Building a National Infection Prevention and Control Programme: the ‘Turn Nigeria Orange’ Programme, 2019–2023

Abstract

Strong infection prevention and control (IPC) programmes are critical to reducing the burden of healthcare-associated infections and antimicrobial resistance (AMR), yet many low- and middle-income countries (LMICs) lack functional IPC programmes at national and health facility levels. Nigeria prioritised the development of a national programme to provide leadership and coordination for IPC activities throughout the country’s healthcare system following a series of outbreaks and gaps identified during the development of the National Action Plan for AMR. We aim to describe the stepwise, evidence-based approach we used to establish and implement Nigeria’s National IPC Programme during its first 5 years. This includes the formation and structure of the IPC Programme within the Nigeria Centre for Disease Control and Prevention; assessment of national and tertiary health facility-level IPC programmes to prioritise interventions; development of a structured implementation strategy (the ‘Turn Nigeria Orange’ programme); publication of national IPC guidelines and revision of the national IPC policy; collaboration with a local university and professional societies to establish a national IPC curriculum and IPC training and mentorship programmes; and establishment of a network of health facilities to strengthen facility-level implementation (the ‘Orange Network’). The development of each was guided by the WHO’s core components of IPC programmes, evidence-based guidelines which aim to inform the development of effective IPC programmes. The implementation approaches, successes and challenges that we share add to the limited existing literature and can serve as a practical example for other countries, particularly LMICs when establishing and implementing IPC programmes.

Summary box.

• Poor infection prevention and control (IPC) practices in health facilities in Nigeria have led to disease transmission among patients, healthcare workers and communities.

• The Nigeria Centre for Disease Control and Prevention established a National IPC Programme in 2019 to provide leadership and coordination for IPC activities throughout Nigeria’s healthcare system.

• Nigeria’s National IPC Programme used a structured implementation strategy and a network of public tertiary health facilities to strengthen national-level and facility-level implementation, developed in line with the WHO’s core components of IPC programmes.

• Nigeria’s IPC programme implementation approach and lessons learned can serve as an example for other countries building national-level and facility-level IPC programmes.

Introduction

Healthcare-associated infections (HAIs) are among the most common adverse events in healthcare reported worldwide¹ and are a major challenge for patient safety globally and in Nigeria. Because of the paucity of nationally representative HAI data, most HAI surveillance data from Nigeria are based on studies from single health facilities,² making extrapolation difficult. Based on a review of ten studies from tertiary health facilities, WaterAid estimated that an average of 18.2% (range: 12.8%–24.0%) of admitted patients were infected with an HAI in Nigeria in 2022.³ The impacts of HAIs include prolonged hospital stays, long-term disability, worsening antimicrobial resistance (AMR), financial burden for health systems, high costs for patients and families and preventable deaths. The total economic cost of HAIs in Nigeria in 2022 was estimated at US$4.5 billion, and these infections resulted in an estimated 93 600 deaths.³ The burden of HAIs is further complicated by AMR. Of the estimated 848 000 HAIs in Nigeria in 2022, half were predicted to involve antimicrobial-resistant organisms.³

Healthcare settings can serve as amplifiers during infectious disease outbreaks. During Nigeria’s 2018 Lassa fever outbreak, inadequate infection prevention and control (IPC) practices contributed to disease transmission among healthcare workers with spillover to the community.⁴ Nosocomial transmission was also a factor during Nigeria’s 2014 Ebola virus disease outbreak, when 65% of those infected were healthcare workers.⁵

Effective IPC programmes play a vital role in protecting patients, healthcare workers and communities from infectious disease transmission and ensuring quality of care.⁶ The WHO has published evidence-based guidelines on the core components of IPC programmes, which aim to inform the development of strong national and health facility-level IPC programmes that effectively prevent HAIs and combat AMR.⁷ The guidelines provide recommendations on the structure of national and facility-level IPC programmes, along with the development and implementation of IPC guidelines, IPC training and education, HAI surveillance, multimodal strategies for implementing IPC activities and monitoring/auditing of IPC practices and feedback at the national and health facility level. At the health facility level, there are also recommendations on the built environment and workload, staffing and bed occupancy.

