Pandemic Flu Planning

in Africa

Thoughts from a Nigerian Case Study

Cheryl Loeb, Lynn McGrath, and Sudhir Devalia 

Center for Technology and National Security Policy 

National Defense University

August 2009 
ii

The views expressed in this article are those of the authors and do not reflect the official 

policy or position of the National Defense University, the Department of Defense or the 

U.S. Government. All information and sources for this paper were drawn from 

unclassified materials. 

Sudhir Devalia is a Research Associate at the National Defense University's Center for 

Technology and National Security Policy, where he has conducted research on various 

aspects of African security. Previously, he served as a Treasury Officer in Zambia for 

Finance Bank Ltd., and a Financial Advisor at Investor's Group, a financial planning 

company in Montreal, Canada. Mr. Devalia holds a Master of Arts in International 

Commerce and Policy from George Mason University. 

Cheryl Loeb is a Research Associate at the Center for Technology and National Security 

Policy at the National Defense University and is also a Ph.D. candidate in the Public and 

International Affairs program at George Mason University. At CTNSP Ms. Loeb works 

on health security and biological weapons proliferation threats. She may be contacted via 

email at loebc@ndu.edu or by phone at (202) 685-2397. 

Lynn McGrath Jr. is a Research Associate at the Center for Technology and National 

Security Policy. His research interests include medical diplomacy, disaster relief 

operations, and innovative use of technology in the military and medical fields. He holds 

a Bachelors degree in Neuroscience from Dartmouth College and will pursue a medical 

degree at the University of Central Florida. 

Acknowledgements: CTNSP would like to acknowledge the exceptional work of North 

American Management and the project team who developed and administered the 

pandemic influenza planning course in Nigeria under contract to CTNSP. Their hard 

work resulted in a very successful course that was lauded by all participants involved. 

The essence of their work is captured in pages 12-16 of this paper. 

Defense & Technology Papers are published by the National Defense University Center for Technology 

and National Security Policy, Fort Lesley J. McNair, Washington, DC. CTNSP publications are available 

online at http://www.ndu.edu/ctnsp/publications.html. 
iii

Contents 

Introduction......................................................................................................................................1 

Epidemics and Pandemics in Human History..................................................................................2 

Health in Africa................................................................................................................................8 

Nigeria: A Pandemic Planning Case Study ...................................................................................12 

AFRICOM and Partnering for Public Health ................................................................................17 

Conclusion .....................................................................................................................................19 
iv
1

Introduction 

Over the past 35 years, dozens of new and frightening diseases have been identified, 

among them hepatitis C virus, Ebola and other hemorrhagic viruses, Legionnaires’ 

disease, Nipah encephalitis, H5N1 influenza, SARS, the new arenavirus Lujo, which 

causes hemorrhagic fever in its victims, and, most pervasively, the human 

immunodeficiency virus (HIV/AIDS). The emergence of H5N1 avian flu in 1996, 

coupled with the recent declaration of an H1N1 influenza pandemic, demonstrate the 

urgent need for countries to have pandemic preparedness plans in place. For nations that 

are unprepared, a pandemic could result in devastating social, economic, and health 

consequences, including a high number of fatalities. Nowhere is this more so the case 

than in countries with underdeveloped health care systems. 

The potential impact of a severe pandemic requires that nations throughout the world 

develop pandemic response plans before the onset of disease. Maintaining continuity of 

operations and protecting a nations’ greatest asset, its people, during a pandemic requires 

developing effective plans before a pandemic becomes severe. These plans need to 

include such key issues as identification of roles and responsibilities, infection control, 

the identification of health care facilities, maintaining security, providing logistical 

support for food, medicine, and other commodities, communication procedures, and 

developing and distributing vaccines and antivirals. 

In recognition of the looming threat of an influenza pandemic, North American 

Management, under contract to the Center for Technology and National Security Policy 

(CTNSP), developed and administered a program to help build pandemic influenza crisisresponse capacities. We held an Avian Influenza/Pandemic Influenza Policy Planning 

workshop in Nigeria in June 2007 with the objective of assisting selected Nigerian 

officials in evaluating their nation’s pandemic response plan. After assessing the viability 

of the Nigerian National Integrated Avian and Pandemic Influenza Plan, a number of key 

action items for various Nigerian ministries were suggested. These action items would act 

to strengthen not only interagency communication and cooperation, but also the 

pandemic response in the country. 

The importance of further pandemic planning in Nigeria and neighboring countries 

cannot be understated. The current H1N1 outbreak, characterized at the time of writing 

by the World Health Organization as moderately severe, still has the potential to mutate 

and become much more deadly, necessitating the urgent need for pandemic planning. 

The recently established U.S. Africa Command, in partnership with the United States 

Agency for International Development (USAID), Pacific Command, and other 

international partners, has developed a Pandemic Response Program aimed at 

strengthening partner nations’ military capacities to plan for, and respond to, pandemics. 

The development of both military and civilian pandemic response plans in Africa, 

through the partnership of AFRICOM and other international partners, is vital in 

preparing for a severe pandemic and mitigating its consequences. 
2

Epidemics and Pandemics in Human History 

“After gasping for several hours they became delirious and ... many died struggling to 

clear their airways of a blood-tinged froth that sometimes gushed from their nose and 

mouth. It was a dreadful business.” 

--Isaac Starr, 3rd year medical student, University of Pennsylvania, 19181

There are many crises that one can imagine could lead to chaos—but perhaps none have 

the potential to affect each member of a society as profoundly as a pandemic.2

 Infectious 

disease knows no boundary, particularly one that is capable of human-to-human 

transmission, such as smallpox or influenza. As history has shown, a large outbreak of 

communicable disease can cause mass morbidity and mortality, resulting in severe social 

and economic disruption. 

