease transmission factors and enables effective prevention and control measures. Nigeria employs a multi- channel approach, including trained spokespersons, to disseminate critical information to the public during emergencies. RCCE personnel are deployed to engage with communities, address concerns and provide clear information about outbreaks, preventive measures and recommended actions. Adaptive interventions based on feedback are also implemented, fostering trust and enhancing communication. The government and health authorities actively seek input from the public and assess the 57 Respond effectiveness of communication strategies. Continuous support from international and local partners, donors and the private sector is crucial for strengthening communication efforts. Media and digital monitoring and scanning tools (online and offline) have helped identify and address misinformation and rumours. The nascent Nigeria Infodemic Management System has continued to guide risk communication approaches, integrating information from multiple sources including social media, traditional media, community listening and utilizing the event-based surveillance system (Connect Centre) to generate useful insights for guiding decisions, strategies and messaging. Human-centred design and community ownership are employed to place the community at the centre of intervention design, planning and implementation, fostering community ownership and effective behaviour change. Indicators and scores R5.1. RCCE systems for emergencies – Score 3 The country team conducted an initial self-assessment exercise and assigned a score of 4 to this technical area. The JEE external evaluation team requested that the country team validate the score by providing supporting evidence. However, there was a lack of consensus at the plenary level, suggesting differing opinions, understanding or interpretations among participants. The JEE external evaluators team and the country team engaged in a detailed discussion to examine the evidence, assess criteria and explore the rationale behind the score initially assigned. After a side discussion, the JEE external evaluators team and the country team reached consensus on a score of 3 for the specific technical area, indicating that the performance or capability level should be adjusted from the initial score of 4. Nigeria has established and operationalized the national RCCE functions, demonstrating a commitment to proactive and organized communication efforts during health emergencies. The country has taken ownership of relevant guidelines and SOPs, including multihazard RCCE guidelines, infodemic management guidelines, social media strategy and other SOPs for RCCE development and management. The national multihazard guideline has been updated to incorporate lessons learned from the COVID-19 pandemic following a review in 2021–2022, demonstrating a proactive approach to learning from real-world experiences and adapting strategies for future response efforts. Nigeria's RCCE efforts are operational across all levels, ensuring a functional communication strategy and seamless integration into the Incidence Management System. However, there is a need for continuous enhancement and strengthening of RCCE functions and resources at the subnational level. This acknowledges the importance of local level communication to ensure accurate and timely information during public health events. Strengths • Strategic documents are available to guide RCCE implementation (e.g. multihazard risk communication guideline, infodemic management guideline, social media strategy, other RCCE SOPs and plans). • A National Risk Communication TWG has been established along with disease-specific TWGs for coordination of RCCE functions and data sharing with the integration of RCCE within the emergency operations centre or IMS. The RCCE structure (with terms of reference) has been established within the NCDC with an adequate number of trained RCCE staff for routine RCCE operations and an arrangement for surge capacity in place across MDAs for emergency deployment. Findings from the evaluation of real emergencies like the COVID-19 pandemic, cholera and Lassa fever outbreak response have been used to continuously improve RCCE interventions. • Continuous RCCE capacity strengthening takes place at national and subnational levels for surge capacity. • A RCCE capacity assessment was conducted at the subnational level; gaps identified are being addressed through ongoing training and engagement of relevant stakeholders at the subnational level. 58 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Challenges • The multisectoral coordinating structure (One Health) is weak at the subnational level and the coordinated approach involving various sectors (health, agriculture, environment) is inadequate. • At the subnational level there is poor ownership (commitment and responsibility) of health security measures. • A dedicated budget line for RCCE is lacking (there is no specific allocation of funds in the budget exclusively for RCCE activities). • Multiple policies and strategies require adaptation/adoption at the subnational level. • Overstretched focal persons have conflicting priorities at the subnational level. R5.2. Risk communication – Score 3 Nigeria has established well-defined plans, strategies and guidelines for risk communication, providing a structured framework for public health emergencies. These guidelines ensure consistency, effectiveness and alignment with best practices. Nigeria's emergency management structure integrates risk communication functions, ensuring seamless coordination and accurate information dissemination. Designated RCCE officials receive training in risk communication, equipping them with the necessary skills to effectively communicate critical information during health emergencies. Nigeria has developed a capacity for social media and infodemic management, addressing the challenge of misinformation and rumours during public health emergencies, at both the national and subnational level (14 states) and conducts periodic insights analysis for public health messaging. Monitoring of trends, discussions and sentiments on social media platforms (offline and online) guides messaging and provides real-time insights into public perceptions, concerns and information gaps. There is ongoing analysis of target audiences based on trusted sources and preferred channels, through online and offline community listening to inform the design of communication interventions. Strengths • There is a coordination mechanism in place at the national level for risk communication messages across sectors. • One Health RCCE training modules have been developed for training of RCCE personnel on communication with other sectors for transparent and early/regular communication with target audiences using appropriate conventional media (print and broadcast), and digital media. • A good relationship exists with media stakeholders. • A functional website serves as a useful resource for the public, partners and media stakeholders. • There are trained spokespersons for proactive engagement of the media as well as deployment of RCCE personnel during public health emergencies. • Media plans, protocols and SOPs are present to support the delivery of timely and accurate information to the public. • A functional infodemic management system is in place that develops insights from analysis and uses it to drive RCCE evidence-based messaging at national and subnational level (14 states). • Capacity exists to use digital media for social listening and public health communication at national and subnational levels (14 states). • There is a pool of trained stakeholders on One Health risk communication at subnational level. 