Interim report for the review of the Global Public Health Intelligence Network

Letter to the Minister of Health from the External Review Panel, outlining the preliminary findings from their independent review of Canada’s Global Public Health Intelligence Network (GPHIN).

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Letter to the Minister of Health from the External Review Panel

February 26, 2021

Dear Minister Hajdu,

In November 2020, you requested an independent review of Canada’s global public health surveillance system, the Global Public Health Intelligence Network (GPHIN), situated within the Public Health Agency of Canada (PHAC). This interim report is to update you on our progress: our work to date, what we have learned, the timeline of events around Canada’s earliest identification of what would become COVID‑19 and our initial conclusions.

We will end with a description of the major themes that we expect will be the focus of our work in the next few months, resulting in the final recommendations we intend to deliver in the spring. These recommendations will propose a path forward for GPHIN, as well as Canada’s future global public health surveillance role.

Mandate and work to date

Our mandate directs us to assess GPHIN’s current capabilities, how it contributes to global and domestic public health surveillance, and its role in informing PHAC’s early response to COVID‑19.

The mandate also asks us to consider the future role of GPHIN in the context of event-based surveillance (EBS), lessons learned from COVID‑19, and how best to position Canada with regard to public health intelligence and public health surveillance in the future.

Approach

Since November 26, the Panel has met virtually 29 times. We conducted interviews with 38 individuals, including former and current PHAC employees, provincial officials, international partners, and technical experts from both the public and private sector.

The main focus of our work to date has been on the past and present state of GPHIN. Consideration of the future state of GPHIN will be founded on the initial conclusions in this interim report and the common themes that have emerged in our interviews and research.

What we learned

Global Public Health Intelligence Network

GPHIN is an online early warning system that monitors global news sources in nine languages for potential public health risks happening anywhere in the world. It is an all‑hazards system that identifies chemical, biological, radiological and nuclear public health threats, and constantly scans public open‑source news in real‑time. It is considered a public health EBSFootnote 1 system, a type of surveillance that searches reports, stories, rumours and other sources of information for events that could be a serious risk to public health.

GPHIN is part of the Office of Situational Awareness (OSA) within the Centre for Emergency Preparedness and Response (CEPR), under the Emergency Management Branch (EMB).Footnote 2 It has been housed in PHAC since the agency’s creation in 2004, but existed previously as part of Health Canada starting in the late 1990s.

GPHIN has a complement of multilingual and multidisciplinary experts with the skills required to review the large volumes of filtered information captured by the system each day and to identify potential events that could point to a serious public health threat. Outputs, described below, are shared widely, including with the World Health Organization (WHO), and throughout PHAC. Currently there are 11 GPHIN analysts, supported by a senior epidemiologist and a team manager, who reports to the Director of the OSA.

GPHIN’s ability to detect emerging events is credited with early detection of the onset of the H1N1 pandemic, the development of Middle Eastern Respiratory Syndrome (MERS) and cases of Ebola virus disease. GPHIN is regarded as one of the most important sources of early information related to outbreaks, the signals of which are often informal and in local electronic news reports. Approximately 20% of the WHO’s collaborative Epidemic Intelligence from Open Sources (EIOS) input comes from GPHIN. While there are now several open‑source EBS systems operating publicly and privately, GPHIN is the only state‑owned moderated system in the world.

The Panel learned how GPHIN has made valued contributions to international EBS systems and the broader global public health surveillance regime; in particular, how GPHIN’s monitoring during the 2003 severe acute respiratory syndrome (SARS) outbreaks contributed to structural changes being made to the International Health Regulations (the IHR [2005]).

The IHR are the main international agreement governing global public health threats and are legally binding on 196 States Parties, including the 194 Member States of the WHO. GPHIN contributes directly to Canada’s obligationsFootnote 3 under the IHR (2005). In 2018, Canada secured the highest possible score for public health surveillance capacity under the WHO’s Joint External Evaluation (JEE) of Canada’s IHR core capacities. As the mission report reads: “The cornerstone of the national public health early warning function is event‑based surveillance, and relies on the GPHIN platform, which also constitutes the foundation of the public early warning function at the global level.”Footnote 4

A brief history

GPHIN’s creation in the late 1990s was a product of multiple convergent factors, though the idea was formed in 1994, when the pneumonic plague was identified in Surat, Gujarat, India through television media broadcast worldwide.