In his History of the Peloponnesian War, Thucydides wrote about a “plague” that struck 

the city of Athens in the summer of 430 B.C.E. Occurring early in the Peloponnesian 

war, the epidemic lasted until 427 B.C.E. and is believed to have killed 25 to 35 percent 

of the Athenian population.3

 The outbreak of disease caused “a serious breakdown in 

respect for laws and social norms ....and that may in turn have played a longer-range role 

in what many scholars have since seen as a collapse of Athenian morality during and 

after the Peloponnesian War.”4 The “plague” described by Thucydides has never been 

identified but is believed to have been either smallpox or measles. 

The first recorded large-scale outbreak of bubonic plague, known as the Plague of 

Justinian, occurred in 541, killing thousands of people in Constantinople, Egypt, and 

elsewhere along the eastern Mediterranean, reaching as far as Italy and Tunisia by 544. 

J.N. Hays, in Epidemics and Pandemics: Their Impact on Human History, describes the 

tumultuous effects the plague had on society: 

 Witnesses agreed that the immediate effect of these plague visitations was 

catastrophic. Social confusion and economic paralysis resulted. All work ceased. 

Shops closed for lack of workers and customers. Fields were abandoned, crops 

remained unharvested, fruits fell rotten to the ground, and flocks and herds 

wandered untended in fields and pastures. Elite members of society remained 

unburied when their servants predeceased them.5

 

The second major outbreak of bubonic plague, known then as the Black Death, appeared 

in 1346. Spread by the bite of infected fleas, it swept rapidly throughout Europe and Asia 

 

1

 Isaac Starr, “Influenza in 1918: Recollections of the Epidemic in Philadelphia,” Annals of Internal 

Medicine, 2006;145:13–140, available at <http://www.annals.org/cgi/reprint/145/2/138.pdf>. 2

 Pandemics, an epidemic of infectious disease that spreads across a large population, often globally, are 

quite rare, generally occurring only 2–3 times a century or less. 

3

 J.N. Hays, Epidemics and Pandemics: Their Impact on Human History (Santa Barbara, CA: ABC-CLIO, 

Inc, 2005). 

4

 Ibid. 

5

 Ibid., 27. 
3

along maritime trade routes, killing between 30 and 40 percent of populations infected 

(some estimates are as high as 60 percent). Poor sanitation and severe overcrowding in 

cities further led to the rapid spread of disease. Small outbreaks of bubonic plague 

continued to reappear in some locations until 1667. According to one author, prior to the 

outbreak of plague, population levels in Europe were at such a height that the economic 

and social situation reflected “a world of labor surplus, land shortage, and food 

shortage—low wages, high rents, and high prices.”6

 Perversely, the outbreak of plague in 

Europe eventually brought higher wages and a better standard of living for the survivors 

due to the large number of human casualties from the disease. 

Pandemic Influenza 

The single deadliest outbreak of disease in the 20th century, and perhaps all of human 

history, was the 1918–1919 influenza pandemic. The outbreak of Spanish Flu, as it came 

to be called, occurred in late winter and early spring of 1918, with mild cases of the flu 

appearing sporadically around the globe. Beginning in August 1918, near the end of 

World War I, a second, more virulent, wave of the virus began appearing, spreading 

rapidly along trade and military troop deployment routes. Efforts to stop the spread of the 

disease were severely hampered by a lack of medical supplies and a severe shortage of 

healthcare workers healthy enough to care for those infected with the influenza virus. 

Hospitals were quickly overfilled with the sick and dying, and morgues were unable to 

deal with the large influx of corpses.7

 During the epidemic, many cities enforced social 

distancing restrictions, closing schools and banning large public gatherings in an effort to 

stem the tide of infection, to no avail. 

While the second wave of the influenza outbreak began declining worldwide by the end 

of December 1918, some countries experienced a third and final wave of the disease in 

January and February 1919. Within the space of a year the Spanish flu virus killed an 

estimated 50 million people worldwide (some estimates have placed the number as high 

as 100 million).8

 

 

6

 Ibid., 48. 

7

 John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (New York: 

Penguin Books, 2004). 

8

 “Influenza research at the human and animal interface,” WHO Working Group Report, 21-22 September, 

2006, available at <http://www.who.int/csr/resources/publications/influenza/ WHO_CDS _EPR _GIP 

_2006_3C.pdf>. 
4

Two more flu pandemics occurred in the 20th century. The 1957 flu (H2N2 type A 

influenza), named the Asian flu for where cases were first identified, caused roughly two 

million deaths worldwide and about 69,800 deaths in the United States.9 The third 

pandemic was first detected in Hong Kong in 1968. The Hong Kong influenza (H3N2 

type A influenza) resulted in less than one million deaths worldwide, with roughly 34,000 

deaths in the United States (this is roughly equal to the number of mortalities that occur 

in the United States during the annual seasonal flu). 

H5N1 –Avian Influenza 

In 1996, epidemiologists discovered an entirely new variety of type A influenza, known 

as subtype H5N1, when it was first isolated from a farmed goose in Guangdong, China. 

In 1997, a massive outbreak of H5N1 avian influenza occurred in Hong Kong poultry 

markets, resulting in 18 cases of bird-to-human transmission of the virus and six deaths. 

A rapid culling of over 1.5 million birds in just three days is thought to have averted 

further transmission of the virus.10 

Since the initial outbreak of avian influenza in poultry and humans in Hong Kong in 

1997, there have been hundreds of cases of human infections throughout the world. As of 

September 24, 2009, the World Health Organization (WHO) reported that there have 

been 442 human cases of H5N1 reported in 15 countries, 262 of which have been fatal.11

H5N1 outbreaks have led to mass culling of infected bird populations, increased disease 

surveillance, including passenger screening at airports, vaccine and antiviral 

development, and pandemic response planning. 