59 Respond Challenges • There is suboptimal use of financial and human resources considering the vast human resources that have not been fully harnessed and poor prioritization of RCCE by the authorities, resulting in limited funding. • Attrition of trained resource personnel is a challenge. • The number of trained media spokespersons from other One Health partners and MDAs is inadequate. • There have been delays in getting approval for spokespersons from other One Health MDAs to respond urgently during emergencies. R5.3. Community engagement – Score 3 The country has established RCCE structures at various levels, including state, local government authorities and community levels to ensure efficient communication dissemination and response coordination. Through this, the communities are actively involved in emergency response efforts, enhancing the effectiveness of response initiatives and ensuring community-relevant strategies. Communities actively co-design emergency response initiatives, shaping them based on their insights, needs and preferences. Nigeria also engages various community stakeholders including traditional leaders, faith-based organizations, persons with disabilities and civil society, ensuring representation and participation in decision-making processes related to emergency preparedness and response. This continuous engagement of stakeholders fosters strong relationships, builds trust and ensures collaboration among different agencies, stakeholders and partners in the communities. It further facilitates coordination, pooling of resources and consistent communication strategies, maximizing the impact of community engagement efforts. There is coordination of risk communication messages across sectors at the national level and risk communication messages and materials are developed in various local languages. Strengths • There are clear community engagement coordination mechanisms in place at national and subnational levels. • Adaptive interventions are developed based on feedback from the target audience and after- action reviews. • In April 2022 Nigeria commenced the use of social science methods such as human-centred design to facilitate bottom-up interventions and community ownership, and is now piloting these methods in three Lassa fever endemic states. • Good collaboration exists among community-based organizations at the grassroot level. • Active structures exist in the community (e.g. Social Mobilization Committee, ward and community development committees, polio control). • Tools are available for conducting rapid RCCE assessments before and during outbreaks. Challenges • Coordination gaps at the state and local government authority’s levels exist due to rivalry among institutions responsible for healthcare service delivery. The recent creation of Primary Health Care Boards in many states of the federation is associated with conflicts with the states’ ministries of health in respect to coordination functions. • Many communities are geographically difficult to reach due to challenging terrain, logistics and insecurity which can be due to conflict, insurgency, natural disasters, etc. • There is an overdependence on partners to lead community engagement functions which may be a result of insufficient government funding for RCCE activities. • Limited human resources capacity exists at the community level due to poor or lack of incentives to motivate volunteers. 60 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria • There is poor state/local government authorities’ ownership of programmes due to the top-down approach of government across all sectors. • Consistent failure of the government to fulfil its promises to the citizens has made it more difficult for communities to trust government information and advisories during public health emergencies. Recommendations for priority actions • Empower the subnational level to promote ownership for sustained coordination, implementation, M&E of One Health RCCE activities at all levels. • Scale up infodemic management and other RCCE strategies/interventions at subnational level. • Sustain capacity-building for message co-creation and RCCE competencies at all levels. • Advocate for the creation of a dedicated budget line for RCCE and health promotion as well as the institutionalization of RCCE across relevant MDAs and at all administrative levels. • Scale up the use of participatory approaches, social behavioural research and feedback mechanisms (offline and online) for evidence-based RCCE and health promotion intervention at all levels. 61 Other IHR-related hazards, points of entry and border health 62 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria POE. Points of entry and border health Introduction All core capacities and potential hazards apply to “points of entry” and thus enable the effective application of health measures to prevent the international spread of diseases. States Parties are required to maintain core capacities at designated international airports and ports (and where justified for public health reasons, a State Party may designate ground crossings), which will implement specific public health measures required to manage a variety of public health risks. Target States Parties designate and maintain core capacities at international airports and ports (and where justified for public health reasons, a State Party may designate ground crossings) that implement specific public health measures required to manage a variety of public health risks. Level of capabilities • Nigeria has 51 manned ground crossings, 10 seaports and five international airports. • The National Public Health Emergency Contingency Plan for Points of Entry (POE) and POE- specific contingency plans are developed. • IHR assessments for IHR core capacities have been conducted at all designated POE and one major ground crossing. • Contingency plans have been developed and reviewed for 18 POE. • There is integration of POE-specific public health emergency contingency plans into POE emergency plans (e.g. Aerodrome Emergency Plan) and the National Public Health Emergency Contingency Plan. Indicators and scores POE1. Core capacity requirements at all times for POE (airports, ports and ground crossings) – Score 4 Routine core capacities are implemented at all designated POE and RCCE for POE is implemented at border communities. Regular inspection of conveyances takes place. Strengths • There is integration into the national surveillance system for biological hazards. • The Surveillance Outbreak Response Management Analysis System reporting platform is used at POE for surveillance. • Primary and secondary screening of passengers takes place. • Use of IDSR is a strength. • Standards are ensured for food hygiene and vector management. • Water sampling and testing takes place. 