The Nigeria Centre for Disease Control (Nigeria CDC) was at the heart of the federal Covid-19 response in Africa’s most populous country. It worked closely with a number of institutions, and its director has been clear about the challenges it has faced and his determination to build a more sustainable public-health infrastructure for the future.
With the largest total population and highest proportion of residents living in urban areas of any country in Africa, Nigeria was at particular risk of extensive spread of Covid-19.[_] Its vast size, federal system of government and the need to respond simultaneously to outbreaks of Lassa fever and measles alongside Covid-19 had the potential to inhibit the speed and coherence of the pandemic response. TBI analysis of data from the Oxford Covid-19 Government Response Tracker suggests that Nigeria was one of the first sub-Saharan African countries to introduce measures to address the pandemic after the disease was confirmed to have spread beyond Asia: The Nigeria CDC established a Technical Working Group that would later evolve into the Emergency Operations Centre, and developed an incident action plan, trained staff, repurposed existing PCR testing capacity and issued guidance before Nigeria’s first case was confirmed on 25 February. Nonetheless, the country acted comparatively slowly and conservatively afterwards. This was at least partly because Nigeria was the first country in the region to confirm a case, while the response playbook was still being written internationally, but Nigeria CDC Director Dr Chikwe Ihekweazu has also been clear that the organisation had to contend with a “low base of public-health infrastructure” and a “vulnerable position” at the start of the country’s outbreak. Its mandate was, in fact, only formalised in legislation two years ago.[_] Despite this challenging context, the Nigeria CDC has played a critical leadership and delivery role, providing advice on containment measures to the Presidential Task Force on Covid-19 and to the Federal Ministry of Health throughout the pandemic, driving public engagement, mobilising the private sector, and scaling testing and contact tracing.
The Nigeria CDC has been the key communicator of government policy through its significant online presence and tech-enabled provision. Its role has proved critical at a time when commentators have recognised the widespread proliferation of Covid-19 misinformation in Africa generally, but particularly in Nigeria.[_] With 2.3 million followers on Facebook and 1.1 million followers on Twitter, the Nigeria CDC has routinely shared information such as its daily situation report and changing guidance on social media, where it regularly receives tens of thousands of interactions.[_] The Nigeria CDC’s public campaign message, #TakeResponsibility, reflects the WHO guidance that outbreaks can be controlled only through sustained behavioural change by the public. The Nigeria CDC’s Covid-19 mini-site brings together dashboards with disaggregated data, health guidelines, travel information, location data on sample collection sites and laboratory capacity, and frequently asked questions in a single place for ease of use, while also embedding global data and material from the WHO. The Nigeria CDC’s automated online tool, NCDCBot, allows users to assess their risk factor and understand when they should contact health agencies for a formal diagnosis or more information. This form of triage allows the Nigeria CDC to more intelligently reserve its contact routes, which range from a toll-free telephone number to WhatsApp, Telegram and Twitter, for other queries. Intelligent use of technology-driven solutions has been key in one of the continent’s most digitally connected countries.[_] This has been true not just for public mobilisation but to facilitate rapid, large-scale training on Covid-19 for health workers, for which the Nigeria CDC has developed an online course.[_]
The federal system of government and fragmented policy architecture in Nigeria has meant working in partnership and using influence where essential to achieve containment goals. The Nigeria CDC has worked closely with a number of institutions at international, federal and state levels, and with scientific and political organisations. A number of legal provisions, public information assets and behavioural adjustments were made possible through its advice, which emphasised political leaders leading by example in adhering to public-health measures.[_] And despite historical challenges, the Nigeria CDC has been especially resourceful in sharing specifications with and securing essential supplies through Nigeria’s private sector.
For example, the Nigeria CDC has highlighted best practice by state public-health departments using its platforms.[_] In partnership with the Nigeria Institute for Medical Research, which has an allied mandate and similarly reports to the Federal Minister of Health, the Nigeria CDC has launched one of the largest national Covid-19 seroprevalence surveys on the continent.[_] The challenge of hosting local government elections at the end of May while minimising transmission through in-person voting at polling stations required the Nigeria CDC to work closely with the National Electoral Commission and political parties. For other government employees working in potential sites of transmission, including prisons and schools, guidance and training was made available.[_] Additionally, the Western Africa Regional Collaborating Center of the Africa CDC is located in Abuja, and the capital is also where the headquarters of the West African Health Organization is located and home to an international office of the US Centers for Disease Control and Prevention, on which the Nigeria CDC was modelled and by which it is supported. This geographic proximity provided potential for greater synergy and more sustained interaction throughout the public-health crisis.
The Nigeria CDC has experience of deploying rapid response capacity in reaction to a number of communicable disease outbreaks including Lassa fever, yellow fever, measles, cholera and monkeypox in the last year alone. The Nigeria CDC’s use of the Surveillance Outbreak Response Management and Analysis System (SORMAS) developed by Germany’s Helmholtz Centre for Infection Research for processing real-time data and surveillance-systems integration grew directly out of its experience responding to the 2014 Ebola outbreak.[_] But like many other African countries, its PCR testing capacity was severely limited at the start of the pandemic. The CDC’s National Reference Laboratory in Abuja and Central Public Health Laboratory in Lagos together tested only 13,000 samples for communicable diseases in 2019.[_] In April, the Nigeria CDC had set a target of analysing at least 2 million Covid-19 test samples within three months through state and federal laboratories – but by November, four months after the time-frame had passed, less than half of this target had been achieved. The director has acknowledged Nigeria’s “diagnostic insufficiency” as a result of a long-term lack of prioritisation when it comes to testing capacity, a challenge which cannot be overcome overnight. Indeed, among countries for which data are available, Nigeria consistently had sub-Saharan Africa’s highest or second-highest test-positivity rate, often by a considerable margin. Not until the start of July was it consistently lower than 20 per cent, and not until the start of September was it consistently lower than 10 per cent.[_] Nonetheless, the growth in capacity has been considerable given the circumstances. In February 2020, only three laboratories were capable of molecular testing for Covid-19; by October, there were 68 sites, with at least one in every state.[_] The Nigeria CDC has acted as the leader in centrally managing the procurement of reagents, but ultimately the fact it operates within the global context of high demand and poor coordination has posed significant challenges.
It is clear that the Nigeria CDC’s director is determined to use the momentum of the pandemic response to help strengthen public-health infrastructure and build more sustainable institutions for the future.[_][_]That will require significant investment in both frontline health-care facilities, diagnostic and research capability, as well as clearer protocols for pandemic response that ensure rapid and unified public-health mobilisation across the country’s vast expanse. The Nigeria CDC can play a critical role in helping to increase the capacity of local and state public-health institutions while placing preparedness at the heart of federal government decision-making.