Testing & Surveillance: Nigeria

Nigeria, along with three other countries, was selected for this study a priori (not through an Exemplar country selection process). These countries were selected for their variability in COVID-19 responses and outcomes, their experience in managing past epidemics of global concern, their strong partnerships between in-country research institutions and ministries of health, facilitating access to data and enabling the translation of findings to action, and the representation of Francophone and Anglophone communities to enhance South-to-South collaboration. While Nigeria is not a positive outlier with respect to its COVID-19 response, there are lessons that can be learned from how the country addressed challenges and subnational success stories with transferable lessons for comparable settings. Furthermore, documenting the country’s response may also inform improvements for future preparedness and response efforts.

This research and analysis was conducted by research partners at the University of Ibadan and the Makerere University School of Public Health.

Introduction and Key Takeaways

Between February 2020, and June 30, 2021, over 2.3 million COVID-19 tests were conducted in Nigeria, with more than 167,000 people testing positive. The country also recorded 2,120 confirmed COVID-19 deaths.¹ However, serological surveys conducted in 2020 suggest that Nigeria’s COVID-19 burden is likely much higher. Nigeria’s experience with epidemic-prone diseases, such as Ebola virus disease (EVD), meant that its public officials had knowledge and infrastructure they could leverage as they developed an efficient, coordinated response to the COVID-19 pandemic.² However, testing and surveillance challenges—including low demand, limited human resource capacity, and long turnaround times—persist. Since the start of the pandemic, Nigeria has increased its COVID-19 testing laboratories (from 3 to 138), introduced rapid diagnostic tests (RDTs), and strengthened its genomic sequencing strategy to prepare for the Delta variant.

To prepare for what officials called “a likely third wave” of COVID-19, and to prevent the spread of the highly transmissible Delta variant, Nigerian officials acted early. ³ In May 2021, the federal government imposed travel bans from several countries and while Nigerian citizens and residents who had been in those countries were allowed to reenter Nigeria, they were subject to a compulsory one-week quarantine in government-approved facilities. Since May 2021, all passengers arriving in Nigeria must show a negative COVID-19 test taken within 72 hours of travel, rather than 96 hours as previously required.⁴

On May 12, the NCDC launched a proactive genomic sequencing strategy, which involved aggressive testing, to help the country prepare for the Delta variant. At the same time, the government announced new mobility restrictions and the Presidential Steering Committee initiated alerts to all treatment centers. Community volunteers and intensive care experts were also trained in anticipation of surging cases.

The following findings are organized according to the Testing and Surveillance framework.

What was Nigeria’s Pre-Pandemic Context? How did it Respond to COVID-19?

Disease Outbreak Experience

Nigeria has experienced several relatively recent outbreaks of epidemic-prone disease—including monkeypox, cholera, Lassa fever, and Ebola virus disease.² It also had a strong preexisting public health surveillance system based on the Integrated Disease Surveillance and Response framework.5 Consequently, it had the knowledge and experience to establish a COVID-19 preparedness plan, along with the tools and infrastructure required to execute the plan, before any case was reported in the country. For instance, the online Surveillance, Outbreak, Response Management Analysis System (SORMAS), an open-source epidemic surveillance software platform developed during the 2014–2015 Ebola outbreak, played an important role in Nigeria’s COVID-19 response.

At first, Nigeria’s COVID-19 guidelines were developed according to a risk-based testing strategy that targeted symptomatic individuals. The country continued to adjust its approach as the pandemic evolved—for example, officials stopped requiring follow-up testing for confirmed cases as global public health recommendations changed.

Assessment of Pre-Pandemic Preparedness

The 2017 World Health Organization (WHO) Joint External Evaluation of the International Health Regulations’ core capacities in Nigeria noted several key areas for improvement, including formulation of a national action plan for health security, enhancement of the emergency operation center and Incident Management System, and strengthening of intersectoral collaboration for emergency response.⁵ The all-hazards preparedness plan lacked coordination. Although draft plans existed for addressing individual diseases or agencies, there was a lack of multisectoral interconnection, which could pose a challenge to coordination in surveillance activities and epidemic control. The evaluation also noted that Nigeria had several points of entry that were doing commendable routine and emergency actions; however, some of these points of entry were not officially designated as such, which meant they had the potential to be missed in the surveillance system. Furthermore, only about half of the more than 32,000 health facilities in the country were identified as Integrated Disease Surveillance and Response reporting sites, indicating a potential for incompleteness in reporting.