 

9

 U.S. Department of Health and Human Services, “Pandemics and Pandemic Scares in the 20th Century,” 

February 12, 2004, available at <http://www.hhs.gov/nvpo/pandemics/flu3.htm>. 10 World Health Organization, “H5N1 avian influenza: Timeline of major events,” March 23, 2009, 

available at <http://www.who.int/csr/disease/avian_influenza/Timeline_09_03_23.pdf>. 11 World Health Organization, “Cumulative Number of Confirmed Human Cases of Avian Influenza 

A/(H5N1) Reported to WHO,” September 24, 2009, available at 

<http://www.who.int/csr/disease/avian_influenza/country/cases_table_2009_09_24/en/index.html>. 

Understanding Influenza Viruses 

Influenza viruses are classified as type A, B, or C, based on their protein 

composition. Type A viruses are found in many kinds of animals, including ducks, 

chickens, pigs, and humans. Type A is the most common and typically causes the 

most serious epidemics and pandemics in humans. Type A viruses are subdivided 

into groups based on two surface proteins: Hemagglutinin (HA) and Neuraminidase 

(NA). Scientists have characterized 16 HA subtypes and 9 NA subtypes. Scientists 

have identified the 1918-1919 pandemic causing virus as an H1N1 type A virus. 

Source: Jeffrey K. Taubenberger and David M. Morens, “1918 Influenza: The Mother of all 

Pandemics,” Emerging Infectious Diseases, January 2006, available at 

<http://www.cdc.gov/ncidod/eid/vol12no01/05-0979.htm>.
5

In light of the potential threat of an H5N1 pandemic, the World Health Organization 

launched an influenza tracking system, is working on the development of new 

recombinant H5N1 vaccine viruses, and has developed guidance documents on infection 

control, diagnosis and treatment, disease surveillance, and laboratory procedures for 

detection of H5N1 virus, to name a few.12 

H1N1 Pandemic Influenza 

In early April 2009, reports began to surface in Mexico of an unusual outbreak of disease. 

Patients began showing up at hospitals symptomatic with fever, cough, vomiting, and, in 

some patients, acute respiratory infections and pneumonia. In late April, the U.S. Centers 

for Disease Control activated its Emergency Operations Center when cases of the disease 

appeared in California, where scientists identified it as novel A influenza virus, H1N1. 

On April 26, with cases of H1N1 identified in Canada, Mexico, and the United States, the 

United States Government declared a public health emergency, which allowed for the 

rapid shipment of the antivirals Tamiflu and Relenza from the strategic national 

stockpile. 

The spread of H1N1 prompted the World Health Organization to declare the outbreak a 

pandemic on June 11, 2009: 

Globally, we have good reason to believe that this pandemic, at least in its early 

days, will be of moderate severity. As we know from experience, severity can 

vary, depending on many factors, from one country to another. On present 

evidence, the overwhelming majority of patients experience mild symptoms and 

make a rapid and full recovery, often in the absence of any form of medical 

treatment.13

The WHO ranks pandemics in six levels (the WHO phases refer to the geographic spread 

of the virus vice the severity of it): 

• Phase 1: no viruses circulating among animals have been reported to cause 

infections in humans. 

• Phase 2: an animal influenza virus circulating among domesticated or wild 

animals is known to have caused infection in humans, and is therefore considered 

a potential pandemic threat. 

• Phase 3: an animal or human-animal influenza reassortment virus has caused 

sporadic cases or small clusters of disease in people, but has not resulted in 

human-to-human transmission sufficient to sustain community-level outbreaks. 

Limited human-to-human transmission may occur under some circumstances. 

 

12 World Health Organization, “Pandemic (H1N1) 2009 briefing note 3 (revised),” July 16, 2009, available 

at <http://www.who.int/csr/disease/swineflu/notes/h1n1_surveillance_20090710/en/index.html>. 13 Margaret Chan, World Health Organization, “World now at start of 2009 influenza pandemic,” June 11, 

2009, available at <http://www.who.int/mediacentre/news/statements/2009/ 

h1n1_pandemic_phase6_20090611/en/index.html>. 
6

• Phase 4: is characterized by verified human-to-human transmission of an animal 

or human-animal influenza reassortment virus able to cause “community-level 

outbreaks.” 

• Phase 5: is characterized by human-to-human spread of the virus into at least two 

countries in one WHO region. While most countries will not be affected at this 

stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent 

and that the time to finalize the organization, communication, and implementation 

of the planned mitigation measures is short. 

• Phase 6: is the pandemic phase. It is characterized by community level outbreaks 

in at least one other country in a different WHO region in addition to the criteria 

defined in Phase 5. Designation of this phase will indicate that a global pandemic 

is under way.14

By October 17, 2009, the WHO had reported more than 414,000 laboratory confirmed 

cases of H1N1 influenza infections, and 5,000 confirmed deaths worldwide.15 However, 

as many countries have stopped counting individual cases, the actual case count is likely 

significantly higher, with some estimates in the millions of cases worldwide. 

Scientists and health officials will continue to monitor the disease as the Northern 

hemisphere enters its annual influenza season. There is a potential for the virus to mutate 

during this time and re-emerge at a later date, causing a much more severe form of 

disease. This is due to processes called antigenic drift and antigenic shift. In antigenic 

 

14 World Health Organization, “Current WHO phase of pandemic alert,” available online at 

<http://www.who.int/csr/disease/avian_influenza/phase/en/>. 

15 World Health Organization, “Pandemic (H1N1) 2009 –Update 71,) October 17, 2009, available at 

<http://www.who.int/csr/don/2009_10_23/en/index.html>. 

Pandemic Severity Index 

The U.S. Centers for Disease Control and Prevention has also developed a five-level 

pandemic severity index (PSI), similar to the system for categorizing hurricanes. 

The proposed PSI has five different categories of pandemics. Category 1 represents 

moderate severity and category 5 represents the most severe. The severity of a 

pandemic is primarily determined by the case fatality rate, or percentage of infected 

people who die. A category 1 pandemic is as harmful as a severe seasonal influenza 

season, while a pandemic with the same intensity of the 1918 flu pandemic, or 

worse, would be classified as category 5. 

