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

Abstract

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

A full-scale simulation exercise of an outbreak of yellow fever was conducted to assess preparedness and response. The exercise was a multi-agency exercise conducted in Lagos, and it involved health facilities, points of entry, state and national public health emergency operation centers, and laboratories. An evaluation of the exercise assessed the capability of the system to identify, respond to, and recover from the emergency using WHO adapted tools.

The emergence of severe acute respiratory syndrome (SARS) in 2003 revealed the potential for the spread of disease across borders, which can threaten the health and economic and social lives of people all over the world.¹ The International Health Regulations (IHR) stipulated that countries should strengthen their response to serious cross border health threats.² Countries require a minimum level of core capacities to prevent small-scale outbreaks from becoming large-scale epidemics, and, in the wake of SARS, governments renewed these commitments under the revised IHR, with the deadlines extended to 2012 and then 2019, following the West African Ebola virus disease (EVD) outbreak.³

As pathogens continue to emerge and spread, a shift from purely responsive activities to proactive management has gained attention.^4,5 The 2014 EVD outbreak in West Africa exposed global deficiencies and inadequacies in emergency preparedness and response.³ It was unmatched in terms of the magnitude and extent to which diseases can spread locally and internationally.⁶ The fact that the disease was unanticipated in regions and areas that were previously non-endemic, in addition to inadequate infrastructure and highly mobile populations, might have contributed to the scale of the outbreak. This was a wake-up call, and it has accelerated swift actions by governments at national, regional, and international levels. These include the establishment of the Africa CDC and its regional collaborating centres,⁷ establishing the National Public Health Institutes (NPHI),⁸ strengthening of public health laboratories, and increasing collaborations among international organizations. The UN Secretary-General's high-level panel recommended that “regional and sub-regional organizations develop or strengthen standing capacities to monitor, prevent and respond to health crises, supported by the WHO” and that “regional organizations facilitate regional simulation exercises for health crisis responses, especially in border areas.”¹

One of the ways to strengthen preparedness is to conduct simulation exercises of different scales and scope. Simulation exercise is a form of practice, training, monitoring, or evaluating capabilities involving the description or simulation of an emergency to which a described or simulated response is made.⁹ The ability to deal with a crisis situation is largely dependent on the structures that have been developed or put in place before the crisis comes. The crisis can in some ways be considered as an abrupt audit at a moment's notice; everything that was left unprepared becomes a complex problem, and every weakness comes to the forefront. Therefore, simulation exercises help to highlight these weaknesses in the system and test preparedness plans in order to identify areas for revision and improvement.

A simulation exercise is more effective and efficient when a simulated event approximates reality as much as possible. The WHO has developed some generic exercise scenarios that can be used by countries.

The West African subregion has continued to experience sporadic outbreaks of infectious diseases, the most common of which are cholera, meningitis, measles, and Lassa fever.¹⁰ Over the past year, there have been laboratory-confirmed outbreaks of yellow fever in Nigeria after 21 years outbreak free. The Ebola outbreak of 2015 was also identified in Lagos State. Hence, the simulation exercise scenario was built around an outbreak of yellow fever in a densely populated setting with features of an urban and semi-urban settlement.

The Nigeria Centre for Disease Control (NCDC), established in 2011,⁸ is the national public health institute that serves as the International Health Regulation National Focal Point (IHR NFP). The NCDC, in collaboration with the West African Health Organization (WAHO), the World Health Organization (WHO), the African Field Epidemiology Network (AFENET), and other partners, organized the full-scale simulation exercise for yellow fever. This exercise was held in Lagos, Nigeria, in March 2018.

Assessment of the public health system response during the simulation exercise was an integral part of the design planning process to the end to enable us to identify gaps and other opportunities for improvement. The specific purpose of this exercise was to assess and strengthen the preparedness and response capacities of the Nigerian health system against a possible outbreak of yellow fever in an urban setting. The objectives were to:

Test the effectiveness of Nigeria's preparedness and response measures in the event of a yellow fever outbreak;

Strengthen the capacity of individuals and institutions to carry out planning to improve response to yellow fever outbreaks;

Strengthen partnership, teamwork, and multisectoral collaboration among the Nigerian health workforce in managing yellow fever outbreaks;

To examine the timeliness and effectiveness of response of key components, such as the Public Health Emergency Operations Centre (PHEOC), clinical management, infection and prevention control, laboratory, point of entry, risk communication, entomology, and immunization.

Share the major conclusions and lessons learned from this exercise with key policymakers on epidemic preparedness and response to inform future exercises.