What was Nigeria’s COVID-19 Response Strategy?

Nigeria’s response strategy has been focused on using a risk-based or targeted strategy of testing symptomatic individuals due to limited testing capacity and availability of supplies. This approach was modified as the outbreak evolved (for example, follow-up testing for confirmed cases was no longer required as of June 5, 2020).⁶

Nigeria’s COVID-19 response benefited from strong public and private sector support. The NCDC and partners from private organizations, civil society, and academic institutions coordinated to improve the country’s COVID-19 response. Early on, the NCDC and its partners conducted a partner mapping exercise to reduce duplication of efforts. Partners from the private, civil society, and academic sectors were also brought in to support with everything from the donation of personal protective equipment to training emergency operation centers. Nigeria also leveraged lessons from past outbreaks and used existing infrastructure to streamline its response.

What was Nigeria’s Testing Strategy? How did it Establish Testing Capacity?

Access to laboratory diagnosis for COVID-19 is important for early case identification and management, as well as breaking the transmission chain and suppressing the spread of the virus. As of June 30, 2021, Nigeria had performed over 2.3 million COVID-19 tests, with 5,000 – 11,000 samples tested per day (up from 600 samples tested daily in April 2020).⁷ The WHO’s benchmark for adequate testing is 10 to 30 tests per confirmed case. By June 2021, there were 90-400 tests conducted per confirmed COVID-19 case in Nigeria.

From the beginning of the pandemic, due to limited testing capacity and supplies, Nigeria adopted a risk-based testing strategy that targeted people who were experiencing symptoms of COVID-19: travelers returning from overseas, contacts of cases, alerts from the community, and health workers. New arrivals from watchlist countries were to observe self-isolation  and report for testing only when they were symptomatic. A negative test was also required to be discharged from quarantine or isolation.⁸

In collaboration with designated laboratories, the COVID-19 federal and state task forces provided testing for anyone who met these eligibility criteria, and anyone testing positive was referred for institutional isolation at a hotel or health facility. Isolation started at four influenza sentinel sites (in Lagos, Abuja, Kano, and Nnewi), expanding to government-owned facilities, and eventually to home-based isolation as cases increased.

At first, tests for people in isolation were repeated every two to three days until a patient tested negative twice within 48 hours, but the surveillance pillar of the Public Health Emergency Operations Centre modified this testing strategy as the outbreak progressed. Those eligible for free COVID-19 tests include symptomatic alerts and high-risk contacts, while all travelers must pay US$ 120 for a test. All incoming travelers must carry out a polymerase chain reaction (PCR) test at an accredited laboratory within seven days of their arrival into Nigeria.

Confirmed cases may be isolated at home or in a facility, and there is no follow-up repeat testing. Instead, officials use set discharge criteria:

• Symptomatic cases can be discharged ten days after symptom onset, plus three days without symptoms
• Asymptomatic cases can be discharged 14 days after initial positive test, assuming they remain asymptomatic

Early in the pandemic, home-based self-isolation was also required for anyone returning from travel abroad, but officials soon found that few returnees complied with home-based quarantine. As a result, they shifted to mandatory institutionalized quarantine at government hotels in June 2020. This eventually reverted to the home-based strategy after case numbers became overwhelming and institutional costs could not be sustained.

Testing Value Chain

SOURCING TESTING SUPPLIES

Before any COVID-19 cases had been reported in Nigeria, officials conducted a quantification exercise to estimate the country’s need for testing supplies and personal protective equipment. As a result, the federal government released a $5 billion Naira (US$12.5 million) special intervention fund for the procurement of testing supplies, and an additional $10 billion Naira ⁹  (US$25 million) for the Lagos State Government. Donor partnerships soon brought additional funding— but because Nigeria did not have the initial capacity to manufacture its own supplies, it relied on other countries’ willingness to sell or donate essential goods. Consequently, limited availability of testing supplies has led to stockouts at test sites.