Recognising the critical need for a national programme to provide leadership and coordination for IPC activities throughout Nigeria’s healthcare system to ensure patient and healthcare worker safety and address HAIs, AMR and outbreaks of diseases of public health importance, the Nigeria Centre for Disease Control and Prevention (NCDC) established a National IPC Programme.

Here, we describe our experience establishing Nigeria’s National IPC Programme, its structured implementation strategy (the ‘Turn Nigeria Orange’ programme) and a network to strengthen public tertiary health facility-level implementation (Orange Network). We aim to share a real-world example of how the WHO’s core components of IPC programmes are being used in Nigeria to develop and implement effective national and health facility IPC programmes.

Nigerian healthcare system

Nigeria, the most populous country in Africa with over 200 million people,⁸ comprises 774 local government areas (LGAs) distributed across 36 states and Federal Capital Territory. Healthcare is delivered through orthodox and traditional means, with orthodox care provided by public and private providers. There are nearly 39 000 operational health facilities (74% public, 26% private).⁹ Services are provided at three hierarchical levels: primary, secondary and tertiary.

Health is on the concurrent list of all three levels of government, meaning all levels have the power to make laws related to health. The Federal Ministry of Health and Social Welfare (FMOH&SW) oversees tertiary care, states manage secondary and private care, and LGAs manage primary care. The National Public Health Institute (NCDC) supports the FMOH&SW to develop evidence-based guidelines and policies and implement programmes related to disease prevention and control,¹⁰ in line with NCDC’s mandate to prevent, detect, monitor and control diseases of public health importance.

National IPC programme establishment

History of IPC in Nigeria

In 2017, Nigeria conducted a situational analysis to inform the development of its AMR national action plan.¹¹ Findings showed that IPC had been neglected in many healthcare facilities despite the existence of IPC policies.¹¹ Identified gaps included a shortage of IPC professionals and a lack of national and facility-level IPC programmes, expertise, guidelines and laboratory capacity.¹¹ The few health facilities with IPC programmes in place at the time often lacked trained IPC professionals with dedicated time to lead the implementation of IPC activities.

In 2018, a Lassa fever outbreak prompted WHO to appoint a consultant to establish the National Lassa Fever Technical Working Group’s IPC pillar. Political support for IPC was mounting at this time, and the consultant was later asked to serve as the first national IPC focal point. The Lassa fever outbreak, findings of the AMR situational analysis,¹¹ political buy-in, and the presence of a national focal point to advocate for IPC programmes created a favourable environment for establishing a national IPC programme.

In 2019, Nigeria’s National IPC Programme was launched under the national IPC focal point’s leadership. Before the programme launched, NCDC undertook a planning phase that involved mapping relevant stakeholders and hiring dedicated staff. Early stakeholder mapping allowed the programme to establish relationships with key partners crucial to its success. These foundational partners brought the following expertise to strengthen the programme:

• Training of IPC professionals and establishing a national IPC curriculum/training programme through a local university (College of Medicine, University of Lagos).

• Coordinating networks of mentorship and continuous professional development for IPC professionals through national and continental IPC networks/professional societies (Nigerian Society for Infection Control and Infection Control Africa Network).

• Advocacy through communication and socialisation of IPC activities conducted by the National IPC Programme through a non-profit partner (Dr. Ameyo Stella Adadevoh Health Trust).

In 2020, the National IPC Programme assessed staffing needs through a strengths, weaknesses, opportunities and threats analysis facilitated by an external business development consulting firm. The analysis identified the need to hire professionals with experience in healthcare epidemiology and data analysis. Given the shortage of IPC professionals in Nigeria, staff were not IPC subject matter experts when they were hired; instead, their IPC expertise was developed over time, in part through participation in the national IPC training programme. IPC programme staff were first onboarded with external funding but transitioned to permanent staff, an opportunity attributed to continuous advocacy to NCDC leadership and successfully communicating the programme’s impact.