63 Other Challenges • There is a lack of inclusion of POE reporting on chemical and radiological into national surveillance. • Human resources capacity is inadequate. • There is a lack of holding and isolation centres. POE2. Public health response at POE – Score 4 Strengths • A Public Health Emergency Contingency Plan exists across all designated POE. • The National Public Health Emergency Contingency Plan is activated. • Well-equipped ambulances are available at all designated POE. • Emergency contingency plans are in place. • A multisectoral Public Health Emergency Management Team (PHEMT) is used for coordination during emergencies. • The Port Health Services passenger health declaration form is digitized (Nigeria International Travel Portal). • RCCE is in place for POE border communities. • SoPs are available. Challenges • There is poor collaboration with agencies for chemical and radiological events within POE. • Human resources capacity is inadequate. • Staff lacks proper training. POE3. Risk-based approach to international travel-related measures – Score 4 Strengths • A central coordination system is used for the development of travel-related protocols. • Collaboration takes place with the national emergency operations centre for public health emergency risk assessment. • Multisectoral collaboration is evident across stakeholders at POE. • The Public Health Emergency Management Team (PHEMT) meeting is used for activation of public health emergency contingency plans on travel-related measures. • The national public health emergency response committees for POE are used for development of travel-related measures. Challenges • Delayed compliance with public health travel-related measures is a challenge. Recommendations for priority actions • Integrate POE into the radiological and chemical surveillance system • Port Health Service to improve POE or exit RCCE among border communities of neighbouring countries using One Health approach. • Improve cross-border collaboration and information sharing. • Review and update port health service SOPs and guidelines • Train Port Health Service staff and frontline agencies at POE using a multisectoral approach. • Develop diagnostics and testing capacities at designated POE. • Digitize and harmonize Port Health Service surveillance tools. 64 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria CE. Chemical events Introduction Timely detection and effective response of potential chemical risks and/or events requires collaboration with other sectors responsible for chemical safety, industries, transportation and safe disposal. This would entail that State Parties need to have surveillance and response capacity to manage chemical risk or events and effective communication and collaboration among the sectors responsible for chemical safety. Target States Parties with surveillance and capacity for chemical risks or events. This requires effective communication and collaboration among the sectors responsible for chemical safety, including health, occupational health, emergencies, environment, transportation and safe disposal, agriculture/veterinary, as well as industries. Level of capabilities Nigeria provided evidence that gaps previously identified in the 2017 JEE report have since been addressed. Significant improvement was made in the documentation related to chemical events. However, the country should focus on improving the standardization of national chemical event guidelines and continuing to enhance capacity in the areas of chemical event management, intoxication, poisoning and assessment. Maintaining collaboration efforts is crucial for ongoing capacity-strengthening. There is a need to enhance the skills of local technical experts through training and the establishment of poison centres and hotline numbers that operate 24/7/365. The state should also keep relevant exercise reports and conduct after-action reviews to analyse the outcomes. Indicators and scores CE1. Mechanisms established and functioning for detecting and responding to chemical events or emergencies – Score 2 There is evidence of a developed draft national guideline on chemical surveillance in Nigeria and existence of an event-based surveillance system in NCDC. Mapping for chemical or toxicology laboratory is ongoing. Mapping and plans for piloting of poison information centres in the national hospitals and at the University of Abuja teaching hospital are in place. Nigeria’s environmental surveillance using the Integrated National Environmental Health Surveillance System reporting platform is currently at the initial stage in 12 states. Strengths • A draft National Chemical Surveillance Guideline is available. • An Integrated National Environmental Surveillance System is available. • A National Committee on Chemical Surveillance and Emergency System is in place. • The National Committee on Chemicals Management is in place. • National policies related to chemicals management exist. • National guidelines are available for the establishment of the Poison Information Control and Management Centre, as well as a public health strategy on Artisanal and Small-Scale Gold Mining. • There is an inventory of polychlorinated biphenyl (PCB)-contaminated sites in the country. 65 Other Challenges • Detection and reporting of chemical events is inadequate at all levels as is the integration of these systems between relevant MDAs. • There are inadequate chemical analytical laboratories across the country. • Funding is insufficient for monitoring chemical surveillance and chemical management in Nigeria. • There is weak inter-agency information sharing, synergy, coordination and collaboration. • Nigeria lacks a poison information centre. CE2. Enabling environment in place for management of chemical events – Score 2 The rationale for scoring is premised on the availability of national legislation and policies on chemical regulations that exist including the National Environmental Standard and Regulation Enforcement Agency (2007), NAFDAC (2004), Environment Impact Assessment, land use acts, Nigeria Mineral and Mining Act (2007), Factories Act (2004) and Fire Service Regulations (2019). There is also the availability of a customs database on imported chemicals. Nigeria has a National Committee on Chemicals Management and a National Committee on Chemical Surveillance and Emergency System. The National Committee on Chemicals Management role includes administrative decision-making on regulated chemicals listed in various multilateral environmental agreements as well as other decisions relating to chemicals management in Nigeria. The NAFDAC has a database of registered chemicals. There is also evidence of a National Chemical and Biological Emergencies Preparedness and Response plan that sets out the roles and responsibilities of relevant stakeholders; however, the plan does not contain the mapping of hazardous chemical sites and facilities. Strengths • The National Policy on Chemical Management is in place as is the National Chemical and Biological Emergency Response Plan, which indicates the roles and responsibilities of stakeholders in chemical emergency response. • National coordinating mechanisms on chemical surveillance and management are functional (the National Committee on Chemical Surveillance and Emergency System, and the National Committee on Chemicals Management). • There is availability of an Integrated National Environmental Surveillance System. • National environmental regulations on chemical permissible limits of effluents are in place. Challenges • The National Policy on Chemicals Management needs to be updated to map more relevant stakeholders and sectors relevant to chemical events. • The existing multihazard plan does not include specific procedures for chemical event preparedness and response. • Inadequate multisectoral coordination and collaboration is evident among relevant stakeholders on chemical management. • There is no harmonized document that clearly defines the roles of the MDAs during chemical events. • Effective collaboration and information sharing is lacking among relevant stakeholders. • Capacity-building on toxicology is insufficient. 