In this article, we document the evaluation of the simulation exercise objectives; we identified strengths, weaknesses, and gaps of the Nigeria health system in responding to a yellow fever outbreak in an urban setting, including recommendations.

Why Yellow Fever? Why Lagos, Nigeria?

Yellow fever is a viral hemorrhagic disease caused by yellow fever virus and transmitted by the Aedes egypti mosquito. The DRC and Angola experienced yellow fever outbreaks in 2017. In 2016, WHO conducted a risk mapping of West African countries with potential for yellow fever outbreaks.¹¹ Because of the results of the risk mapping exercise and outbreaks of yellow fever in the Democratic Republic of Congo and Angola in 2017 and laboratory-confirmed yellow fever outbreaks in 2018, NCDC's preparedness and response to the reemergence of yellow fever had to be assessed.

Evaluation Methods

The exercise was designed to assess the Nigeria public health response system and ultimately to strengthen the capacity of the system and foster improved partnerships among organizations involved in the management of infectious disease outbreaks in Nigeria. The exercise examined the timeliness of activation and effectiveness of response of the PHEOCs, clinical management, laboratory, land and air borders, communication, entomology, and immunization.

A team of consultants was recruited to facilitate the evaluation process. Alumni of the Nigeria Field Epidemiology and Laboratory Training Programme (NFELTP) worked with the consultants to review and adapt the WHO evaluation tools. The tools were reviewed using the existing technical documents, standard operating procedures (SOPs), and plan, and they served as evaluation instruments for the exercise.

The evaluation team developed and collated relevant policies, plans, and procedures of the participating organizations to aid in design of the evaluation frameworks. The team also reviewed a WHO evaluation plan to come up with an integrated evaluation framework specific to the exercise objectives, using key reference documents, such as contingency plans and protocols for each site, and national plans.

Evaluators involved in the exercise assessed important events that are related to the specific objectives of the exercise, using a standardized WHO evaluation tool to help measure outcomes objectively. Evaluators used a strong pretested observational checklist during the exercise and compiled a report.

The report is a compilation of the assessed observations of the evaluators. It included observations, grades, deficiency classifications, and, where pertinent, recommendations. The report also contained details on lessons learned and recommendations for strengthening the system. Exercise debriefing was also used to review the exercise objectives with the participants and capture feedback on achievements, challenges, and critical gaps. The debriefing captured what was learned by the participants and observed by the evaluators, and what can be brought forward as a recommendation to improve response capacity.

The evaluation team was composed of personnel who possess the requisite knowledge and expertise in the areas to be evaluated, and the evaluation team had a workshop before the exercise, to ensure an excellent understanding of the plan, the procedures, and the distribution of responsibilities in the emergency organization.

Evaluation Process

The evaluation process focused on health facilities, local government areas, state and national identification, IHR notification, and response after the incident. The evaluation of the system's response to this simulation gauged the expected actions, based on the procedures, guidelines, and plans that describe preparedness and response to public health threats at different locations in the public health system.

Evaluators processed, reviewed, and adapted the WHO evaluation tools, using the existing key reference national technical documents, SOPs, and national plans to develop an integrated evaluation framework specific to the exercise objectives. (Evaluation tools can be found in the Supplemental materials at https://www.liebertpub.com/doi/suppl/10.1089/hs.2019.0048). Each site had a team of evaluators who assessed important events related to the specific objectives of the exercise. All participants in the exercise documented their decisions and actions. These documentations, together with the observations of the evaluators and feedback from the exercise debriefing, were used for the final scoring and results of the evaluation.

Evaluation Tools

The tools used for the evaluation of the simulation exercise include review and adaptation of the available technical documents, observations of the simulation exercise implementation, and the debriefing workshop.

Review of Available Documents

The documents used to develop the evaluation tools are:

Murtala Muhammed International Airport Port Health Public Health Emergency Contingency Plan

National VHF plan for Nigeria-Clinical Guidelines; Communications and EOC

Integrated Disease Surveillance and Response technical guideline

Sèmè Border Port health public health emergency contingency plan

Beninois land border SOP

WHO protocol for rapid field entomological assessment during yellow fever outbreak

Nigeria-Benin cross border public health information-sharing document

Lagos University Teaching Hospital (LUTH) Viral Hemorrhagic Fever Decision instrument

Evaluation checklists were designed across different key sectors after review of available national technical documents. Evaluators observed the actual reactions to events and injects, and these were compared to expected outcomes as per the master events list. The actions and behavior of the participants in the simulation exercise were evaluated, and good practices and challenges faced during the simulation exercise were identified.