Since its inception, the programme has served as a central hub for IPC leadership, coordination and advocacy, driving the country’s IPC agenda.

A timeline of significant milestones in the formation of the National IPC Programme is presented in figure 1.

Figure 1. Timeline of significant milestones in the formation of Nigeria’s National IPC Programme, 2017–2022. IPC, infection prevention and control.

National IPC baseline assessment

National IPC assessment methods

An initial step of the National IPC Programme was to assess the national-level state of IPC to identify strengths, gaps and weaknesses. Members of the National IPC Programme responded to WHO’s National Infection Prevention and Control Assessment Tool 2 (IPCAT2), a self-assessment tool which measures progress towards implementation of guidelines and recommendations for WHO’s six core components of national IPC programmes.¹² The tool’s companion summary worksheet is programmed to calculate overall percentage scores for each component. Detailed standardised scoring methods are published by WHO.¹² Briefly, each core component has 3–6 subcomponents, each containing 1–6 essential elements of national IPC programmes. Elements are scored as fully implemented (1 point) or not (0 points). Percentage scores are calculated by subcomponent and then core component (average of subcomponent scores).

National IPC assessment results

The 2019 national IPC baseline assessment findings are shown in figure 2 The IPC programme, education and training, and multimodal strategies national-level core components were identified as strengths, with baseline scores between 61% and 75%. Gaps were identified in national-level guidelines (36%), HAI surveillance (24%) and monitoring/audit of IPC practices (25%) components. These results helped identify the national programme’s priorities and informed the development of a national IPC strategy.

Figure 2. Findings from the National Infection Prevention and Control Assessment Tool 2 baseline assessment of Nigeria's National IPC Programme, 2019. HAI, healthcare-associated infection; IPC, infection prevention and control.

The ‘Turn Nigeria Orange’ Programme

On 5 May 2019, to align with World Hand Hygiene Day, the National IPC Programme launched its national IPC strategy, the ‘Turn Nigeria Orange’ programme. The programme selected the colour orange to represent strong IPC programmes based on its prominent use to symbolise patient safety internationally.

‘Turn Nigeria Orange’ is a comprehensive approach to establishing a national IPC programme with strong links to other national programmes, particularly AMR, and supporting the development of national, subnational and facility-level IPC programmes in line with WHO’s core components of IPC programmes. The programme’s philosophy ‘one nation, one plan’ unites stakeholders under a common goal of advancing IPC across Nigeria. A critical component of the programme is the establishment of a network of public tertiary health facilities working to become centres of excellence in IPC. This ‘Orange Network’ seeks to ‘Turn Nigeria Orange’ as it expands to reach facilities across the country.

Initial priorities of the programme were informed by IPCAT2 scores and were implemented in phases. Phase 1 prioritised IPC programmes, guidelines and education and training. Phase 2 incorporated HAI surveillance and monitoring and audit. This approach grew from a recognition that certain components lay the foundation for others. For example, continued investment in training of IPC professionals was critical to address lower scoring components including HAI surveillance; therefore, training was prioritised in the first phase.

Priorities of the first phase of the ‘Turn Nigeria Orange’ programme are detailed in figure 3 and include:

Figure 3. Initial priorities of the Turn Nigeria Orange programme. CDC, Centers for Disease Control and Prevention; IPC, infection prevention and control; NCDC, Nigeria Centre for Disease Control and Prevention.

1. Development of an IPC manual (guidelines) for health facility-level implementation.¹³

2. Revision of the national IPC policy to ensure the presence of a clear policy direction.

3. Strengthening of IPC expertise through a national IPC training programme.

4. Development of a network of public tertiary health facilities that will become IPC centres of excellence (Orange Network) (see Strengthening Facility-Level IPC Programmes).

Implementation of these priorities followed the national programme’s approach, which involves starting small, revising as needed based on lessons learnt, and then scaling.