66 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Recommendations for priority actions • Establish an effective policy, institutional and regulatory framework for CE management (policies, guidelines, SOPs, regulations). • Improve and harmonize existing public health surveillance systems to include chemical surveillance and integrate with poison information services. • Identify and describe priority CE. • Develop capacity for CE surveillance, alert and response at national and subnational levels. • Develop capacities for diagnosis and treatment of chemical poisonings and establish a poison information service. 67 Other RE. Radiation emergencies Introduction To counter radiological and nuclear emergencies, timely detection and an effective response towards potential radiological and nuclear hazards/events/emergencies are required in collaboration with sectors responsible for radiation emergency management. Target States Parties should have surveillance and response capacity for radiological emergencies and nuclear accidents. This requires effective coordination among all sectors involved in radiation emergencies preparedness and response. Level of capabilities Nigeria has a National Institute for Radiation Protection and Research Laboratory with the capacity for detection and systematic analysis of radiation emergency situations. Nigeria has managed to procure radioactivity detection equipment to enhance and improve radiation detection. There is evidence of strategies and activities in place to support capacity strengthening on radiation emergency and monitoring events. However, more funding is required to continue strengthening and monitoring this thematic area. Indicators and scores RE1. Mechanisms established and functioning for detecting and responding to radiological and nuclear emergencies – Score 3 Nigeria has an updated National Response Plan and there is an authority responsible for radiation surveillance/monitoring in the country. The NAFDAC monitors consumer goods and foodstuffs for radiation contamination. Training programmes were conducted during the development of the national response plan however further training is required for the public health workers and first responders, in line with the updated National Nuclear and Radiological Emergency Response Plan. The Country is a signatory to the Convention on Assistance in Case of Nuclear and Radiological Emergencies. There are sufficient human resources for existing needs. Funding needs are provided by the National Emergency Management Agency; however, some funding gaps still exist in the country. There are six reference hospitals (one per geopolitical zone) for attending to radiation or nuclear emergencies. Protocols and guidelines are in place for case management of persons over-exposed to radiation emergencies. The country also leverages the Convention on Assistance in Case of Nuclear and Radiological Emergencies. There are no national stockpiles; however, hospitals that use radioactive sources have limited stock for managing cases should they occur within their facilities. 68 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Strengths • A well-developed legislative framework exists for the control of radiation sources and the prevention and detection of radiation and nuclear emergencies, with clear legislation covering licensed applications, transport, disposal and use in specific industries. • Multi-sectoral stakeholders with responsibilities in the preparedness and response to radiation events have been identified. • The West African Nuclear and Radiological Monitoring Detection and Response Centre (Emergency Communication Centre) has been established. • Communication, collaboration and coordination occurs between the Nigerian Nuclear Regulatory Authority and the NFP. Challenges • Ineffective synergy is evident with authorities responsible for activating and authorizing national emergency response for Nuclear and Radiological Emergency Response activities. • The budget line is inadequate for funding the National Nuclear and Radiological Emergency Response Plan. • Inadequate collaboration occurs between human health MDAs for planning and implementing relevant activities (e.g. training of human health workers, simulation exercises). • Operability of the National Nuclear and Radiological Emergency Response Plan has not been tested on a full scale. RE2. Enabling environment in place for management of radiological and nuclear emergencies – Score 3 The rationale for the scoring is that there are updated policies and plans for ensuring the safe use of radiation in the country. Nigeria has a national emergency coordinating body on radiation and nuclear events. The National Emergency and Response Committee for Radiological and Nuclear Emergencies (the National Emergency Management Agency, the Nigerian Nuclear Regulatory Authority, the Nigeria Atomic Energy Commission and others) serves as the multisectoral coordination mechanism for preparedness and response to radiation emergencies. There is a need for joint training on radiation for healthcare workers. Audits or evaluation systems for exercises/drills exist at facility levels across the country. There are policies and plans for waste management and transportation of radioactive materials. Strengths • The National Institute for Radiation Protection and Research Laboratory is operational with capacity for detection and systematic analysis of radiation emergency situations. • Procurement of radioactivity detection equipment has taken place. • Internal drills are held within licensed premises: hospitals, oil and gas companies, servicing companies and nuclear research centres. • Ongoing capacity development is conducted for frontline officers, designated hospitals and users of radiation sources. • A Central Alarm Station is established to monitor and communicate the activities of some high- risk radiological facilities in Nigeria. • A Design Basis Threat is developed, and all associated facilities and organizations are continuously updated on all associated risks and threats. • The Centre for Energy Research and Training (CERT) is established with capacity to manage waste and spent fuel. 69 Other Challenges • There is a lack of adequate opportunities for capacity-building of all key stakeholders in emergency response. • Additional training of case managers and related hospital workers is needed on management of nuclear and radiological emergencies. • The Mobile Vehicle for Emergency Response on Nuclear/Radiological Detection needs to be upgraded. Recommendations for priority actions • Collaborate with NCDC and the Federal Ministry of Health to train human health workers on medical response to nuclear and radiological safety and security-related emergencies at the six designated hospitals located in each of the six geopolitical zones. • Ensure budgetary provision for operationalization of the National Nuclear and Radiological Emergency Plan. • Improve collaboration between Nigerian Nuclear Regulatory Authority and health-related MDAs for planning and implementation of related activities (training of human health workers, first responders). • Create opportunities for testing relevant policies and plans (Nuclear and Radiological Emergency Preparedness and Response Plan) through simulation exercises (in the absence of real nuclear and radiological incidents). 