Source: U.S. Department of Health and Human Services, “HHS Unveils Two New Efforts to 

Advance Pandemic Flu Preparedness,” February 1, 2007, available at 

<http://www.hhs.gov/news/press/2007pres/ 20070201.html>. 
7

drift, gradual changes occur through point mutations in two main surface proteins, 

hemagglutinin and neuraminidase. These mutations can cause minor changes to the 

surface proteins, resulting in new virus strains that may not be recognized by antibodies 

developed in response to previous influenza strains.16 Antigenic shift refers to an abrupt, 

major change that produces a novel influenza A virus that was not previously circulating 

in humans. This can occur through direct animal-to-human transmission or through 

mixing of human influenza A and animal influenza A virus genes. In this case, 

individuals are unlikely to have antibodies from previous influenza strains, making the 

population more susceptible to infection.17 

Given pandemic influenza’s potential to cause massive loss of life (if, in fact, the virus 

goes through antigenic shift), it is important that a nation have in place a proper action 

plan to protect its people and ensure the continuity of operations essential to the 

maintenance of a viable state. While the importance of U.S. domestic preparedness is 

obvious, the nature of a pandemic requires that we also consider the implications for our 

national security of poorly prepared nations abroad. As the former Director General of 

the WHO, Gro Harlem Brundtland has stated, “in a globalized world, we all swim in a 

single microbial sea.”18 

 

16 Centers for Disease Control and Prevention, “Influenza Viruses,” November 18, 2005, available at 

<http://www.cdc.gov/flu/avian/gen-info/flu-viruses.htm>. 

17 Ibid. 

18 Brundtland, G.H, “Address to the Codex Alimentarius Commission meeting,” July 2-7, 2001. 
8

Health in Africa 

Few places on earth demonstrate the devastating effects widespread disease can have on a 

society as clearly as Africa. Indeed, in sub-Saharan Africa, more than 60 percent of all 

deaths are due to infectious disease.19 Outbreaks of cholera and Ebola occur frequently in 

Africa, and HIV and malaria are endemic throughout the continent. In 2006 alone, 

malaria was declared endemic in 45 countries in Africa, with over 212 million cases and 

roughly 800,000 deaths, 91 percent of which were in children under 5 years of age.20 In 

urban areas the danger is exacerbated by population density, unsanitary living conditions, 

and unhygienic water sources. In Zimbabwe, for example, from August 2008 to June 

2009, 98,000 cases of cholera and over 4,000 deaths were reported that were attributable 

to unsanitary living conditions and lack of medical care.21 

African countries have to deal with many diseases, and widespread poverty means that 

they are less able to combat them. At the personal level this means inability to afford 

such necessities as household cleaning products, soap, and mosquito nets. It can also 

mean a village farmer refusing to cull protein-rich poultry in an avian influenza outbreak, 

or a patient unable to afford vaccines, antivirals, or other prophylactics. At the national 

level, a lack of government funds has meant a reduction in capacity of the health care and 

education sectors. In the health care sector this has led to fewer clinics with fewer beds, 

and outdated medical equipment run by underpaid medical staff. For every 10,000 people 

in the Democratic Republic of Congo (a hotbed for disease due to its tropical climate), 

only eight hospital beds and one physician are available, compared to 31 beds and 26 

physicians in the United States.22 Due to a lack of funding, few government-subsidized 

medicines are available and transport and infrastructure weaknesses hamper their 

distribution to remote areas. 

A dearth in the education sector has similar consequences. Fewer schools and a low 

standard of education have led to entire populations unable to understand what HIV is 

and how it is transmitted.23 Locally educated doctors and nurses have learned their trade 

in educational institutions limited by lack of both equipment and skilled professors, 

making available treatment basic in nature, and research and development on 

pharmaceuticals almost non-existent. During the 2008 outbreak of the “Lujo virus” in 

South Africa, for example, an infected individual in Zambia could not be treated for the 

disease and had to be airlifted to South Africa for treatment, resulting in four deaths in 

 

19The Global Health Council, “The Impact of Infectious Diseases,” available at 

<http://www.globalhealth.org/infectious_diseases/>. 

20 Global Malaria Partnership, “Key malaria facts,” 2008, available at 

<http://www.rollbackmalaria.org/keyfacts.html>. 21 World Health Organization, “Cholera in Zimbabwe: Update 4,” June 9, 2009, available at 

<http://www.who.int/csr/don/2009_06_09/en/index.html>. 

22 World Health Organization, “World Health Statistics 2009: Health workforce, infrastructure, essential 

medicines,” available at <http://www.who.int/whosis/whostat/EN_WHS09_Table6.pdf>. 23 In a 2006 rape trial, now-President Jacob Zuma of South Africa admitted having unprotected sex with his 

HIV-positive accuser, saying he showered afterwards to stop infection. More information available at 

<http://www.nytimes.com/2006/05/08/world/africa/08cnd-africa.html?scp=6&sq=zuma%20hiv&st=cse>. 
9

both countries. The identification of the virus and all genetic testing was done in the 

United States as neither African country had the means to do so.24

African countries unable to cope with health issues are further burdened by the high 

prevalence of HIV in their populations. The average life expectancy in many sub-Saharan 

African countries has plummeted in recent years, leaving even relatively prosperous 

countries such as South Africa with a life expectancy of just 49 years because of an HIV 

prevalence of over 18 percent.25 In 2007, sub-Saharan Africa, which is home to 12 

percent of the world’s population, accounted for two-thirds of the world’s HIV-positive 

population, an estimated 22 million cases.26 HIV has caused a contraction in human 

capital, a shortage of teachers and doctors, and a surge of orphans that governments can 

not support. It has afflicted African societies from the remotest of villages to the highest 

echelons of society and has caused a “hollowing out” effect that has weakened essential 

state infrastructures, priming states for internal collapse and regional conflict. 