Strengthening facility-level IPC programmes (the Orange Network)

In 2020, the National IPC Programme launched the Orange Network, a network of public tertiary health facilities across Nigeria supported by the national programme to strive to become IPC centres of excellence. Initially, the network focused on five of eight WHO core components of facility IPC programmes, with the long-term goal of strengthening all eight components through mentorship, workshops and training opportunities and advocacy for improved IPC funding and research.

As of 2023, there were 41 active Orange Network facilities, including 25 from the first cohort (launched in 2020) and 16 from the second cohort (launched in 2022). There is at least one network facility in each state.

Network onboarding and participation

To address the gaps from the AMR situational analysis (see History of IPC in Nigeria), a requirement for joining the Orange Network was the nomination of an IPC focal point with dedicated time to oversee IPC programmes. Facility focal points include medical doctors, nurses or other healthcare-related professionals who have completed or agree to complete a certified postgraduate IPC training course. Focal point responsibilities include forming the IPC team and committee and developing and leading the implementation of the IPC annual plan.

Focal points are onboarded through a series of three workshops to equip them with the knowledge, skills and attitudes to practice safely and ethically as IPC leads. The workshops train focal points on the IPC core components, development of IPC action plans, and multimodal hand hygiene improvement and compliance. During the workshop series, focal points receive training on IPC and hand hygiene assessment methods to benchmark progress. In addition to the workshops, focal points are prioritised for enrolment in the national IPC training programme.

Onboarded focal points and their teams begin applying skills gained during workshops to improve IPC practices. Examples of early activities include implementing a multimodal hand hygiene improvement programme and developing standard operating procedures for environmental cleaning. Focal points routinely assess IPC practices and hand hygiene compliance, develop and execute annual IPC action plans, allocate IPC budgets and monitor and evaluate activities. Network facilities are also prioritised to pilot NCDC IPC initiatives (eg, surgical site infection surveillance protocol).

Network focal points have opportunities to engage with each other for information sharing and mentorship both virtually (eg, using group messaging apps) and in-person (eg, via peer facility visits). In addition to peer mentorship, the national programme provides mentorship and supportive supervision, as well as opportunities for professional development through IPC networks and professional societies.

The National IPC Programme also collaborates with FMOH&SW and Infection Control Africa Network to engage annually with network facilities’ chief medical directors (CMDs) to advocate for support of IPC programmes, including human and financial resources.

Orange Network facility-level IPC assessments

Facility-level assessment methods

One tool selected to identify gaps and monitor progress in IPC promotion and practice in Orange Network facilities was WHO’s Infection Prevention and Control Assessment Framework at the Facility Level (IPCAF).¹⁴ The IPCAF is a structured questionnaire with an accompanying scoring system. Detailed standardised scoring methods have been published by WHO.¹⁴ Briefly, the IPCAF is structured into eight sections based on the eight WHO core components of health facility IPC programmes, each with 5–17 questions and a maximum score of 100 points (maximum possible score: 800 points). Based on the total scores, facilities are categorised into one of four levels: 0–200 points: Inadequate, 201–400 points: Basic, 401–600 points: Intermediate and 601–800 points: Advanced.

All Orange Network facilities use the IPCAF to conduct baseline and annual follow-up assessments. Assessments are led by facility IPC focal points who receive training on IPCAF assessment methods (see Network Onboarding and Participation). Submission of IPCAF scores to the National IPC Programme is voluntary.

Facility-level assessment results

Baseline and 1-year follow-up overall IPCAF levels for the 41 active Orange Network facilities are presented in table 1. When comparing IPCAF levels at baseline and 1-year follow-up, 83% of facilities scored in the Intermediate or Advanced level of IPC promotion and practice after 1 year in the network compared with 41% at baseline. Similarly, median total IPCAF scores increased from 386 (IQR: 167.5) at baseline to 502.5 (IQR: 89) at 1-year follow-up.

Table 1. Baseline and 1-year follow-up Infection Prevention and Control Assessment Framework at the Facility-Level (IPCAF) tool overall IPC promotion and practice levels in 41 active Orange Network facilities, 2020–2023.