70 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Annex: JEE Background Field visits to the National Reference, National Emergency Operations Centre, Points of Entry and Abattoir Photo credit: @NCDC 71 Annex. JEE background Mission location and duration Abuja, Nigeria, 14–18 August 2023. List of participants and participating agencies JEE External evaluators : Team Lead: Hendrik Jan Ormel Team Co-leads: Richard Garfield Name Organization JEE technical area Buba Manjang Ministry of Health, Gambia P3. IHR coordination, national IHR focal point func- tions and advocacy D2. Surveillance POE. Points of entry and border health Catherine Nyamaza- ma Airports Company of Zimbabwe CE. Chemical events RE. Radiation emergencies Forgwei Binyo Kisum Independent consultant JEE writer and editor Geofrey Jagero FHI 360/ Ministry of Health, Nairobi, Kenya P7. Biosafety and biosecurity D1. National laboratory system Hendrik Jan Ormel WHO headquarters P2. Financing R2. Linking public health and security authorities Henry Wamwayi World Organisation for Animal Health P4. Antimicrobial resistance (AMR) P5. Zoonotic disease Kazi Noore Alam Independent consultant R3. Health services provision Ohirweoluhya Guy Independent consultant - IPC Adviser R4. Infection prevention and control Richard Garfield US CDC P6. Food safety P8. Immunization R1. Health emergency management Sarah Emami Resolve To Save Lives P1. Legal instruments D3. Human resources Vachel Harris Lake WHO Country Office for Liberia R5. Risk communication and community engagement JEE technical coordinators: Jinadu Arisekola Ademola, Tendai Makamure. 72 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Key host country participants and institutions: Names Organization Abdullateef Rasheedat B. Federal Ministry of Health/Port Health Services Abimbola Ajileye Federal Ministry of Justice Abiodun Ogunniyi Nigeria Centre for Disease Control and Prevention Abubakar Bagudu Muhammad State Ministry of Health Aderanti Samuel Federal Ministry of Water Resources Agada Blessing Nigeria Centre for Disease Control and Prevention Agha Ukpai Agha Nigerian Bar Association Agim Benegna National Agency for Food and Drug Administration and Control Ahmed Bah Ibrahim Federal Ministry of Environment Aishat Shittu National Environmental Standards and Regulations Enforcement Agency Ajani Love Adeiye Federal Ministry of Health Akinbowale Saheed Ogun State Ministry of Health Akindele Adebiyi National Observer/University College Hospital Akor Josephine National Environmental Standards and Regulations Enforcement Agency Alalade Oyinloluwa Nigeria Centre for Disease Control and Prevention Ali Mohammed Jidde Nigerian Nuclear Regulatory Authority Alozie Adaeze Miriam Federal Ministry of Health Amedu Michael Onoja Nigeria Centre for Disease Control and Prevention Amira Abubakar Nigeria Centre for Disease Control and Prevention Anjolaoluwa Popoola Nigeria Centre for Disease Control and Prevention Arutu Oluwakorede Nigeria Centre for Disease Control and Prevention Atanda O. John Federal Ministry of Health Ayodeji Adebayo National Observer/University College Hospital Babbo Ibinabo Stephanie Nigeria Centre for Disease Control and Prevention Bala Musa Halilu Ministry of Defence Health Implementation Programme Bamidele Mutiu Lagos State Ministry of Health Bello Oluwatosin Ifeoluwa Nigeria Centre for Disease Control and Prevention Benshak John Audu National Veterinary Research Institute Bitrus Samuel National Emergency Management Agency Bola Lawal Nigeria Centre for Disease Control and Prevention Brig. Gen. O. R. Ayemoba Ministry of Defense Health Implementation Programme Catherine Okoi Nigeria Centre for Disease Control and Prevention Celestine Egbeukwu Nigeria Centre for Disease Control and Prevention Cg. Capt. E. A. Ifebi Nigerian Air Force Charles Ikeah Federal Ministry of Environment Chiamaka Iwuzor National Biotechnology Development Agency Chike Ajaero Ministry of Mines and Steels Development 73 Annex. JEE background Names Organization Chioma Akwulundu National Agency for Food and Drug Administration and Control Dakum Longii Benji Federal Ministry of Health Damola Emmanuel Oladipo Nigeria Centre for Disease Control and Prevention Danga Sule E. State Ministry of Health Disu Yahya Nigeria Centre for Disease Control and Prevention Dogunro Festus A. National Arbovirus and Vectors Research Centre Yewande Olaifa National Agency for the Control of AIDS Ebofin Olusoji Charles Federal Ministry of Water Resources Elsie Ilori National Observer Emelda Anumene Ministry of Interior Emembolu Ekenedilichukwu Nigeria Centre for Disease Control and Prevention Emmanuel John Nigeria Christian Pilgrim Commission Ephraim Dogara Nigeria Centre for Disease Control and Prevention Esemeje David Nigeria Agricultural Quarantine Services Eze Ogechi L. Nigerian Nuclear Regulatory Authority Ezeudu Chinyere Enugu State Ministry of Health Ezewvzie Chinenye National Orientation Agency of Nigeria Fahad Muhammad Nigeria Centre for Disease Control and Prevention Fareedah Mohammed Munir Nigeria Centre for Disease Control and Prevention Fatai S. Olanrewaju Federal Ministry of Health Fatima Mohammed Yusuf Federal Ministry of Health/Port Health Service Fatima Saleh Nigeria Centre for Disease Control and Prevention Gbenga Joseph Nigeria Centre for Disease Control and Prevention Genevive E Mutu Federal Ministry of Transport Gogo Bala S. National Primary Health Care Development Agency Habeebah Bakare Johns Hopkins Program for International Education in Gynaecology and Obstetrics Habu Ikubemi Efi Federal Ministry of Finance Ibeh Bartholomew National Biosafety Development Agency Ibrahim Aliyu Muhammad Nigeria Centre for Disease Control and Prevention Idoko Simon National Orientation Agency Idris Aminu Nigeria Centre for Disease Control and Prevention Idris Fatima Nnrani National Biosafety Management Agency Ifedayo Adetifa Nigeria Centre for Disease Control and Prevention Ifeoluwapo Ojo Nigeria Centre for Disease Control and Prevention Ifeyinwa Okoli Office of National Security Advisor Focal Point Igbodo Gordon Nigeria Centre for Disease Control and Prevention Ikpi Eno William Nigeria Centre for Disease Control and Prevention Inyang E. Ekpo Catholic Relief Services 74 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Names Organization Isaac Oladimeji Nigeria Centre for Disease Control and Prevention Isah Samaila Federal Ministry of Health Isaiah Owolabi Nigeria Centre for Disease Control and Prevention Isiyaku Shuaibu Gani Nigeria Centre for Disease Control and Prevention Itohan Imasuen Nigeria Centre for Disease Control and Prevention Janet C. Agba Federal Ministry of Health John Oladejo Nigeria Centre for Disease Control and Prevention Karatu L. David Gombe State Ministry of Health Kayode Fasominu National Observer Kayode Ilugbo University College Hospital Kazeem A. Osudale Nigerian Institute of Medical Research Khadijat Kubra Mohammed Federal Ministry of Environment Kingsley Odiabara Federal Ministry of Health Kolade Daniel Damilola Nigeria Centre for Disease Control and Prevention Lawal Amadu Ahmadu Bello University Teaching Hospital, Zaria Levin Damisah Office of the National Security Adviser Lois Olajide Nigeria Centre for Disease Control and Prevention Mahmood Dalhat Nigeria Centre for Disease Control and Prevention Major Hamji Mohammed Nigerian Army Makama Sunday National Veterinary Research Institute Mosudi Segun Nigeria Centre for Disease Control and Prevention Munachimso Dim Nigeria Centre for Disease Control and Prevention Muntari Hassan Nigeria Centre for Disease Control and Prevention Musa Abdullahi Abdullahir Nigeria Centre for Disease Control and Prevention Musa Tanimu Nigeria Centre for Disease Control and Prevention Muzzammil Gadanya Nigeria Centre for Disease Control and Prevention Mwapu Ndahi Federal Ministry of Agriculture and Rural Development Nasir Ahmed Omar Nigeria Centre for Disease Control and Prevention Ngaji Bestman Ogar Nigerian Communications Commission Nkoli Winifred Emeter National Biosafety Development Agency Nsikak Inam Nigeria Centre for Disease Control and Prevention