At the onset of the COVID-19 outbreak in Nigeria, the country used only molecular PCR tests, the testing modality recommended by the WHO.¹⁰ These tests are still the gold standard, but due to the long turnaround times and the need to decentralize testing services, point-of-care PCR was adopted in May 2020, using the GeneXpert platform. Since September 2020, imported antigen rapid diagnostic tests (RDTs) from Abbott and Biosensor have been incorporated into Nigeria’s testing strategy, initially just as a screening tool for selected populations in closed settings such as boarding houses and prisons. More recently, however, RDTs have become more widely used and account for 15% of total tests conducted in Nigeria. As of June 2021, Nigeria does not yet manufacture COVID-19 testing kits, and the two kits developed by The Nigerian Institute of Medical Research reportedly failed validation testing, leaving Nigeria reliant on imported products.^{11, 12}

While most countries in Africa relied on two to four testing products, the Nigeria CDC and UNICEF took an approach that aimed to diversity suppliers. This helped prevent critical dependencies, allowing for a competitive market and the ability to adapt to different needs per location, procuring eight different types of COVID-19 tests that were delivered to 50 diagnostic laboratories across the country.¹³

SAMPLE COLLECTION AND TEST DEMAND

At first, Nigerian health officials found inadequate demand for testing services, which led to underutilization of the established testing capacity. Access to testing has improved over time, as the number of sample collection sites and testing sites have increased. The NCDC conducted a campaign to test people experiencing influenza-like symptoms (such as cough, sore-throat, muscle or body aches, fatigue, etc.) and public sites, such as public laboratories supported by state governments, began to provide free testing (except for travelers). The NCDC also introduced regular communications to the general public via SMS, regarding the location of testing centers.

By January 2021, Nigeria had increased the number of COVID-19 testing laboratories from 3 to 97 (including 18 private fee-based laboratories), spread across the 36 states and Federal Capital Territory. Laboratory distribution was determined by caseload, population, and density. As a result, many are clustered in outbreak epicenters in large cities such as Lagos, Abuja, and Kano. Nigeria’s 23 GeneXpert machines were also recalibrated for COVID-19 tests. Together, all these laboratories have the capacity to test at least 15,000 to 20,000 samples every day. As of June 30, 2021, Nigeria had 138 laboratories—84 public and 54 fee-based—distributed across all of the country’s states.¹⁴

Persistent barriers to testing access include: long distances to few sample collection and testing sites; long turnaround time for results; and the relatively high cost of testing for travelers. COVID-19 patients reported stigmatization in their communities, so people who felt sick sometimes avoided being tested. On the other hand, officials noted excessive demand for testing from well-connected people who did not meet testing criteria but requested frequent testing for themselves and their family members and staff.

SAMPLE DELIVERY

By November 2020, the turnaround time from sample collection to results was 24 to 48 hours for PCR testing and less than 24 hours for GeneXpert—a substantial improvement from five days in the early phase of the outbreak. Further improvements came from increased laboratory testing capacity, decentralization of services, adoption of point-of-care testing, and the scale up of RDTs. There were also improvements in the sample transportation system when the NCDC, in collaboration with the WHO, began to set up and train dedicated sample collection teams in all 36 states.

Key challenges noted were poor road networks, logistical challenges (for transportation and the supply of commodities), and weak coordination across the diagnostic testing laboratories. For example, there were reports of sample delivery to laboratories that were not ready to test the samples because of poor communication; these samples were destroyed.

LABORATORY ANALYSIS

Nigeria rapidly expanded its testing capacity by leveraging molecular testing in January 2020, adopting point-of-care PCR in May 2020, and adapting the GeneXpert platform and introducing antigen RDTs in September 2020. The quality of laboratory analysis has also improved as laboratories implement better staff training and quality assurance protocols. As a result, sample rejection rates have declined from 13 percent (three to four daily batches every month) to three percent (less than of one batch per month).

RESULTS COMMUNICATION

Results from the public and private laboratories are returned to the NCDC and the state government emergency operation center. From there, they are directed to the tested individuals and their health care providers. Since June 2020, results could be received via SMS and state hotlines were established to help individuals access their results.¹⁵ Most results are delivered within 24 to 48 hours, an improvement from the five or more days common at the start of the pandemic. However, instances of much longer turnround times still occur. Some tests still had such long turnaround times that the COVID-19 incubation period had elapsed by the time results were communicated; many then chose not to get their results.

Nigeria’s results-communication process leverages a preexisting system using databases integrated with states’ District Health Information Software (DHIS2) information technology infrastructure for real-time transmission and collation at state and federal levels.

What was Nigeria’s Surveillance Strategy? How were these data used to Guide Public Health Actions?