Hot debriefings were conducted with participants of the simulation exercise at the various sites in order to discuss their perspectives concerning the different aspects of the exercise. The hot debriefing reflected on the exercise outcome and drew out achievements, challenges, and recommendations We also conducted a full-day debriefing workshop 1 day after the exercise, in which we reviewed the purpose and objectives of the exercise. This was followed by a discussion of what worked and what did not work during the simulation exercise. The debriefing workshop included a 4-corner exercise in which participants shared “what I enjoyed,” “what I did not enjoy,” “what I learned,” and “what I will do differently” on Post-it notes placed on boards in 4 corners of the workshop hall.

The exercise was evaluated over 2 days (March 13-14, 2018) covering a simulated 2 months of a yellow fever outbreak in Lagos. This exercise was evaluated at 14 sites, including:

The Lagos State Ministry of Health (state PHEOC and Disease Control Department)

Lagos University Teaching Hospital (tertiary hospital accident and emergency, laboratory, and wards)

Mainland Hospital (casualty and isolation wards)

Seme land border (port of entry)

Badagry General Hospital

NCDC Abuja

Shomolu LGA and private clinics

NCDC Lagos Campus (Central Public Health Laboratory)

Entomology and vector control

Murtala Muhammed International Airport

Exercise Control Room

National EOC

Results

The exercise was well received, with the majority of participants, observers, and evaluators in their responses to the survey either strongly agreeing or agreeing that the exercise was well-structured and organized. Participants also strongly agreed that the exercise helped them to identify strengths and gaps in their understanding of the emergency response systems and plans. Many of the participants valued the opportunity to participate in a simulated exercise for the first time, becoming more aware of the importance of preparedness plans and testing them, and enhancing the cooperation and partnership work with different organizations. The organization of such a large-scale exercise, which largely ran smoothly in a complex urban environment like Lagos, was also noted as a strength.

The overall objective of the simulation exercise was to strengthen the preparedness and response capacities of the Nigerian health system to a possible outbreak of yellow fever in an urban setting. The evaluation feedback strongly suggests that this objective was met through the knowledge gained by staff participating in the simulation exercise and the strengths and weaknesses identified. Specific strengths and gaps identified by the evaluators in relation to preparedness and response at each of the main exercise sites are outlined in Table 1.

Table 1.