Nwachukwu William Nigeria Centre for Disease Control and Prevention Nwodoh Judith C. Nigeria Centre for Disease Control and Prevention Nyior Audrey Iveren Federal Ministry of Health/ Port Health Service Oduyingbo Esther Oyintofe Nigeria Centre for Disease Control and Prevention Ofili Donald Ibe Medical Laboratory Science Council of Nigeria Ofoegbu U. O. Federal Airport Authority of Nigeria Ofora Rita C. Federal Ministry of Water Resources Ogarega Daudu Nigeria Centre for Disease Control and Prevention 75 Annex. JEE background Names Organization Ogbu Chibueze Nigeria Centre for Disease Control and Prevention Okea Rita A. Federal Ministry of Environment Okoeguale George Ayemere Federal Ministry of Health Okokwu Steven Nigeria Centre for Disease Control and Prevention Okoro V. Onyinye Federal Ministry of Finance Okotete John Federal Ministry of Environment Oladeji Iwarere Nigerian Navy Oladele Deji Nigeria Centre for Disease Control and Prevention Oladeru Peter National Emergency Management Agency Olajumoke Babatunde Nigeria Centre for Disease Control and Prevention Olohitare J. Uduokhai Federal Ministry of Health Olufuwobi-Yusuf Adeola Federal Ministry of Health Oluwadamilare Olowoshile Nigeria Centre for Disease Control and Prevention Oluwafemi Stephen Federal Ministry of Health Oluwasogo Ayodele Nigeria Centre for Disease Control and Prevention Onajole Adebayo National Observer/Lagos University Teaching Hospital Ondachi Jerry Ministry of Budget and Economic Planning Onyekachi Nwitte-Eze Federal Ministry of Health/ Port Health Service Osadiaye Olanlesi Nigeria Centre for Disease Control and Prevention Osaretin James Agbonlahor Medical Laboratory Science Council of Nigeria Osuagwu Victor Federal Ministry of Health Oyekunle Adedamola Federal Ministry of Health Oyeladun Okunromade Nigeria Centre for Disease Control and Prevention Peace David Umar Nigeria Centre for Disease Control and Prevention Peters Oladosu National Institute for Pharmaceutical Research and Development Pharm Chibuzo Eneh Nigeria Centre for Disease Control and Prevention Rejoice Kudirat Luka-Lawal Nigeria Centre for Disease Control and Prevention Rovieno Dickson Amalada Federal Ministry of Justice Safiya Musa Nigeria Centre for Disease Control and Prevention Salome Samuel Bawa Federal Ministry of Agriculture and Rural Development Samuel B. Thliza Borno State Ministry of Health Sarah Peter K. Nigeria Centre for Disease Control and Prevention Sebastian Yennan Nigeria Centre for Disease Control and Prevention Sikiru Badaru Nigeria Centre for Disease Control and Prevention Silas Jacob Guluwa Federal Ministry of Health Solomon John Adobun Nigeria Centre for Disease Control and Prevention Sp. Suzie James Nigeria Police Force Suraju Olawale Funsho Nigeria Immigration Service Suwaiba B. Abdullahi Nigeria Centre for Disease Control and Prevention 76 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Names Organization Tanimowo Akande National Observer/University Of Ilorin Teaching Hospital Tarik Mohammed Nigeria Centre for Disease Control and Prevention Theresa Nwachukwu Federal Capital Territory Public Health Department Ukpai Ifeanyi Nigeria Agricultural Quarantine Services Vivian Nwechi Nigeria Centre for Disease Control and Prevention Wilfred Haggai Nigerian Civil Aviation Authority Yashe R. Usman Nigeria Centre for Disease Control and Prevention Yvonne Iyadoo Ikhide National Agency for Food and Drug Administration and Control Partner attendance Name Organization Abah Peter Johns Hopkins Program for International Education in Gynecology and Obstetrics Abioye Olusola Research Triangle Institute Abraham Zirra Food and Agriculture Organization Adachioma Ihueze Gerogetown University Adebayo Adebisi The Medicines, Technologies, and Pharmaceutical Services Adedire Elizabeth African Field Epidemiology Network Ademuyiwa Damilola Legislative Advocacy Initiative for Sustainable Development Goals Adetunji Adedokun International Centre for AIDS Care and Treatment Programs Adewale Akinjeji International Centre for AIDS Care and Treatment Programs Akin Oyemakinde LAFIYA Alegwu Obande Johns Hopkins Program for International Education in Gynecology and Obstetrics Aminu Muhammad Task Force for Global Health Annette Ofodum Project Hope Assad Hassan The Task Force for Global Health Aurepien Pekezuo World Health Organization Babatunde Akinola Medicine, Technologies and Pharmaceutical Services Banji Ipadeola United States Centers for Disease Control Celestina Obiekea Resolve to Save Lives Celestine Okorie Health Systems & Response Connector Chavah Laximikant World Health Organization Chijioke Mba Institute of Human Virology Nigeria Chinemerem Onwuliri Medicine, Technologies and Pharmaceutical Services Chioma Dan-Nwafor Africa Centre for Disease Control Chukwuji Martin World Health Organization Comfort Emmanuel Japan International Cooperation Agency Ebireri N.U. John Bill & Melinda Gates Foundation 77 Annex. JEE background Name Organization Edwin Isotu Edem World Health Organization Ekanem Blessing World Health Organization Emem Udoh Resolve to Save Lives Emmanuel Agogo Resolve to Save Lives Emmanuel Alhassan Global Health Advocacy Incubator Emmanuel Lucky Johns Hopkins Program for International Education in Gynecology and Obstetrics Emmanuel Oga Research Triangle Institute Eromosele Ogbeide World Health Organization Esemweughian Osagie Palladium Estelle Mbadiwe Ducit Blue Solutions Felix Imafidon Resolve to Save Lives Fritz Fonkeng Foundation for Innovative New Diagnostics Guyohirwe'olohya Mulumeoderwa World Health Organization Hambali Idris Umar CORE Group Partners Project Ijeoma Anya UK Health Security Agency Ikelionwu John Georgetown University Imaobong Isang West African Health Organization - Regional Centre for Surveillance and Disease Control Imiegha Favour E. Georgetown University Innocent B. Rwego The CORE Group Partners Project Innocent Ujata Georgetown University Islamiyyat A. Olatinwo West African Health Organization - Regional Centre for Surveillance and Disease Control Jemia Quinta Akumefula UK Health Security Agency Jenom Danjuma Resolve to Save Lives Jerry Pantuvo UK Health Security Agency Joseph Odu Resolve to Save Lives Joshua Ofoli World Health Organization Kayode Fasominu VOLTE Health Kenneth Enwerem Institute of Human Virology Kikiope Oluwarore World Health Organization Kumshida Balami World Health Organization M.A. Boyd United States Centers for Disease Control M.M. Saleh United States Centers for Disease Control Madingar D. Patrick African Society for Laboratory Medicine Makava Favour Adeniyi Johns Hopkins Program for International Education in Gynecology and Obstetrics Mfon-Obong Paul Ibara West African Health Organization - Regional Centre for Surveillance and Disease Control 78 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Name Organization Micheal Olugbile World Bank Mie Okamura World Health Organization Mohammed Lamorde Resolve to Save Lives Muhammad Balogun African Field Epidemiology Network Muhammad Jaafar Johns Hopkins Program for International Education in Gynecology and Obstetrics Obagha Chijioke Public Health Institute Obaroene Ogidiagba Clinton Health Access Initiative Obiora Ezebilo United Nations International Children's Emergency Fund (UNICEF) Ogbonna Nneka Palladium Oguntola Ibukun Nigeria Health Watch Okon Ubong A. European Hematology Association Olaoluwa Akinloluwa Pro Health International Olubunmi Nogedu-Monoh UK Health Security Agency Omolara Oyinlola Breakthrough Action Nigeria Omoseye Ayodamola World Health Organization Otto Muhinda Food and Agriculture Organization Patrick Nguku African Field Epidemiology Network Paul Irabor UK Health Security Agency