Observing the outbreak from Ottawa, Dr. Ronald St. John, a former Director General of the CEPR, saw the need to develop a more effective early‑warning system that could monitor news media via the Internet and provide filtered signalsFootnote 5 from open‑source data to the WHO, who could then undertake additional verification of potential events and enable measured responses from Member States.

At that time, the sudden availability of massive amounts of open‑source information through the Internet made real‑time global EBS possible, and allowed public health practitioners to have access to information faster than ever before. Another factor was globalization; international trade and travel were rapidly expanding, and microbial threats, such as new variants of influenza, could now spread more quickly and disperse more widely.

It was in this context that GPHIN’s development began. The prototype started as a partnership between Health Canada and the WHO in 1997, and was first deployed in 1999. It was limited to French and English articles and used websites, news wires and newspapers to monitor infectious diseases in humans. Without machine translation capabilities, GPHIN analysts translated foreign‑language articles manually into English before dissemination.

In 2002, GPHIN expanded to its second prototype phase, engaging  Canadian private sector technology firm Alis Technologies Inc.Footnote 6 through a collaborative research agreement (CRA) to improve the automated capacity and functions of Internet‑based news monitoring. The scope of the prototype was also expanded to include all hazards; in addition to infectious diseases in humans, it could also search for animal diseases, food, radiation and chemical and nuclear threats, as well as public health threats related to natural disasters.

In 2004, GPHIN evolved with the launch of an updated multilingual platform capable of machine learning and natural language processing in Arabic, Chinese (traditional and simplified), English, French, Russian and Spanish (Portuguese and Farsi were added in 2008). Analysts were instrumental in the development of search terms and taxonomy in multiple languages, as well as algorithms that further refined bulk search records and ranked them into specific categories.

Funding for this new platform included C$800,000 from Health Canada, as well as C$560,000 from the Nuclear Threat Initiative (NTI), led by philanthropist Ted Turner. The WHO contributed an additional C$100,000. The new system was unveiled at the United Nations on November 17, 2004 by Canada’s Minister of Health, Ujjal Dosanjh, and PHAC’s first Chief Public Health Officer, Dr. David Butler‑Jones.

The ability to monitor events in other countries also helped address some of the challenges of the existing global surveillance approach. Prior to EBS, the main tools for monitoring and reporting on public health threats were a combination of indicator‑based surveillance (IBS) and formal reporting requirements of WHO Member States. IBS involves the systematic collection, monitoring, analysis, and interpretation of structured data, such as indicators produced by a number of well‑identified, mostly health‑based, formal sources,Footnote 7 and requires a high standard of data quality to be of use. As a surveillance tool, IBS can be slower to detect signals, particularly in countries that might lack capacity. EBS and IBS are complementary, and both are considered important to global public health surveillance, as well as early warning and response (EWAR).

Under the IHR (2005), WHO Member States are obliged “to notify WHO of events that may constitute a public health emergency of international concern,”Footnote 8 but a lack of public health capacity and infrastructure, or a reluctance to report for fear of economic or political repercussions, can delay detection and subsequent response. Until 2007, the WHO could act upon only official information. Thereafter, following the coming into force of the IHR (2005) , faster signals from EBS surveillance, including GPHIN, allowed the WHO to investigate possible public health events and request Member States to verify unofficial reports.

GPHIN’s platform underwent another renewal between 2015–2019, in partnership with the National Research Council (NRC), at a total cost of C$7.9 million. The objective of the GPHIN Renewal Project (GRP) was to create an enhanced platform, compliant with existing IT policies, that could use emerging technologies to automate the collection of open‑source information. The project was completed on time and under budget but required re‑scoping and a high degree of additional governance and oversight, added mid‑project, to help improve project management capacity. The Panel has heard that while the GRP led to some enhancements, some potential opportunities might not have been realized and not all were satisfied with the amount of improvement that resulted.