Strengths and Gaps Identified at Each Simulated Exercise Site

Site	Strengths	Gaps
Lagos State Ministry of Health and State PHEOC	• Strong coordination & communication between PHEOC and field • Necessary subject matter expertise present; PHEOC staff knowledgeable and capable • Flexibility of the team; when unexpected twists occurred in scenario, people adjusted quickly. • Incident manager's leadership and direction consistent and thorough • Teamwork • All members came together and stayed focused to execute responsibilities.	• No SOPs and templates for the EOC agendas, terms of reference • No budgetary process to mobilize resources for PHEOC • The unavailability of designated space for PHEOC led to ad hoc hurried arrangements for alternative. • No hotline, dedicated email address, or other required infrastructure in place.
Central Public Health Laboratory	• Laboratory cold chain maintained • Pre-analytical side very good • Biosafety cabinet used, cleaned, and maintained • Packaging process for shipment well known and understood • Communication of result timely and electronic	• Persons involved in sample packaging and transport lack IATA certification • The laboratory sample reception process needs improvement. • Criteria for sample rejection and acceptance not applied • Waste management processes inadequate, especially segregation, decontamination, and disposal • Reagent supply chain coordinated by WHO office not functioning well • Delays in diagnosis due to lack of capacity to do RT-PCR in Lagos lab • No standardized template for reporting results between central public health laboratory and regional laboratory in Dakar • Nonfunctioning incinerator
Muritala Muhammed International Airport	• Good decontamination processes • Availability of PPEs • Ambulance fully equipped • Cooperation between port health service and airport security • Correct use of medical assessment form	• Improve incident command structure and application • Infection prevention and control (IPC) especially correct use of personal protective equipment (PPE) • Shortage of manpower (no doctor on duty and history taking and examination by nurse judged inadequate) • No resuscitation equipment for secondary screening area • Poor infrastructure at secondary screening area (ventilation, air-conditioning, and running water)
Lagos University Teaching Hospital	• Effective communication between emergency unit and holding area • Adequate use of PPE and disinfectants • Even though most staff did not know patient was part of exercise, they initiated the correct clinical management. • Good IDSR reporting system	• Delay in initiating treatment • Delay in cordoning off holding area • Vehicle transporting patient was not disinfected • Patient relatives not counseled • Delay in obtaining laboratory results
Seme Nigeria- Benin Land Border	• Seme Port Health has good isolation area. • Good communication between PHS team and DSNO for Badagry • Good teamwork among Seme Port Health Services (PHS) staff. Public Health Emergency Contingency Plan in place • Prompt attention given to ill passenger at Badagry General Hospital	• Infection prevention and control at border port health services inadequate • The border port health unit had no ambulance, delayed transfer of patient to hospital. • Cross-border communication between Nigerian and Beninois port health authorities weak • Border health screening did not follow standardized process. • Response of port health and DSNO suggested absence of standardized tools for responding to public health emergencies.
Shomolu Local Government Area (DSNO and private health facilities)	• Communication between various tiers of surveillance system good • Timely response of clinicians, DSNO, and surveillance system • Case review by the clinicians and surveillance team good, even without prior knowledge of scenario • Staff displayed good teamwork.	• Preparation for field investigation weak • Rapid response team not activated to assist in active case search • Some healthcare workers appeared to lack awareness of surveillance system and notifiable diseases. • Sharing and documentation by the RRT & EPR teams and IDSR, updating epidemiologic information showed weaknesses • Surveillance tools not readily available at DSNO's office
Entomology	• Prompt response from entomology unit following request for survey by EOC (within 24 hours). • Good teamwork	• Team arrived at site without key tools, terms of reference, and data collection tools.
NCDC	• Administration, documentation, organogram in place and adequate • SOPs and plans developed and implemented • Communication plan and mobilization of partners activated • IHR notification to WHO AFRO prompt, and WHO AFRO responded within 2 hours	• Inadequate space for side meetings • Evaluators unable to assess some aspects of response • Improve response to social media (Twitter and WhatsApp)
Exercise control room	• Evidence of planning/preparation, staffing, partnership • Strong coordination/command • Timely communication • Clear roles and responsibilities • Flexibility, perception, and troubleshooting	• Dual role of some individuals in control room as exercise participants and exercise managers • Clear labeling, signage, and organization of space • Adequate IT infrastructure • Formal starting and ending of exercise and key points • Contingency plans

The simulation exercise identified existing gaps in the current capabilities of several areas that would be involved in a yellow fever response. Table 2 shows these gaps along with several suggested recommendations for areas including case identification, notification, laboratory confirmation, case management, IPC and biosecurity, response, entomology, state PHEOC, national PHEOC, and IHR/POE. Some of the gaps identified were: IDSR reporting tools were not available, there were no case definition charts at the health facility, case notes were inadequate, and the facility register was not properly reviewed for possible case search. Laboratory sample collection was done at the facility, but the packaging was done at the LGA, and there was neither capacity nor materials for triple packaging. Reporting structure was adequate, but IDSR technical guideline was not cited.

Table 2.

Thematic Area Matrix of Simulated Exercise Objectives Rating System with Comments and Recommendations

Note. Medium gray represents available and adequate, light gray means available but not adequate, and black signifies not available at all.

At the tertiary health facility, triaging was done, the protocol and infectious disease unit was available, the holding area and isolation unit were available, but the triage area was inadequate, and the vehicle used to convey the index case was not disinfected. Response time could not be assessed, but DSNO response time was prompt: less than 30 minutes. At the isolation ward at Mainland Hospital, history was taken but examination was inadequate; ambulance was decontaminated, isolation unit was available but not adequately spacious in case of a large-scale outbreak; handwashing equipment was available at the isolation unit; IDSR notification was prompt and adequate.

At the laboratory, a ready-made triple packaging system was supplied by WHO, but personnel were not certified by the International Air Transport Association (IATA). Appropriate personal protective equipment (PPE) was worn, and there was a functional biosafety cabinet used for sample preparation. Liquid waste was properly disposed of through the sewer, but solid waste was not decontaminated before disposal by open pit burning. Equipment for yellow fever diagnosis was functional, but specific controls were unavailable. However, pan-flavivirus positive control was used; hence, results could not be specific for yellow fever.

The entomologist responded promptly, within 24 hours of notification, but there were no data collection tools onsite, and there was poor coordination among the state, the entomologist, and the community. Only larvae of Aedes egypti were captured.