Pembi Emmanuel World Health Organization Pindar Wakawa World Health Organization Piring'ar Mercy Niyarig Georgetown University Rabi Usman Resolve to Save Lives Rahmat Ibrahim Johns Hopkins Program for International Education in Gynecology and Obstetrics Saiki Musa University of Maryland Baltimore Salamatu Yahaya Bill and Melinda Gates Foundation Salisu Ibrahim Audu World Health Organization Salma Mijinyawa LAFIYA Sarbyen Sheni Breakthrough Action Nigeria Sola Aruna UK Health Security Agency Solome Okware World Health Organization Sonia Biose Nigeria Health Watch Taiwo Olubayode Data for Implementation Toru Kondo Project Japan International Cooperation Agency Walter Kazadi World Health Organization Winifred Ukponu Georgetown University Yusuf A. Ibrahim Johns Hopkins Program for International Education in Gynecology and Obstetrics Zorto Philip World Health Organization 79 Annex. JEE background List of relevant documentation Supporting documentation provided by Nigeria P1. Legal instruments • NCDC Act, 2018 • Ports Health Service Bill, 2022 • Animal Disease (Control) Act, 2022 • Public Health Emergency Bill, 2022 • National Health Act (Amendment) Bill, 2022 • NCDC Act (Amendment) Bill, 2022 • IHR Implementation in Nigerian Law: Mapping of Legal Authorities and Analysis of Legislation at the Federal Level (report) • Legal Assessment Report for seven states P2. Financing • Annual National Budget 2021–2023 • National Health Act, 2014 (Act No. 8 of 2014) • NCDC Act, 2018 • Review of National Financing Mechanisms for Public Health Emergencies in Nigeria, 2021 • A report on the implementation of ‘Basic Health Care Provision Fund’ for Public Health Emergencies by Nigeria Centre for Disease Control, 2022 • Operational Guidelines of the NCDC Gateway, BHCPF • Report of the workshop on National Validation, Re-prioritization and Dissemination of REMAP, 2021 • Medium Term Expenditure Framework (2019–2021, 2021–2023) P3. IHR coordination, national IHR focal point functions and advocacy • NCDC Act, 2018 • IHR 2005 (WHO) • National Capacity Monitoring IHR (WHO) • IHR core capacity Monitoring Framework - Questionnaire for monitoring progress in the implementation of IHR core capacities in States Parties 2015–2016 • IDSR Technical Guidelines • SOPs on Dissemination of public health measures during emergencies • SOPs on Communication with other MDAs • JEE 2017 • NAPHS (2018–2022) • Draft IHR TWG SOPs monitoring progress in the implementation of IHR core capacities in States Parties 2019 • NAPHS Tracker P4. Antimicrobial resistance (AMR) • National Action Plan for AMR 2017–2022 review report • AMR National Action Plan 2.0 Situation Analysis • National One Health AMS strategic plan • One Health AMR Governance Manual • AMR CoP Framework • Tracking AMR Country Self-Assessment reports 80 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria • Performance of Veterinary Services report • JEE 1.0 report • AMR surveillance guideline • Standard Treatment Guidelines • Essential Medicine List • Guidelines for Antimicrobial Stewardship Programme Implementation in Health Facilities in Nigeria • Antimicrobial Consumption Data Collection Manual in Human Health • Antimicrobial use point prevalence survey guidelines in healthcare facilities • Fungal surveillance module • Infection Prevention and Control manual • Active surveillance for AMR in poultry • Expanded surveillance plan– Animal Health • Guidelines for Antimicrobial Surveillance in Aquaculture • Guidelines for the use of antimicrobial drugs in animals • AMR in the Environment policy • Integrated Environmental Surveillance System Guidelines • Environment sector landscape assessment for AMR response in Nigeria P5. Zoonotic disease • FMARD, Fed Dept of Livestock and NADIS, Vet-epid e-Newsletter, Dec 2016 Vol 1(2), pp 1–9 • Livestock population estimate (2010–2016), Federal Department of Animal Husbandry Services • Estimates based on projection of report on National Agricultural Sample Survey (NASS), 2011 • OIE Annual Animal Health report, Jan–Dec 2016, Terrestrial and Aquatic • Draft Joint Zoonotic Contingency Plan for Brucellosis and Anthrax, 2019–2023 • Performance of Veterinary Services Gap Analysis Report, 2019 • OIE listed diseases, infections, and infestations in force, 2017 • Proficiency test for Avian Influenza and Newcastle disease diagnosis 2016, (Questionnaire) Zoonotic diseases • Integrated National Avian and Pandemic Influenza response plan, 2007–2009 • Animal Disease Control Act, 2022 • Rabies Elimination guidelines, October 2016 • National Strategic Plan for the Elimination of Dog-mediated Rabies in Nigeria 2022–2026 • Emergency preparedness and differentiated action plan for the surveillance and control of highly pathogenic Avian Influenza in Nigeria, Sept 2006 • One Health Strategic Plan 2019–2023 • OIE Training on the World Animal Health Information System for national focal points for Animal Disease Notification to the OIE (English-speaking Africa and Middle East) 1–3 Nov 2016 • Strategic Plan for Brucellosis and Anthrax (2020–2036 and 2020–2030 respectively) • Published Joint prioritized list of zoonotic diseases, 2017 • Report of Priority Zoonotic disease reprioritization workshop, 2022 • Strategic plans on priority zoonotic diseases (rabies, Lassa fever, Bovine tuberculosis, mpox etc.) • Codex Alimentarius reports • Foodborne disease priority list (Food Safety Technical Area) • Anthrax Situation Report, 2023 • National Aquaculture Strategy 81 Annex. JEE background P6. Food safety • National Integrated Guidelines for Foodborne Disease Surveillance and Response • List of Food Safety State Coordinators • Report on the activities of NCDC-lead multi-agency RRT - investigating the outbreak of unknown illness • DVPCS quarterly newsletter • List of food safety stakeholders in Nigeria • Veterinary Epidemiology eNewsletter • NAFDAC Guidelines and regulations on food fortification, 2005 • National Food Safety and Quality Bill • Sanitary SOP and guidelines for abattoirs and slaughter • Institute of Public Analyst Act, 30 December 1992, CAP 116 • National Policy Guidelines on Food Sanitation, April 2016 P7. Biosafety and biosecurity • OIE Performance of Veterinary Services Evaluation Follow-up Mission Report of the Veterinary Services of Nigeria, 2019 • www.internationalbiosafety.org - Directory of Certified professionals • www.nsf.gov • NCDC Guidelines for Specimen Transport, 2022 • Nigerian Biosafety and Biosecurity Situation Analysis Report, 2020 • Confidence Building Measure – office of National Authority, SGF, Nigeria • National Biosafety Management Agency Act 2015 as amended • National guidelines on biosafety and biosecurity - https://web.mlscn.gov.ng/wp-content/uploads/ mdocs/Guidelines%20On%20Biosafety%20an%20Biosecurity%20in%20Nigeria.pdf • Federal Ministry of Health Endorsed National Integrated Sample Referral Network Operational Manual Policy, May 2020 • MLSCN Guideline on Safe Transport of Infectious and Exceptional Substances • National Biosecurity Policy and Action Plan (2022–2026) • National Biosafety Emergency Response Strategy, 2020 P8. Immunization • Nigeria Strategy on Immunization and Primary Health Care Systems Strengthening (NSIPSS) strategic document 2018–2028 • National Immunization coverage survey report/Multiple indicator Cluster survey, 2021 • Nigeria Measles Elimination Strategic plan 2019–2028 D1. National laboratory system • Nigeria Medical Laboratory Strategic Plan (2021–2025) • Nigeria National Medical Laboratory Services Policy (2019) • Nigeria Essential Diagnostics List, 2022 • Nigeria National Strategic Plan for TB, 2015–2020 • MLSCN Guideline on Safe Transport of Infectious