Dear Readers:
Please enjoy this guest expert column by Professor Adrian Levy on an important issue of how Canada confronts and understands threats posed by emerging infectious diseases.
Dr. Levy describes himself here:
Adrian Levy is professor of epidemiology at Dalhousie University on a mission to improve health. Find a backgrounder on pandemic preparedness in Canada: “After COVID: Global Pandemics and Canada’s Biosecurity Strategy”. https://www.cigionline.org/publications/after-covid-global-pandemics-and-canadas-biosecurity-strategy/
As the world faced the onset of SARS-CoV-2 in early 2020, the Public Health Agency of Canada (the Agency) led our nation's response. Tasked with gauging the impending threat, the Agency conducted a series of five rapid risk assessments between January and March 2020, concluding each time that the risk to Canadians remained low.
As we witnessed, the reality that unfolded was starkly different.
The Agency’s response to SARS-CoV-2 revealed significant deficiencies in its risk assessment procedures. The Agency's approach was unable to adapt to the rapidly evolving spread of the virus. Coordination with key international health bodies was lacking and flawed risk assessments resulted in an absence of accurate intelligence for decision-makers to prepare for the pandemic. These shortcomings resulted in delayed responses, missed opportunities for early preparation, and ultimately, less effective containment in Canada. By March 2021, the Auditor General of Canada confirmed that the Agency’s risk assessment methodology had significantly underestimated the health threat posed by SARS-CoV-2 to Canadians.
Risk assessments for infectious diseases begin with a real-time surveillance system to collect, analyze, and report public health data from around the world. In Canada, this surveillance role is performed by the well-regarded Global Public Health Intelligence Network (GPHIN). GPHIN identified the initial pneumonia outbreak that foreshadowed COVID-19, demonstrating the Network’s pivotal role in anticipating biosecurity threats in a timely fashion. However, the Independent Review Panel’s May 2021 report on GPHIN established that its work was inadequately connected to the Agency’s core function of risk assessment for emerging infectious diseases. The consequence? Valuable information from GPHIN was not effectively used in the risk assessments for SARS-CoV-2.
By identifying critical vulnerabilities, the Auditor General and the Independent Review Panel on GPHIN communicated the urgent need to establish an effective risk assessment process for emerging infectious diseases.
In response, in September 2023, the Agency released its updated Health portfolio emergency response plan(ERP). The extensive documentation available on the PHAC’s website indicates the substantial effort and resources invested by the Agency in developing this plan. The Agency has made efforts to rectify the issues in its risk assessment process highlighted during the response to SARS-CoV-2, summarizing as follows:
“The 2023 version of the ERP seeks to address initial lessons learned from the COVID-19 pandemic, as well as other recent activations and exercises. Analysis of COVID lessons learned and incorporation of updated best practices will be ongoing for some time, however, both nationally and globally.”
This update provides a valuable opportunity to reexamine the Agency’s risk assessment process that will inevitably become central when the world faces the next public heath emergency of international concern.
Risk Assessment in the Agency’s 2023 Update of the Emergency Health Plan
In the Agency’s updated plan, risk assessment is the responsibility of the newly-created Centre for Integrated Risk Assessment (CIRA). Central to CIRA’s risk assessment process is an “all-hazards” plan that “defines the framework within which the Public Health Agency of Canada (PHAC) and Health Canada (HC) will operate to ensure an appropriate response to any emergency”. In plain terms, this means that CIRA proposes to use the same risk assessment process for chemical, radiological, nuclear, and biological threats.
This all-hazards approach is fatally flawed because it overlooks a basic principle of risk analysis: the dynamics of emerging infectious diseases. In contrast to chemical, radiological, or nuclear threats, in which the health risk depends on the level of exposure, even minimal exposure to a rapidly replicating infectious disease can pose large health risks. For this reason, assessing the risk of infectious diseases requires a different approach than that used for other types of health threat.
Unlike the Agency’s response to the 2009 H1N1 influenza pandemic in which it publicized its Lessons Learned Review within a year-and-a-half, no similar self-assessment of the Agency’s response to COVID-19 has been made public. Nevertheless, none of the 18 occurrences of the word “COVID” in the updated plan appear to address the concerns about risk assessment for infectious diseases raised by the Auditor General of Canada and the Independent Review Panel on GPHIN.