The state PHEOC was not fully utilized, and protocols and SOPs were not available; however, the incident manager was appointed, and internet connectivity and the social media group were available at the PHEOC to enhance information sharing and good communication among the PHEOC members. There were no working groups, no vaccination plans, no International Coordination Group (ICG) request made, and no action tracker for the outbreak.

The national PHEOC has functional space with side rooms for meetings, and an administrative system was present but not fully functional. An incident manager was appointed, and SOPs and an organogram (organizational chart) were available. Most of the working pillars were not represented, and NCDC notified relevant partners.

At the point of entry, there were good decontamination processes; PPE was available; the ambulance was fully equipped; there was good cooperation between the port health service and airport security; and medical assessment forms were used to track patients. The IHR NFP was promptly notified; they then immediately notified their counterpart in Benin republic and the WHO AFRO. The IHR notification was prompt and timely; WHO-AFRO took action within 2 hours of notification.

Discussion

The NCDC has demonstrated leadership in public health emergency activities in the country through a simulation exercise program that employs realistic scenarios and rigorous evaluation to meet its objectives. The full-scale simulation exercise was an avenue to educate the public health workforce on key public health system emergency preparedness. It was also a test of systems of early warning and notification of disease, and it identified specific systems-level challenges in the response to public health emergencies.

Public health system performance should include immediate disease identification and notification, epidemiologic investigations, laboratory testing, prevention, and coordination of response activities through incident management. Current measurements of public health systems usually assess capacities. More important is the assessment of capabilities—that is, the collective ability to undertake functional or operational actions using available preparedness assets to function in a coordinated manner.¹²

One opportunity for evaluating and assessing public health system capabilities is the occurrence of emergencies in countries in the subregion, including Nigeria. This can be leveraged to assess the system in real time. However, the complexity and limited advance warning makes it difficult to systematically assess the system.¹²

The IDSR focal person, DSNO, and health facility participants had prior knowledge of the simulation exercise. This resulted in a quick response from these participants. There were instances of limited observation by the evaluators in the holding area in the acute phase, especially at the Shomolu General Hospital, where evaluators did not have access to the health facility isolation area. This hinders objective evaluation of the health facility staff's management of patients.

Key Recommendations

The following recommendation are specific to the sites evaluated during this simulation exercise.

Local Government Area Health Facilities

Ensure that case definition charts and IEC and IDSR materials are available and accessible to DSNOs.

Provide regular supportive supervision of DSNOs, perhaps bimonthly.

Increase awareness and use of IDSR by clinicians in primary, secondary, and tertiary health facilities in the private and public sectors.

Lagos University Teaching Hospital

Improve laboratory turnaround time, perhaps by ensuring staff are available on a 24-hour basis.

Redesign triage area at the accident and emergency department, as currently it is too open and accessible to the public.

Conduct in-house drills to test and improve detection, management, surveillance, and notification of infectious diseases.

Laboratory

Put in place 24-hour sample transportation mechanism and monitoring.

Establish more regional laboratories for tests.

Ensure staff transporting samples are IATA trained and accredited.

Use the autoclave for decontamination, as it should be used in waste management, and ensure incinerator is functional.

Improve biohazard diagnostic process and capacity.

Reduce the logistics challenges and time delays in sending samples to Dakar.

Ensure availability of reagent supplies and strengthen understanding of the supply chain from WHO.

Mainland Hospital

(designated hospital for infectious diseases in Lagos State)

Develop SOP for decontamination of ambulances.

Train and retrain staff regularly, given continuous posting of staff out of the facility. Trained staff should disseminate their training, to ensure continuity.

Expand isolation area for management of cases of infectious diseases.

Points of Entry

(Murtala Muhammed International Airport and Seme Border)

Provide resuscitation material and basic life support training for all staff.

Recruit more clinical staff doctors to address current shortage; recruit more nurses, as many of the current nurses will be retiring in the next few years.

Increase resilience of staffing at port health (there appears to be an over-reliance on a few capable staff).

Provide better training for existing staff and develop protocols, SOPs, flowcharts, and decision instruments for health workers at port health, where they do not exist.

Examine why protocols already in place are not being used consistently, and implement actions to improve use.

Strengthen infection prevention and control.

Fast track designation of point of entry.

Conduct regular drills and simulation exercises to strengthen capacity.

Lagos State

Designate state Public Health Emergency Operations Centre.

Develop EOC activation plan and SOPs.

Determine minimum costing for EOC start-up and operation.

Identify a dedicated EOC space and 2 or 3 possible backup sites.