Level of IPC promotion and practice*	Level at baseline, n (%)	Level at 1-year follow-up, n (%)
Inadequate	1 (2)	0 (0)
Basic	23 (56)	7 (17)
Intermediate	13 (32)	28 (68)
Advanced	4 (10)	6 (15)

^*Inadequate (IPCAF score 0–200 points), Basic (IPCAF score 201–400 points), Intermediate (IPCAF score 401–600 points), Advanced (IPCAF score 601–800 points).

IPC, infection prevention and control.

Baseline and 1-year follow-up findings for the eight IPCAF sections across the 41 active Orange Network facilities are presented in figure 4. At baseline, the lowest scores were observed in monitoring/audit of IPC practices, multimodal strategies and HAI surveillance. Across the eight core components, improvements were observed in all areas at 1-year follow-up. The greatest improvements were in multimodal strategies, monitoring/audit of IPC practices, IPC education and training and HAI surveillance. However, monitoring/audit of IPC practices and HAI surveillance remained the lowest scoring sections at follow-up.

Figure 4. Baseline and 1-year follow-up Infection Prevention and Control Assessment Framework at the Facility Level (IPCAF) tool section results across 41 active Orange Network facilities, 2020–2023. The boxes represent the IQRs, the middle horizontal lines within the boxes are the medians, and the white circles on the boxes are the means. The whiskers represent the full range and the black dots represent the outliers. HAI, healthcare-associated infection; IPC, infection prevention and control.

The highest scoring sections at 1-year follow-up (IPC programmes, guidelines and education and training) aligned with areas of focus during the first year of Orange Network participation (workshop outputs and focal point participation in the national IPC training programme).

Orange Network next steps

Moving forward, engagement will continue across the Orange Network to strengthen all core components, with an increased focus on HAI surveillance and monitoring/audit of IPC practices. We also plan to expand the network to all public tertiary facilities in Nigeria and to engage other facility types/levels (eg, private and secondary) using the same implementation approach.

Lessons learnt and key takeaways

The establishment of Nigeria’s National IPC Programme was based on a deep understanding of the country’s health system and the development of a strategy that reflected the system’s strengths, opportunities and challenges. The complex nature of Nigeria’s healthcare system required a flexible, coordinated approach, which led to the development of the ‘Turn Nigeria Orange’ programme. This programme provided a platform to improve IPC at all levels of the health system, with the Orange Network serving as a key driver of facility-level interventions. Importantly, the ‘Turn Nigeria Orange’ programme emphasised implementing in phases, which prioritised certain IPC core components to lay the foundation for others, as well as an iterative implementation approach, where interventions at all levels started small and were revised based on lessons learnt before scaling.

Since the national programme’s formation in 2019, IPC has been integrated into routine healthcare service delivery, no longer limited to outbreak responses, with coordination by the relevant structures at all levels of the health system. The ‘Turn Nigeria Orange’ approach has led to notable improvements in both national and facility IPC programmes.

Below are some of the factors that contributed to the success of Nigeria’s National IPC Programme during its first 5 years, which other programmes might benefit from and replicate:

• Advocacy and leadership buy-in: Building IPC programmes requires continuous advocacy to promote buy-in from leaders at all levels of the health system. Advocacy and outreach plans must be linked to a clear vision and involve repeated engagements with leaders. The ‘Turn Nigeria Orange’ programme provided a clear vision to advocate for the work of the National IPC Programme and communicate its impact. At the facility level, regular engagement with CMDs led to leadership buy-in and the availability of resources to support programmes.

• Partnerships and collaboration: Forming collaborative partnerships is critical to building IPC capacity and expertise. In Nigeria, there has been strong collaboration with many relevant institutions, including Infection Control Africa Network, the College of Medicine, University of Lagos, Dr. Ameyo Stella Adadevoh Health Trust and the Nigerian Society for Infection Control.