Structure

GPHIN has always relied on a two‑step structure comprising automated processes and human analysis. A team of experienced, multilingual analysts with diverse backgrounds take initial automated output and manually filter and select news reports relevant to public health. The team works Monday to Friday between the hours of 6 am and midnight, and Sundays from 2 pm to midnight.

The current platform retains a two‑step system based on automated and human analysis. Analysts continue to adjust and refine search algorithms and taxonomy so that GPHIN’s monitoring can evolve over time.

GPHIN at a glance

GPHIN collects data from multiple open sources every day. The system automatically collects about 7,000 articles initially, about half of which are filtered out before analysts manually review the remaining 3,500. The largest single source of information GPHIN collects is from a global news and monitoring service owned by Dow Jones & Company called Factiva, which accounts for 84% of all input, at a cost of C$1.8 million every two years. Additional sources, including news aggregators and social media, are also monitored by analysts, but are not automatically captured by the platform.

GPHIN does not undertake risk assessments. Within PHAC, risk assessment of an issue or event is often informed by signals flagged or partially verified by GPHIN, but preparing assessment and recommending responses is undertaken by PHAC’s program areas. A GPHIN Alert is not a risk‑assessed signal; it is a highlighted article of potential interest. Likewise, although GPHIN products are sent to other parts of government, including the Government Operations Centre (GOC), they do not include recommendations for specific action or response.

GPHIN develops and disseminates a variety of products, listed below, free of charge to subscribers.

The GPHIN Daily Report (previously known as the Situational Awareness Section Daily Report) captures the top articles of interest, organized into sections.Footnote 9 On average, 5–10 articles are selected for inclusion, though volumes during COVID‑19 have been significantly higher, at 50–60 per day. Articles with source links are briefly summarized in an email, and full articles are attached. Daily Reports are sent only to domestic public health and government officials (just under 500 subscribers), the majority within the federal government. Daily Reports are not sent to international subscribers. The Daily Report is issued every morning at 8:30 am, Eastern time.

A 2019 user satisfaction survey revealed high levels of satisfaction with the Daily Reports, and found that they are widely and regularly read by subscribers. Respondents reported they use the Daily Reports for contextual awareness, as a starting point for further investigation and as a component of their risk assessments. Enhancements to the product have been made to better meet the needs of subscribers.

GPHIN Alerts, unlike the Daily Report, are not scheduled or summarized. An Alert is a flag to a subscriber that there is a signal they may wish to take notice of or follow up on, based on consideration of the specific risk criteria set out in Annex 2 of the IHR (2005). It consists of an email with a link to a single article about a health event occurring outside of Canada. Alerts are a tool for rapid dissemination of information on potential events (defined as verified signals) of public health concern and intended for both domestic and international audiences. Alerts are sent to both international and domestic subscribers, on an opt‑out basis; 982 subscribers receive Alerts.

Standard operating procedures (SOPs) governing the issuance of Alerts were implemented only recently, in September 2020. According to the SOPs, the decision to issue an Alert begins with a discussion among the GPHIN analysts on‑shift, in consultation with the senior epidemiologist, on whether a signal meets specific criteria set out in the IHR (2005), as well as additional internal considerations, such as whether the source is credible and the size of the impacted population. A brief verbal justification is then submitted to the Director of the OSA for approval.

When an Alert is issued, GPHIN analysts immediately begin enhanced surveillance with the goal of finding supplemental articles that can help validate the initial signal, until the event is resolved. Alerts may not be issued if an event has already been verified by the WHO, or if the credibility of the source is in question. Since 2014, Alerts have not been issued for potentially significant public health events in Canada; in those instances, PHAC relies on formal and informal reporting from the provinces and territories, for example, through the Canadian Network for Public Health Intelligence (CNPHI).