Nigeria’s experience with epidemic-prone diseases, such as Ebola virus disease, meant that its public officials had knowledge and infrastructure they could leverage to rapidly develop a coordinated response to the COVID-19 pandemic.

When the first wave of the pandemic reached Nigeria in February 2020, officials instituted surveillance at international border points of entry, including airports and land crossings. Teams designated by State Disease Surveillance and Notification officers screened travelers entering Nigeria for COVID-19 symptoms via temperature checks and questionnaires on travel and contact history. Confirmed cases of COVID-19 were isolated and treated. The surveillance data gathered at these checkpoints eventually resulted in the restriction of international travel into Nigeria.¹⁶

Eventually, surveillance covered every point of entry—land, sea, and air—as well as health facilities (where sick individuals have gone to seek care) and workplaces. In health facilities and communities, state workers and volunteers engaged in active case search, or the systematic identification of people with COVID-19. For example, community volunteers visited households to identify people at high risk or with symptoms associated with COVID-19 and helped them get tested. Passive surveillance relied on the cooperation of health workers to report suspected cases of COVID-19 to State Disease Surveillance and Notification officers or through established channels such as the state hotline for COVID-19.

One of the key strengths of Nigeria’s surveillance system was its adaptation of preexisting disease surveillance systems developed in response to previous outbreaks of contagious disease. Instead of the paper-based Integrated Disease Surveillance Response system, officials adopted the online Surveillance, Outbreak, Response Management Analysis System (SORMAS), an open-source epidemic surveillance software platform developed during the 2014–2015 Ebola outbreak.

SORMAS’s new COVID-19 dashboard continuously displays updated case numbers, epidemic curves, maps of spatial distribution, contact tracers, laboratory results, and fatalities. It includes interfaces for 12 different user types, including laboratory clerks, contact tracing officers, and epidemiologists, and its centralized epidemiology database allows health workers and officials easy access to high-quality data that can guide public health action.

The SORMAS platform was used to enhance information management systems in laboratories across Nigeria: laboratory data clerks in different states can update their results immediately and in real time. The platform also has functions for basic data analysis using simple analytic tools and features, and enables users to export data for advanced analysis using other standard tools.

Integrating testing laboratories into the SORMAS system improved capacity and allowed for more effective contact tracing. However, the surveillance system did encounter some challenges: a lack of internet connectivity in some rural and remote areas of the country made it difficult to upload data to the SORMAS platform. Inadequate human resources in some states, as well as lack of funds to conduct activities like contact tracing, and a lack of public cooperation resulting from negative perceptions about COVID-19 also hampered surveillance activities more generally.

Early Warning and Alert Response System (EWARS) In three conflict states in northeastern Nigeria—Borno, Yobe, and Adamawa—the Early Warning and Alert Response System (EWARS) mobile app supplemented COVID-19 surveillance through a partnership between the WHO and the Nigerian Federal Ministry of Health. EWARS is a health management information system that can be deployed in areas where the routine surveillance system has broken down. It uses a smartphone app to collect weekly data (both online and offline) and analyze essential data on 17 epidemic-prone diseases in conflict areas. Each field-ready EWARS kit covers 50 health centers, or around 500,000 people. Data is received in real time at the state and federal levels, and automated epidemiological bulletins are generated to rapidly analyze and share results.17 However, EWARS and SORMAS are not integrated with one another and interoperability remains a challenge. Learn more about the WHO’s Global EWARS projects here.

Nigeria’s surveillance strategy is also detecting only a proportion of its COVID-19 cases, as many asymptomatic cases may not be counted, and post-mortem surveillance has been limited. Across the country, 9.4 percent of RT-PCR tests for COVID-19 were positive¹ —but in September and October 2020, a community serological survey of 10,000 blood samples taken from people in Lagos, Enugu, Nasarawa, and Gombe states found seroprevalence as high as 23 percent in Lagos and Enugu, 19 percent in Nasarawa, and nine percent in Gombe.¹⁸ Nigeria has since conducted another serological survey but, as of June 2021, the results have not been published.