Highly Virulent H5N1 Avian Influenza in Africa 

Our early research on pandemic influenza planning took place in Nigeria. Highly 

pathogenic H5N1 was first detected in chickens in the northern Nigerian state of Kaduna 

in January 2006. H5N1 quickly spread to 25 of 26 Nigerian states and led to the culling 

of roughly 368,000 domestic birds.27 

Nigeria acts as the wintering area for the garganey (Anas querquedula), the most 

numerous waterfowl species migrating between Africa and Eurasia.28 In a study 

investigating the impact of migration routes for Nigeria, the CDC found that “the 

wintering area in Nigeria where this duck was caught and remained for 8 weeks before 

spring migration is located where a large number of outbreaks have occurred repeatedly 

since February 2006.”29 

Scientists now believe that some migratory waterfowl, carrying the H5N1 virus, have 

travelled along their traditional migratory routes and introduced H5N1 influenza to 

various poultry flocks, thus spreading the disease across long distances and introducing it 

to new populations (see figure 1). In mid-2005, for example, more than 6,000 migratory 

 

24 Thomas Briese, et al, “Genetic Detection and Characterization of Lujo Virus, a New Hemorrhagic FeverAssociated Arenavirus in Southern Africa,” PLoS Pathogens, May 2009, available at 

<http://www.plospathogens.org/article/info%3Adoi%2F10.1371%2Fjournal.ppat.1000455>. 25 Central Intelligence Agency, “World Fact Book: South Africa,” available at <https://www.cia.gov/ 

library/publications/the-world-factbook/geos/sf.html>. 

26 UNAIDS, “2008 Report on the Global Aids Epidemic: Annex HIV and AIDS estimates and data, 2007 

and 2001,” 2008, available online at <http://data.unaids.org/pub/GlobalReport/2008/jc1510 

_2008_global_report_pp211_234_en.pdf>. 

27 Fusaro A, Joannis T, Monne I, Salviato A, Yakubu B, Meseko C, et al, “Introduction into Nigeria of a 

distinct genotype of avian influenza virus (H5N1),” Emerging Infectious Disease, March 2009, available at 

<http://www.cdc.gov/EID/content/15/3/445.htm>. 

28 Gaidet N, Newman SH, Hagemeijer W, Dodman T,‡ Cappelle J, Hammoumi S, et al, “Duck migration 

and past influenza A (H5N1) outbreak areas,” Emerging Infectious Disease, July 2008, available at 

<http://www.cdc.gov/EID/14/7/1164.htm> 

29 Ibid. 
10

Many water birds (ducks, geese, swans) migrate between wetlands in the northern breeding areas and 

southern non-breeding areas, regularly crossing the borders of two or more countries. The birds can 

cover up to 1,000 miles per day. Source: World Food Program Emergency Preparedness and 

Response Branch.

birds, infected with highly pathogenic H5N1, died at the Qinghai Lake nature reserve in 

central China. “Scientific studies comparing viruses from different outbreaks in birds 

have found that viruses from the most recently affected countries, all of which lie along 

migratory routes, are almost identical to viruses recovered from dead migratory birds at 

Qinghai Lake.”30 Further, in a recently published study, a group of scientists identified 

three distinct sublineages of H5N1 circulating across Africa from 2006 to 2008. One of 

these sublineages can be traced back to the outbreak of H5N1 in migratory waterfowl at 

China’s Qinghai Lake in 2005.31 

Figure 1. Waterfowl Flyways 

 

30 World Health Organization, “Avian Influenza (bird flu): The Disease in Birds,” February 2006, available 

at <http://www.who.int/mediacentre/factsheets/avian_influenza/en/#role>. 31 Giovanni Cattoli, et al, “Highly Pathogenic Avian Influenza Virus Subtype H5N1 in Africa: A 

Comprehensive Phylogenetic Analysis and Molecular Characterization of Isolates,” PLoS, March 2009, 

available at <http://www.plosone.org/article/info:doi/10.1371/journal.pone.0004842>. 
11

Another possible way for the virus to circulate to countries not previously affected with 

H5N1 is through trade in poultry. Failure to use proper sanitation techniques and conduct 

inspections of the poultry could lead to the sale and distribution of infected poultry to 

new locations. 

Nigeria is not the only African country affected by outbreaks of highly pathogenic avian 

H5N1. Since the initial outbreak in Nigeria in 2006, outbreaks have occurred in Benin, 

Burkina Faso, Cameroon, Cote d’Ivoire, Djibouti, Egypt, Ghana, Niger, Sudan, and 

Togo.32 Of the outbreaks of H5N1 in Africa, human cases of infection have occurred in 

Djibouti, Nigeria, and Egypt. As of September 24, 2009, Egypt had reported 87 

confirmed cases, with 27 fatalities. In many of these cases individuals infected with 

H5N1 had close contact with sick or dead poultry.33 

H1N1 in Africa 

Africa has also begun to report its first cases of pandemic H1N1 influenza. 26 African 

countries have reported a total of 13,536 laboratory confirmed cases of human infection 

with H1N1, including 75 deaths.34 Countries that have developed, or begun developing 

pandemic H5N1 response plans will need to quickly adapt the plans to respond to 

pandemic H1N1 before the virus spreads further into Africa. Weak health infrastructures, 

limited disease surveillance capabilities, and a whole host of underlying health issues 

such as large populations of HIV-infected individuals, will only exacerbate the potential 

devastating effects a serious H1N1 pandemic could have in Africa. 

 

32 World Organization for Animal Health, “Outbreaks of Avian Influenza (subtype H5N1) in poultry. From 

the end of 2003 to 11 April 2007, available at <http://www.oie.int/downld/AVIAN%20INFLUENZA/ 

Graph%20HPAI/graphs%20HPAI11_04_2007.pdf>. 