• Realistic, achievable approach: Setting reasonable and attainable goals for IPC programmes at all levels of the health system is important to programmatic success. New programmes can feel pressured to move faster than they could feasibly do well. Starting small and slowly will provide the bandwidth and time to ensure that activities are implemented effectively and lay the foundation for larger-scale implementation in the future.

• Sustainable workforce: Investing in the people who will lead and implement IPC programmes is a fundamental element of building a sustainable IPC workforce. Our first step was to gather a sizeable team of healthcare workers passionate about IPC to lead programmes and serve as IPC champions. They were then prioritised for the first national IPC training programme cohorts to ensure that they had access to the training and mentorship needed to be successful in their roles. Additionally, having a functional network of IPC focal persons during the COVID-19 pandemic was immensely beneficial, providing a valuable platform for communication with health facilities around IPC improvements and to pilot interventions.

• Leverage existing resources: Finding creative ways to leverage existing resources, like identifying partners with mutual areas of interest, is an important strategy for newly established IPC programmes. This is not only a strategic approach to funding IPC priorities but also promotes collaboration.

Next steps for the programme

Despite the National IPC Programme’s successes, the work has not been without challenges and gaps remain. Following the phased approach, a strong foundation for IPC was established, and the focus can now expand to other areas. Next steps for the National IPC Programme include:

• Repeating the IPCAT2 to inform the programme’s next 5-year cycle.

• Establishing state-level IPC programmes using an approach that mirrors the Orange Network model.

• Expanding the Orange Network approach to other health facility levels and private facilities.

• Increasing opportunities for state and facility IPC focal points to complete the national IPC training programme.

• Developing a system to facilitate IPC data collection, analysis and reporting.

• Building capacity for data collection and reporting at state and health facility levels.

• Establishing a national HAI surveillance strategy and system.

• Establishing monitoring and evaluation frameworks for the national programme and Orange Network.

• Increasing efforts to integrate IPC and antimicrobial stewardship in the Orange Network.

Funding remains a challenge to building sustainable IPC programmes. In Nigeria, the establishment of these programmes was supported by non-state actors, with funding often limited in time and scope. A sustainable approach to maintain and advance the ‘Turn Nigeria Orange’ programme and the Orange Network will involve leveraging funding from all three levels of government. The adoption of a revised national IPC policy also represents a good step in institutionalising IPC programmes, and ultimately, a legal framework and standards for IPC will lead to long-lasting, holistic, sustainable changes.

How our experience contributes to global literature and resources

According to a 2024 global report, only 39% of countries had national IPC programmes that were fully implemented nationwide.¹⁵ There is a growing call for all countries, including low- and middle-income countries (LMICs), to establish strong IPC programmes at the national, subnational and facility levels to close this gap, as described in WHO’s 2023 Global Strategy on IPC.⁶ WHO has published strategies, guidelines, assessment tools and other technical and practical documents to guide countries in establishing IPC programmes in evidence-based ways.67 12 14 16,18 These resources describe the features and standards of strong IPC programmes, provide strategic directions to strengthen IPC programmes and offer some implementation examples at the core component level. Our paper provides a complementary, practical example of how a country established a national IPC programme using these resources. In our experience, implementation examples and lessons learnt shared by other countries were crucial to informing our own approach. Yet published practical examples of approaches used to establish national IPC programmes in LMICs like ours are limited in the literature. We are only aware of two: one from Egypt published in 2006¹⁹ and one from Sierra Leone published in 2015.²⁰ Our paper contributes another perspective to the limited literature, this time from a country vastly larger in both population size and number of health facilities.

Conclusions

The value of IPC in patient and healthcare worker safety and combating AMR is clear; however, many LMICs lack functional IPC programmes at national and health facility levels. While every country is unique, in Nigeria, we achieved success by understanding the system, starting small and implementing in evidence-based ways. The story of the formation of Nigeria’s National IPC Programme and development of a network of IPC centres of excellence can serve as an example for other LMICs when building national and facility-level IPC programmes.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention or the CDC Foundation.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.