Develop a Lagos State Infectious Disease Preparedness and Response plan or adapt existing national plan to Lagos State.

Identify subject matter experts trained in incident management.

Formalize Epid Alert's role in supporting Lagos State in communication and mobilization; other states to examine whether they require similar arrangements.

Ensure immunization system is robust enough to deal with multiple outbreaks at the same time.

Entomology

Provide training and materials for technical staff on emergency response (checklist, terms of reference, national protocol for entomology, SOPs).

Strengthen community engagement in working with entomology during surveys; clarify process and roles of DSNO, community development workers, and entomologist.

Perform national entomology survey.

Build relationships between state ministries of health and academic departments of entomology as Lagos State has done.

NCDC

Strengthen collaboration with partners involved in outbreak preparedness and response activities, including NPHCDA for vaccination, port health services, and other key partners.

Address issues identified by evaluators.

Support state EOCs in building capacity through exercises and other activities.

WAHO

Facilitate support to Nigeria in relation to epidemic preparedness.

Facilitate intercountry collaboration among ECOWAS states in sharing experiences and lessons learned in incident preparedness.

Other states in Nigeria and other ECOWAS countries should review their own preparedness and response capacities.

Lessons Learned

The simulation exercise served as a valuable tool to enhance participants' competency-related knowledge and skills associated with key public health system emergency preparedness. In addition, it enabled us to test early warning and notification of disease capabilities and to identify specific systems-level challenges in the response to public health emergencies in Nigeria.

During Preparation

Pre-exercise briefing with participants served as an orientation and sensitization on the exercise and part of the planning phase. Some of these participants are therefore made aware of the scope of the exercise and when the exercise would take place. This prior knowledge and sensitization alerted them to be at their best, and practices at the workplace were present that might not have been employed in a situation where an actual emergency occurred.

Engaging entomologists without a clear term of reference and guidelines hampers their productivity during the exercise.

During the Exercise

Early notification of outbreaks facilitated quick action for effective response.

Transparency by the NCDC in quickly reporting the public health emergency of international concern (PHEIC) contributed to effective communication and collaboration among the member states.

Unavailability of a designated structure for PHEOC hindered effective coordination of the exercise.

The simulation exercise fully met the stated objectives; however, some gaps were identified in the process. Our recommendations for future simulation exercises would include the following:

While pre-exercise briefing is important and must be conducted with stakeholders, the simulation exercise should not be implemented immediately and the sites to be evaluated need not be aware of the day and time the simulation will occur.

The exercise should be made more confidential, and the participants being assessed should not be in the know.

Evaluators and simulators should have a walk-through training session for a better understanding of the processes and outcomes.

There should be terms of reference for the entomologist.

There should be a unit simulation to test individual components prior to a full-blown simulation.

Conclusion

The simulation exercise, the first ever held in West Africa on a large scale, was successful in providing an experience of a full-scale simulated exercise to a large cohort of participants, the exercise management group, observers, and evaluators. The exercise successfully tested the effectiveness of preparedness and response measures in Nigeria in the event of a yellow fever outbreak, drawing out strengths and gaps, with lessons for other ECOWAS countries. Through the planning and delivery of the exercise, the capacity of the participating individuals and institutions to improve response to yellow fever and other infectious disease outbreaks has been strengthened. Working together in planning and delivering the exercise provided opportunities to deepen partnerships, teamwork, and multisectoral collaboration among the Nigerian health workforce in managing yellow fever outbreaks. Useful collaborations and relationships were also developed at a regional level.

Taken together, the increased awareness, identification of gaps, and building of capacity brought about by the exercise have strengthened the preparedness and response capacities of the Nigerian health system in the event of a possible outbreak of yellow fever in an urban setting. The dissemination of the findings from the exercise and implementation of the action plans developed will help strengthen the capacity of countries in West Africa to prepare for and respond to infectious disease outbreaks. The exercise highlighted, in a practical way, the importance of putting in place plans and processes for responding to infectious disease outbreaks. The dissemination of the exercise materials across West Africa will hopefully help initiate and foster a culture of exercise and testing of preparedness and response plans across the region.

Footnotes

Acknowledgments

The authors wish to acknowledge the West Africa Health Organization (WAHO) and The World Bank for funding this simulation exercise. They are also grateful to the Africa Field Epidemiology Network (AFENET), the World Health Organization (WHO), GIZ, Public Health England (PHE), Pro Health International (PHI), the US Centers for Disease Control and Prevention (USCDC), the Red Cross, and Lagos state government for providing technical assistance.

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