The Agency’s updated plan provides scant information on the data sources and methods for rapid risk assessments. Nowhere does it recognize the different types of government officials who must respond to a rapidly spreading virus. Instead, the bulk of the plan describes CIRA’s reporting structures and authorities. The sheer volume of information – a stultifying 110,000 words plus – with hundreds of loosely organized paragraphs that includes an alphabet soup of acronyms, overwhelms the reader, and obscures meaning:
“The Event Manager is identified by the VP EMB/DG CER and may be appointed from a roster of qualified EMs from across the Health Portfolio with previous experience and/or specialized training. Selection is approved by the DG CER, VP EMB, HPEG (if established) and/or the Agency President.”
Who can claim to understand those lines of authority?
CIRA’s updated risk assessment process seemingly operates in isolation from other national and international agencies. There's a notable absence of integration with other Canadian surveillance efforts for emerging infectious diseases such as the Canadian Forces Intelligence Command. Nor is there mention of collaboration with international agencies such as the United States (US) Centers for Disease Control and Prevention, US Defence Intelligence Agency National Center for Medical Intelligence, and the World Health Organization's Pandemic and Epidemic intelligence hub. Similarly, there is no mention of coordination with provincial epidemic risk assessment processes, a persistent issue highlighted again in the March 2021 Auditor General’s report regarding unsigned data sharing agreements with provinces and territories.
The “heart of the ERP (emergency response plan) is a seven-phase response process designed to optimize the delivery of a coordinated Health Portfolio emergency response”. CIRA’s current approach to risk assessment may be characterized by deliberation, consultation, and attempts at comprehensiveness. At the same time, the Agency has established a three-week target for completing this seven-step process. CIRA’s exemplar is a Rapid Risk Assessment for Influenza A (H1/N5) Clade 2.3.4.4.4b (June 2023). The risk question asked was “What is the likelihood and impact of at least one human infection with avian influenza A (H1/N5) Clade 2.3.4.4.4b due to exposure to either birds or mammals in Canada up to the end of the 2023 fall bird migratory season?”
It is hard to envisage who or what this extraordinarily narrow question would inform. The response is 26 pages long, includes 47 citations, and acknowledges 116 persons working in 23 Canadian agencies. The conclusion is: “Therefore, the overall impact to the Canadian population would be minor, with low uncertainty.”
CIRA’s response to a meaningless question was a confident no.
It is impossible to make sense of CIRA’s approach to risk assessment without a concrete grasp of the data sources and methods used. That said, the exemplar effectively demonstrates the implausibility of the three-week target for the updated risk assessment process.
What to do about it?
Crucially, the Agency must abandon its all-hazards approach to risk assessment. First, as explained, infectious diseases do not follow the same dose-response, temporal and geographic patterns as do chemical, radiological and nuclear threats. Second, while all risk assessments are critical for protecting the health of the population, the type of outputs must be tailored for different officials facing different types of health threat. For emerging infectious diseases that risk becoming public health events of international concern, the key target audience must include federal and provincial officials considering the use of emergency powers to protect the health of the population.
The COVID-19 pandemic laid bare the critical gaps in Canada’s readiness to assess the risk from emerging infectious diseases. The Agency has taken commendable steps to address the shortcomings that increase the focus on deliberation, consultation, and comprehensiveness. However, this approach creates a barrier that hinders the agility necessary to effectively assess, and prepare for, the risk of an emerging infectious disease.
Fixing this problem cannot be achieved by incremental changes to the current system. Instead, what is required is a comprehensive overhaul that includes dedicated and agile infrastructure capable of mobilizing within days - not months - to anticipate, detect, and prepare for emerging infectious diseases. The core of that infrastructure must be one or more disease surveillance systems such as GPHIN. The risk assessment process must actively combine the data from those systems with expert judgment. The process must include effective mechanisms for rapidly upgrading and downgrading the risk assessment.
Canada’s security depends on it.
Thank you for sharing this response to a very important government initiative. If this criticism is correct- and it seems persuasive to me- then Canada will not be well prepared to respond to the next covid outbreak. We will have learned little from our covid experiences.
A follow up on your part Mr Wark seems more than appropriate. What has happened since Public Health issued this plan last September? Any public criticisms, any government or Public Health responses?
This appears to be a very inadequate response to very legitimate concerns about Public Health of Canada’s capacity to respond to the emergence of global disease outbreaks. . Surely, our public service, health experts and politicians can do better than this.
Without your publication, I fear this issue would pass unnoticed— perhaps just what Public Health prefers?