and Exceptional Substances • MLSCN Guide to medical lab continuous quality improvement and accreditation, Dec 2012 • World Organisation for Animal Health Terrestrial Manual and Terrestrial Code • MLSCN Checklist for Medical Lab Inspection • MLSCN National Lab audit checklist • MLSCN Guide to medical lab continuous quality improvement and accreditation, Dec 2012 • MLSCN Guideline for external quality assurance • MLSCN Guideline for in-Vitro Diagnostics Regulation in Nigeria 82 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria D2. Surveillance • IDSR Technical Guideline 3rd Edition, 2019 • IDSR training manuals • Integrated Training of Surveillance Officers in Nigeria training curriculum • National Community-Based Surveillance Strategy Plan • SOPs for event-based surveillance • SOPs for data analytics and visualization tool D3. Human resources • JEE Mid-Term report, 2019 • JEE report, 2017 • National Implementation Roadmap for SURGE 2022–2024 • National Human Resource for Health Strategic Plan 2021–2025 • National Human Resource for Health Policy, November 2020 • National Plan for Health Security Workforce, 2023–2027 • Human Resource for Health Immigration Policy (Draft), 2022 • Electronic Database for Heath Workforce Profile at HRH Federal Ministry of Health, 2022 R1. Health emergency management • National Public Health Multihazard Emergency Preparedness and Plan • Multihazard plan simulation exercise report • National and Subnational STAR Report • National Medical Counter Measures plan • RRT pocket guide • SOPs for supply chain management • National PHEOC handbook • Subnational PHEOC handbook • Emergency operations centre activation plan • Database of trained RRT • Contingency plans for VHF, cerebrospinal meningitis, mpox and acute watery diarrhoea • Concept of operations (CONOPS) • PHEOC facility assessment checklist • PHEOC training manuals • Database of trained personnel on PHEM • Data Information Management reporting templates • Simulation exercise reports • Intra-action review report • Mid-action review report • After-action reports for cerebrospinal meningitis, Lassa fever and mpox • Training reports R2. Linking public health and security authorities • National Crisis Management Doctrine, 2022 • Report of Bio-Risk Management and Public Health Emergency Preparedness, 2022 • Report of Joint capacity-building (tabletop/full-scale operational simulation exercises), 2021 • Database of members of TWG Linking Public Health and Security and invitation letters to TWG members, 2019 • Signed National Public Health Emergency Response Committee for Point of Entry, 2020 • National Security Strategy, 2019 83 Annex. JEE background • The National Counter Terrorism Strategy, 2016 • Terrorism Prevention and Prohibition Act, 2022 • Draft National Action Plan for CBRNE, 2022 R3. Health services provision • National Public Health Multihazard Emergency Preparedness and Plan • Standard case definitions of priority diseases/conditions in Nigeria • Multihazard plan simulation exercise report • National guidelines for Lassa fever case management • States incident action plan • National Health Promotion Policy, 2019 • National PHEOC Handbook R4. Infection prevention and control • IPC professional training reports (basic, intermediate, advanced courses) • HCAI surgical site infections surveillance protocol document • Reports on establishment of state IPC programmes • State and healthcare facility IPC policies and guidance documents R5. Risk communication and community engagement • MHRC Guideline • Social media and Infodemic management guidelines • Health Emergency Preparedness and Response • IAPs • Polling results • Social media strategy • Creative briefs • NCDC spokespersons database • after-action reviews • RCCE Subnational assessment report • One Health RCCE training for public health and media practitioners (facilitators guide) POE: Points of entry and border health • National Port Health Policy • Port Health Services implementation guidelines • National Public Health Contingency Plan for Points of Entry • Multihazard RCCE guidelines • National Strategic Plan of Action on Cholera control • Protocols for COVID-19 response CE. Chemical events • Report on the Inauguration of the National Committee on Chemical Surveillance and Emergency System • National Guidelines on the establishment of PICMCs in Nigeria • National Guidelines on Chemical Surveillance in Nigeria (Draft) • National Policy on Chemicals Management • Report on Chemical Simulation Exercise • National Multihazard plan • Acts – National Environmental Standard and Regulation Enforcement Agency, NCDC, NAFDAC, 84 Joint External Evaluation of the International Health Regulations (2005) core capacities of the United Republic of Nigeria Nigeria Minerals and Mining Act (2007), Factory Act (2004), Fire Service Regulations (2019) • Healthcare Waste Regulations • Hazardous Chemicals and Pesticides Regulations • National Guidelines on Chemical Surveillance in Nigeria (Draft) • Terms of reference for the operationalization of the National Committee on Chemical Surveillance and Emergency System and National Committee on Chemicals Management • Priority list of chemicals of public health importance in Nigeria. • Roadmap document for the establishment of PICMC in Nigeria • Report on Chemical Laboratory mapping survey in Nigeria. • National Environmental Standard and Regulation Enforcement Agency PCB Regulations • National Chemical and Biological Emergency preparedness response plan RE. Radiation emergencies • The Nuclear Safety and Radiation Protection Act 19 of 1995 • Nigeria Atomic Energy Act 46 of 1976 • National Emergency Management Agency Act 12 as amended by Act 50 of 1999 • National Agency for Food and Drug Administration and Control Act • National Nuclear and Radiological Emergency Plan • Nigeria Basic Ionizing Radiation Regulations, 2003 • Nigerian Nuclear and Radiological Emergency Preparedness and Response Regulations (Draft) • Nigerian Radiation Safety Regulations in Nuclear Medicine, Radiotherapy, Diagnostic Radiology, 2006 • Nigerian Transportation of Radioactive Sources Regulations, 2006 • Nigerian Radiation Safety Regulations in Industrial Regulations, 2008 • Nigerian Safety and Security of Radioactive Sources Regulations, 2006 • Nigeria Radioactive Waste and Spent Nuclear Fuel Management Regulations (Draft) • Nigerian Safety of Research Reactors Regulation, 2021 • Nigerian Physical Protection of Nuclear Materials and Nuclear Facilities Regulation, 2021 • Nigerian Safety in Industrial Irradiator Regulation, 2008 • CERT Emergency Plan • CERT Operational Radiation Safety • NHA Local Rules for Radiation Protection in the Radiology Department • NHA Local Rules for Radiation Protection in Radiotherapy and Oncology Department • Protocols on Nuclear Medicine Procedures • Protocol for the Treatment of Radiation Injuries • The Convention on Early Notification of an Accident (Legal Series No. 14, International Atomic Energy Agency (IAEA), Vienna, 1986) • The Convention on Assistance in the Case of a Nuclear Accident or Radiological Emergency (IAEA- INFCIRC/336, IAEA, Vienna, 1986) • IAEA Manual For First Responders to Radiological Emergency • IAEA Response and Assistance Network (RANET) • IAEA Emergency Preparedness and Response Method 2003 – Method for Developing Arrangements for Response to a Nuclear or Radiological Emergency (IAEA TECDOC-953) • IAEA Preparedness and Response for a Nuclear or Radiological Emergency, No. GSR-Part 7 • IAEA Guidelines on the harmonization of response and assistance capabilities for a nuclear or radiological emergency

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