Surveillance Modalities

CONTACT TRACING

Nigeria began active case finding through contact tracing at the end of February 2020. The country’s previous experience with contact tracing in the context of the 2014 Ebola virus disease outbreak (where 899 contacts were traced in Nigeria) meant that it had infrastructure and knowledge that could be leveraged for the threat of COVID-19. ¹⁹

The national Public Health Emergency Operation Centre and state-level surveillance pillar leads (the State Epidemiologist and State Disease Surveillance and Notification Officer) deployed response teams to support Port Health Services authorities as they entered passenger information electronically into SORMAS at the Lagos and Abuja international airports. The response teams also captured information about cases and contacts in all states of the federation. The state contact tracing team includes all health officers from all local government areas, but in higher-burden states (Lagos, Federal Capital Territory, and Oyo), volunteer contact tracers were recruited, trained, and deployed as case numbers increased. In Lagos State, volunteers were recruited from each ward within the local government areas, with a minimum of three volunteers per ward. In Oyo, some volunteer contact tracers were recruited from among the postgraduate students of the Faculty of Public Health at the University of Ibadan. Volunteers assisted the statutory disease surveillance officers for each locality, following up with contacts of confirmed cases. Those who developed symptoms within 14 days of contact were tested for COVID-19.

Apart from contacts’ loss to follow up, other challenges in contact tracing included inadequate staff, and lack of transportation and fuel to trace contacts in the community, in addition to COVID-related stigma that may have made some people reluctant to participate.

ISOLATION AND QUARANTINE

Prompt isolation was conducted immediately after detection of confirmed cases, followed by notification to the epidemiology unit of the state ministry of health for clinical management and contact tracing. At the beginning of the outbreak in Nigeria, officials used four preexisting influenza sentinel sites—Lagos State University Teaching Hospital (South West), Aminu Kano Teaching Hospital (North West), Asokoro Teaching Hospital (North Central), and Nnamdi Azikiwe University Teaching Hospital Nnewi (South East)—for COVID-19 isolation. However, as the number of cases increased, isolation was expanded to government-owned public facilities, such as secondary and tertiary hospitals designated for COVID-19. Additional isolation centers were established in each of the 36 states, but capacity was still inadequate. Rising case counts prompted a change from institutionalized public isolation centers to home-based isolation in July 2020. ²⁰

At first, in isolation, tests were repeated every two or three days until two negative results were obtained within 48 hours. However, as emerging scientific evidence showed that viral RNA detected beyond ten days was no longer infectious, tests were repeated less frequently until one negative result was obtained. Under current guidelines, tests are not repeated; a confirmed case is discharged using the clinical discharge criteria. In October 2020, states had closed down the majority of isolation centers (following a decline in cases) and the country had adopted home-based care for 60 percent of positive cases (determined to be low-risk, see below), while accommodating remaining cases in isolation centers still in operation.

In alignment with the Africa Centres for Disease Control and Prevention and the NCDC guidelines, the NCDC categorizes confirmed cases into two groups: high-risk (direct physical contact with a positive or probable case) and low-risk (no direct contact). ²¹

• Low-risk contacts quarantine at home for 14 days, supervised via phone calls from the NCDC
• High-risk contacts self-quarantine at home or at a state-designated facility; as of June 2021, they are monitored by a health team that reviews daily temperature logs and conducts at least three physical visits

GENOMIC SEQUENCING

On May 12, the NCDC launched a proactive genomic sequencing strategy, which involved aggressive testing, to help the country prepare for the Delta variant. The Delta variant’s increased transmissibility prompted the government to announce new mobility restrictions and the Presidential Steering Committee initiated alerts to all treatment centers. Community volunteers and intensive care experts were also trained in anticipation of surging cases. By the end of June, 81 percent of analyzed samples were of the Delta variant (see below).

Data Management, Reporting, and Use

DATA CAPTURE AND COLLECTION

Local offices of the Disease Surveillance and Notification Officer routinely collect COVID-19 case data and enter it into DHIS2 for real-time transmission and collation at the state and federal levels.

Data systems such as SORMAS and EWARS improve key decision makers’ access to data they can use to support a targeted, efficient COVID-19 response. Incorporation of testing laboratories into databases for better results transmission has improved surveillance, and Nigeria adopted several electronic solutions (such as virtual meetings and digital SORMAS, instead of the paper-based Integrated Disease Surveillance and Response system) to improve communication and enable faster decision making for surveillance officers, supervisors, and contact officers. However, a confluence of factors including underreporting of case counts and varying utilization of emergency operation centers contributed to performance gaps at the subnational level.

How did Nigeria Coordinate its Testing and Surveillance Efforts?