33 World Health Organization, “Avian influenza – situation in Egypt – update 23,” September 24, 2009, 

available at <http://www.who.int/csr/don/2009_09_24/en/index.html>. 

34 World Health Organization, Regional Office for Africa, “Pandemic (H1N1) 2009 in the African Region: 

Update 54,” October 19, 2009, available at <http://www.afro.who.int/ddc/influenzaa/index.html>. 
12

Nigeria: A Pandemic Planning Case Study 

In recognition of the threat of an avian influenza pandemic, North American 

Management, under contract to the Center for Technology and National Security Policy 

(CTNSP), developed and administered a program to help build pandemic influenza crisisresponse capacities in Nigeria. The strategic goal of CTNSP in providing this course of 

instruction was to work with the authors of the Nigerian National Integrated Avian and 

Pandemic Influenza Plan (National Plan) to assist them in defining an appropriate role for 

the Nigerian military in preserving national security during an influenza pandemic. 

To achieve this aim, in June 2007, the project team developed a 41⁄2-day Avian 

Influenza/Pandemic Influenza (AI/PI) Policy Planning workshop (see figure 2 for the 

curriculum). The Nigerian participants were representatives from the Departments of 

Agriculture, Health, and Information, as well as members of the Pandemic Influenza 

Control Center. 

The primary focus of the workshop was to assist the attending Nigerian Ministerial 

officials in exercising and evaluating their nation’s pandemic response plan, with the goal 

of furthering their understanding of potential national security implications pandemic 

influenza could produce. A secondary goal was to understand the area of responsibility 

for military preparedness for pandemic influenza and identify the range of detection, 

response, and containment roles the Nigerian military might be tasked to perform prepandemic, intra-pandemic, and post-pandemic. 

Figure 2. Avian Influenza/Pandemic Influenza Policy Planning Course Curriculum 

A secondary goal was to define the Nigerian military’s Area of Responsibility (AOR) in 

preparing for pandemic influenza and to identify the range of detection, response, and 

containment roles the military may be tasked to perform throughout the pandemic alert 

and pandemic periods. Several case studies were used in the training to uncover these 

details – —studying the gaps in planning in New Orleans in the wake of Hurricane 

Katrina was particularly emphasized. The training exercises provided were designed to 

identify coordinated actions required within Nigeria’s military and civilian agencies to 

plan for, respond to, contain, and mitigate a pandemic influenza event; and to identify 

critical seams and gaps in planning and responding to pandemic influenza. 

The training agenda, pictured in Figure 2, outlines the exercises which took place at the 

National War College, in Abuja, Nigeria. The exercises were designed to emulate the 

type of classroom experience offered at the U.S. National War College at the National 

Defense University. 

 Preparing for the Pandemic 

o Understanding the virus (discussion of H5N1 and the methods of 

transmission) 

o Communicating the risk: development of culturally relevant materials 

(strategic communication plan) for distribution to the population. 

 Planning for the Pandemic 

o Assessing the national infrastructure (ability to maintain food 

availability and other essential services) 

o Identifying workforce availability and preparation of continuity of 

operations plans (COOP) 

o Developing medical and non-medical response plans 

 Managing the Pandemic 

o All-day table-top exercise drawing on work of the previous three days 

 After Action Review 

o Assessment of course objectives completion 

o Provide recommendation for follow on action plan, i.e. advanced Avian 

Influenza /Pandemic Influenza Senior Leadership Planning Course, 

Conference on Development of AI/PI National Response Plan 
13

Analyzing the National Integrated Avian and Pandemic Influenza Plan 

On June 13, 2007, eight of the workshop participants attended a “Technical Committee” 

of the Nigerian AI/PI planning group. The purpose of the AI/PI planning group was to 

discuss the strengths and weaknesses of the National Plan and suggest ways of filling in 

the gaps. The authors of Nigeria’s National Plan, primarily representatives from the 

Ministries of Health, Agriculture, and Information, initially wanted to keep the working 

group to a small number by including only those entities that would, in their eyes, “add 

value to the process.” This definition lead to a planning group composed exclusively of 

representatives from the Ministries of Agriculture, Health, and Information, and members 

of the Pandemic Influenza Control Center. 

As a direct result of the program, the AI/PI planning group later identified a number of 

areas in which significant work was required to develop a full National Plan. Some of the 

most pressing areas included: the absence of specific roles for the Red Cross, nongovernmental organizations (NGOs), and the Nigerian military, a lack of a national 

security perspective, a weak administrative structure requiring strong agency “support 

plans,” and the absence of decision points for declaring a state of emergency. 

According to the seminar participants, planning for the development of the new National 

Plan is one of the first times there has been extensive inter-ministry coordination. 

Normally, the ministries work independently of one another, however, the AI/PI issue 

brought them together. Furthermore, the Nigerian armed forces had been mentioned just 

once in the 72 pages of the March 22, 2007 draft of the National Plan. The workshop 

discovered that, until the seminar, the issue of the military’s role had not been carefully 

considered. The three departments (Agriculture, Health, and Information) responsible for 

drafting the document agreed that the military played an integral part of maintaining 

order in a peaceful democratic country and needed to be included in any future pandemic 

planning. When the participants returned in the afternoon to the workshop, they reported 

that the military and civil defense organizations were from that point forward to be 

invited into the planning efforts. 

While it was recognized that the National Plan is a fluid document, the participants stated 

that “you have to put your plan into action, even if it is incomplete;” and to “go with the 

plan you have and continuously revisit it.” It was the intention of the workshop 

participants to implement the current plan as it was and to continue to enhance it with the 

support of several of the ministries that were not previously part of the initial planning 

process (i.e., Defense and Civil Defense). 

 

The Value of the Military in Domestic Preparedness 

The military’s role in preparing for a pandemic can be defined as defending the nation by 

filling logistical gaps under the command of civilian authorities. The command structure 

under civilian authority was emphasized as the basis for success, particularly where 

communal conflict was occurring or expected. 
14

In many countries, the military is considered the only institution capable of filling certain 

logistical roles (i.e., providing air transport, 24/7 security, mass distribution of key 

resources in multiple locations). Their ability to perform these functions is predicated on 

their being self-contained and self-sustaining. The military is uniquely able to rapidly 

deploy trained personnel, maintain an independent organized health care structure, and 

exercise unified command and control. Thus, the military can provide unparalleled 

resource allocation to civilian agencies through robust personnel, transportation, and 

communication capabilities, without being an additional burden to the civilian systems. 

It is, therefore, imperative that Nigerian military representatives be involved in any future 

preparedness activities—specifically pandemic influenza exercises, participation in 

disaster response units, and the conduct of force health protection training. Based on 

discussions held during the June 2007 workshop in Nigeria, a list of proposed action 

items for the Ministry of Defense were identified: 

• Assist civil response (Borders, Law Enforcement) 

• Regulate poultry in barracks (Agriculture) 

• Create awareness in barracks (Information) 

• Poultry and human monitoring 

• Report outbreaks to civilian authority through proper channels 

• Request information that may impact military readiness 

• Strengthen military health facilities (Health) 

• Designate quarantine facilities on military bases 

These planning functions were derived from the areas where the military would be 

involved in the response phase. In a severe pandemic event, typical support roles for the 

military would include operating in a single unified command structure under civilian 

leadership, providing command, control, and communications infrastructure, affording 

logistical assistance to first responder NGOs, including the Red Cross, and establishing a 

joint task force to coordinate efforts from all branches. 

The most recent and updated version of the National Plan does a better job of 

incorporating the military into the planning process, however, their role is mentioned 

only briefly in the document and we recommend that it continue to be further expanded: 

In the early stages of pandemic emergence, the efforts of Government may be 

overwhelmed. It is envisaged that the armed forces, security agencies, and 

paramilitary forces (customs, immigration and prison officers) may be called 

upon to support pandemic containment activities at their source. They will then 

be called upon to provide vehicles, aircraft and operators to move personnel, 

equipment and supplies, as requested by the APIP&CC [Avian and Pandemic 

Influenza Prevention and Control Centre]; provide logistical support and 

air/ground transportation of disaster relief supplies, personnel and equipment; 

provide personnel and equipment for triage and emergency medical care and 

portable medical aid stations; provide space, as available to serve as resource 
15

staging areas; and provide/and or coordinate traffic control and expedited routing 

for supply missions or personnel movements.35

Next Steps for Ministries of Health, Agriculture, and Information 

In addition to the drafting of an improved National Plan, every Ministry that was a 

member of the initial Steering Committee and an author of the original National Plan 

agreed to draft a Ministry Support Plan that would address the execution of each element 

of the National Plan from that Ministry’s perspective. Utilizing the knowledge gained in 

the training seminar, each Ministry also agreed to draft their Support Plan with the role of 

the military in mind. Further, a list of proposed action items for the Ministries of 

Agriculture, Health, and Information were identified. These action items provide a useful 

guide for other African countries in the process of developing national pandemic 

influenza response plans. They show the types of activities that should be included in 

pandemic planning. 

Ministry of Agriculture: 

• Surveillance in poultry farms and markets 

• Strengthen and enforce bio-security measures 

• Frequent cleaning of poultry farms 

• Strengthen regional laboratories to diagnose influenza subtypes 

• Upgrade veterinary quarantine services at borders (equipment, training, etc.) 

• Control movement of poultry and poultry products 

• Register all poultry farms (locations, operations) 

• Program for alternative livelihood (rehabilitation) 

• Continue robust compensation program 

Ministry of Health: 

• Mobilize trained medical personnel 

• Increase stockpiles of antivirals 

• Develop protocols for access to stockpiles 

• Standard operating procedures for pharmacological intervention 

• Public personal protective measures and education 

• Identify isolation facilities 

• Active surveillance and contact tracing 

• Health risk communication 

• Activation of national and international health regulations 

 

35 Government of Nigeria, “Integrated National Avian and Pandemic Influenza Pandemic Influenza 

Response Plan 2007-2009,” available at <http://nigeria.gov.ng/NR/rdonlyres/44FA9DCA-AFEF-4C0E8076-0C78984A175D/808/NIGERIAINTEGRATEDNATIONALAVIANAND 

PANDEMICINFLUENZA.pdf>. 
16

Ministry of Information: 

• Public information campaign and national press conference coordination with 

Agriculture, Health, and Defense 

• Mobilize states’ Ministry of Information for downstream information 

management 

• Provision of public education via mass media coordination with Agriculture, 

Health, Defense, and Police 

• Distribution of Information, Education, and Communication (IEC) materials 

(military and police support) 

• Feedback mechanism coordination with NGOs, Community Based Organizations, 

(CBOs), and traditional rulers 

According to the participants in the workshop, one of the most valuable lessons for them 

as a group was the newfound understanding of the importance of collaboration and 

communication between the various ministries. In a demonstration of this new paradigm, 

the ministries proposed a number of ways their agencies could collaborate. The 

participants identified opportunities to work cooperatively on issues such as the control of 

poultry movement and quarantine, ensuring continuity of the food supply, public 

education campaigns, medical waste management, carcass disposal, poultry culling 

oversight, capacity building for the military on AI/PI, activation of the command 

structure (Ministers, Governors), and conducting of simulations with participation from 

all stakeholders. Each of the above actions requires the involvement of a wide range of 

ministries, and their collaboration requires practiced interagency communication. 
17

AFRICOM and Partnering for Public Health 

“Improving the health infrastructure in African nations is a ‘productive and nonthreatening’ way to build stability on the continent” 

- Dr. (Col) Schuyler Geller, Command Surgeon of U.S. Africa Command 

On October 1, 2008, U.S. Africa Command (AFRICOM) was declared a fully unified 

command. One of six Department of Defense regional military headquarters, 

AFRICOM’s mission is to conduct sustained security engagement with African nations 

through military-to-military programs, military-sponsored activities, and other military 

operations as directed, to “create a stable and secure African environment in support of 

U.S. foreign policy.”36 As part of its strategic objectives, AFRICOM has identified 

protecting populations from deadly contagions, and in particular, deterring and containing 

pandemic influenza in Africa, as one of its priority objectives. 