Nigeria acted quickly and with commitment to start testing and surveillance activities even before the virus that causes COVID-19 was detected in the country. The preparedness plan established numerous official bodies charged with developing and implementing COVID-19 response activities—although there was some overlap in their responsibilities, especially at the local level, and gaps in coordination sometimes hampered policy implementation on ground. Despite this, the quick response to the pandemic yielded some positive results.

The WHO declared coronavirus disease a public health emergency of international concern at the end of January 2020. That same month, the NCDC established a multisectoral National Coronavirus Preparedness Group that included representatives from Port Health Services, the Federal Ministry of Health, and other stakeholders that met daily (at first) to review global COVID-19 epidemiology, assess the risk of spread, and initiate measures to strengthen the country’s preparedness for early detection and timely response in the event of a COVID-19 outbreak in Nigeria.

At the end of February 2020, when the first case of COVID-19 was reported in Nigeria, the National Coronavirus Preparedness Group coordinated partners—including UNICEF, the Clinton Health Access Initiative, UK Support Initiative and the WHO—and became the Public Health Emergency Operation Center. The center built on and adapted the structures of the preexisting Incidence Management System left over from the 2014 Ebola outbreak, and it activated across seven major pillars of disease response: laboratory, case management, risk communications, logistics, points of entry, and coordination.

On March 9, 2020, officials established a Presidential Task Force to coordinate the national COVID-19 response. This task force and the Public Health Emergency Operation Centre were intended to work in parallel: the task force made strategic decisions, developed national guidance for COVID-19 response, and oversaw and supported the center’s operations to contain the disease’s spread and mitigate its impact.

Individual state task forces for mobilizing multisectoral pandemic response were established in each of Nigeria’s 36 states as soon as any given state reported its first COVID-19 case.²² Response coordination varied by state: some states (e.g., Kano, Cross River, and Kogi) were slower to respond than others (e.g., Kaduna, Lagos, and Federal Capital Territory). This was reported to be influenced by the level of perceived risk, which was higher in states with international airports. Kano was a special case where perceived risk was low, due to a probable combination of factors including religion, education, and cultural beliefs.

As of December 2020, Nigeria’s total spending on COVID-19 was $244.64 billion Naira (US$642 million): $86.4 billion Naira (US$227 million) from the federal government of Nigeria, and the rest from donors including the United Nations COVID-19 Response Basket Fund, the Coalition Against COVID-19, and the World Bank.²³ Different partners supported different aspects of Nigeria’s response. For instance, the World Bank provided funds for contact tracing, the UK Support Initiative and Clinton Health Access Initiative supported state and local capacity-building and ongoing vaccine development, and the Africa Centres for Disease Control and Prevention funded active case search.

What are the Key Lessons from Nigeria’s Response to COVID-19?

Because Nigeria had a great deal of experience with surveillance for other infectious diseases, it had preexisting tools and systems that could be leveraged and adapted for its COVID-19 response. However, a lack of resources and supplies, as well as communication breakdowns at the local level, continue to limit the country’s ability to roll out comprehensive testing and surveillance solutions to the entire population.

Conclusion

In July 2021, the director general of the NCDC told journalists that “Nigeria, like other countries across the world, is at risk of a surge in COVID-19 cases,” especially after officials confirmed they had identified a traveler to Nigeria who was infected with the highly transmissible Delta strain of the virus. ²⁴

At the time of publication, inadequate supply of COVID-19 vaccines and delivery challenges in Nigeria are cause for concern. As of June 30, 2021, 3.4 million COVID-19 vaccine doses had been administered in the country, covering less than two percent of Nigerians.^{3, 25}

To prepare for the likely third wave of the COVID-19 pandemic, and to prevent the spread of the Delta variant, the Nigerian government acted early; however, how lessons learned and systems designed for testing and surveillance throughout the first phases of the pandemic will be adapted or challenged is still being understood.

While Nigeria has experienced challenges with their COVID-19 response, there are lessons that can be learned from how the country innovated and adapted strategies to address these challenges. Documenting the country’s response may also inform improvements for future pandemic preparedness and response efforts.

AUTHORS Alice Namale, Olufunmilayo I. Fawole, David M. Dairo, Ayo S. Adebowale, Segun Bello, Eniola A. Bamgboye, Mobolaji M. Salawu, Rhoda K. Wanyenze