AFRICOM has stated that it views health as a “bridge to peace and security,” and has 

developed an impressive number of health initiatives focused on Africa, including the 

Pandemic Response Program (PRP). In partnership with USAID, U.S. Pacific Command, 

and other international partners, such as the World Food Program, AFRICOM is 

spearheading a multi-year pandemic response program aimed at strengthening partner 

African national military capabilities to respond to pandemic influenza in the context of 

larger national pandemic preparedness and response plans. The PRP is part of the much 

broader USAID International Partnership on Avian and Pandemic Influenza (IPAPI) 

effort aimed at enhancing global pandemic preparedness. To date, USAID has already 

committed $543 million to international pandemic prevention and readiness issues.37 

The PRP recognizes that national militaries have a critical role in health crisis response 

by providing logistical support for the transfer of food and medical supplies to pandemicaffected regions, protecting medical staff, maintaining communications, and maintaining 

order and security in a time of uncertainty.38 In an effort to assist African counties in the 

development of civil-military response plans, partners of the PRP will “train senior and 

mid-level military leaders in disaster management and humanitarian assistance, with a 

particular focus on pandemic preparedness; to ensure that militaries in targeted 

‘pandemic preparedness’ countries have developed detailed plans of action directly 

supporting national plans; and to conduct exercises to test the implementation of these 

plans and identify gaps or deficiencies.”39 

 

36 AFRICOM, “Fact Sheet: AFRICOM Posture Statement: Ward Updates Congress on U.S. Africa 

Command,” March 12, 2008, available at <http://www.africom.mil/getArticle.asp?art=1799>. 37 USAID, “Avian and Pandemic Influenza: Preparedness and Response,” June 4, 2009, available at 

<http://www.usaid.gov/our_work/global_health/home/News/news_items/avian_influenza.html>. 38 AFRICOM, “International Conference Focuses on Civil-Military Influenza Pandemic Response Plans,” 

May 19, 2009, available at <http://www.africom.mil/getArticle.asp?art=3030>. 

39 Ibid. 
18

The PRP comes at a vital time in pandemic influenza planning. With the recent WHO 

declaration of an H1N1 pandemic, many African nations need immediate assistance in 

the development of civil and military pandemic response plans. During an influenza 

pandemic it is estimated that up to 40 percent of an organization’s staff may be absent at 

any time. For a nation that is already hosting a large population of immuno-compromised 

individuals—such as an African nation with high rates of HIV or AIDS patients—the 

absenteeism rate will likely skyrocket. As a result, an influenza pandemic may be most 

devastating in fragile democracies where stability is constantly in jeopardy. These states 

are significant due to their vulnerability and the consequently greater need for them to 

develop a strong action plan. To be most effective in preserving a state’s human capital, 

preparations for an influenza pandemic must focus on the readiness issue—particularly in 

a state with a medical establishment that will assuredly not be able to handle the stresses 

created by a pandemic.40 An international presence, such as is being developed by the 

AFRICOM PRP, may be helpful in preventing an untoward outcome by assisting in the 

development of a contingency plan and thorough training of military personnel to ensure 

its execution.41

 

40 Robert Armstrong et al., “Weathering the Storm: Leading Your Organization Through a Pandemic,” 

Defense and Technology Paper 38 (Washington, DC: Center for Technology and National Security Policy, 

November 2006), available at <http://www.ndu.edu/CTNSP/Def_Tech/DTP%2038% 

20Weathering%20The%20Storm.pdf>. 

41 One potential partner outside of African national militaries for the PRP to engage with is the Economic 

Community of West African States (ECOWAS). Founded in 1975, ECOWAS is a regional group of fifteen 

West African countries. Among the agencies under ECOWAS is the West African Health Organization 

(WAHO). Civilian components under the PRP, such as USAID, could potentially engage with WAHO in 

pandemic preparedness planning for governments in Africa, thus ensuring national governments and 

militaries have cohesion in their planning. 
19

Conclusion 

In the opinion of the participants from the various Nigerian Ministries and the Nigerian 

military, the workshop “was a huge success.” However, they also recognized that the 

interdependencies they discovered throughout the workshop need further refinement and 

assignment of responsibility. In recognition of these lingering deficiencies, many 

participants requested additional training in their post-workshop comments. 

A further concern of the participants in the training workshops was the universal belief 

that a “pandemic knows no boundaries.” The National Integrated Avian and Pandemic 

Influenza Plan Steering Committee members have addressed, and will continue to refine 

through their respective agency support plans, the issues of border control in the event of 

a pandemic incident. However, they were concerned that their neighboring countries have 

not developed plans or strategies to address a pandemic. To support the integrity of the 

National Integrated Avian and Pandemic Influenza Plan, it is essential to provide similar 

training to border countries and the guidance necessary to operationalize each of their 

national pandemic plans. 

The unresolved concerns of the Nigerian participants present an opportunity for 

AFRICOM and its Pandemic Response Program partners to help selected African 

partners build their pandemic response capabilities. The recent declaration of an H1N1 

pandemic demonstrates the urgent necessity for countries to have pandemic response 

plans in place and the necessity for continued international aid resources devoted to 

assisting our partner nations in pandemic response planning and mitigation.