Past changes to GPHIN Alerts

Prior to fall 2020, there were no written procedures governing the issuance of GPHIN Alerts. The Panel heard conflicting descriptions of the Alert process and how any desired changes were communicated between management and the GPHIN team. For instance, the Panel has heard on several occasions that some senior leaders were concerned about Alerts being interpreted as official Government of Canada positions on events happening internationally. The Panel has also heard from some senior management directly overseeing GPHIN who could not describe the purpose or audience for Alerts, and may not have had a complete understanding of their intent. Finally, the Panel did hear a few concerns that some issued Alerts may have been premature or unnecessary.

In the last 10 years, the number of Alerts has varied significantly, with the highest number occurring in 2009, when 887 Alerts were issued—largely in relation to the H1N1 pandemic—followed by 198 in 2013, corresponding with the H7N9 outbreak. While most other years in the past decade have seen between 21–90 Alerts per year, only one was issued in May 2019, and only two in 2020 (August and November).

It is clear that some form of direction was given to pause the Alert process, and that the level of approval for Alerts was elevated and then downgraded at least once. The Panel has not seen any written documentation in respect to the timeline of those changes, who requested them and why they might have occurred.

However, the Panel did receive specific recent examples of Alerts that were recommended to senior managers, but were not issued. In one instance, an Alert waiting for approval was withdrawn because information arose in the interim that disputed the signal. In another, the existence of reporting by local health authorities negated the need for an Alert. In a third, an Alert was not issued at the direction of the Director General, but no rationale was provided.

The Panel would note that while this product is known as an Alert, it does not conform with existing WHO guidance around the specific definition and scope of Alerts in the context of EWAR. The more rigorous definition of Alert, according to this guidance, would be a public health event that has been a) verified, b) risk‑assessed and c) requires intervention, including investigation, formal response or a communication.Footnote 10 Though the Panel has heard several different interpretations of what the purpose and use of Alerts are, there appears to be consensus that GPHIN provides only signal detection and initial verification.

The Panel has identified Alerts as a key line of inquiry, particularly in light of conflicting information and lack of clarity around their purpose and application. Whether it is accurate to call these products Alerts or not, they are currently the only tool GPHIN has at its disposal to signal potential events to international public health subscribers. This does not appear to have been well understood by some management within PHAC. The purpose and use of Alerts will be addressed in the final report.

GPHIN Public Health Measures Reports: GPHIN analysts compile extensive lists of the public health measures implemented worldwide to respond to events. For COVID‑19, this specialized reporting started on January 29, 2020, and continues to this day. These reports are sent to a separate distribution list maintained by GPHIN, including the Office of Border and Travel Health, the Health Portfolio Operations Centre (HPOC)Footnote 11 and the WHO.

Special Reports: GPHIN analysts also produce Special Reports, which are searches for information on a specific public health event. Special Reports can include broader search criteria and additional analysis than the GPHIN Daily Report, and both the format and distribution are tailored to the client’s needs. Although articles that appear in Special Reports may also appear in the GPHIN Daily Report, Special Reports do not make up part of the GPHIN Daily Report. There are no SOPs for Special Reports.

Mass gathering surveillance reports: GPHIN also contributes to public health surveillance plans developed for major mass gatherings, like the Charlevoix G7 Summit in 2018. A typical mass gathering event will involve GPHIN Baseline Reports for two weeks before the event, a daily GPHIN Mass Gathering Surveillance Report during the event and post‑event surveillance reports. These reports have a broader scope, or selection criteria, than the GPHIN Daily and Special Reports (for example, they might include information about health security threats from terrorism, chemical spills and political unrest).

Database: While the GPHIN database is not a product, it is nonetheless available to all subscribers and constitutes a significant resource of value. Of the 3,500 records analysts review on a given day, 1,000–1,500 will be published in the GPHIN database, which can then be accessed by subscribers to undertake independent research and monitoring. (During COVID‑19, volumes have been higher—between 2,500–3,000 records a day.)

There are just under 1,000 database subscribers: 54% are international, with the remaining 46% comprising federal, provincial, regional, academic and private sector experts in Canada. While subscriptions to the database are limited to public health professionals, there is no charge to use it.

GPHIN analysts apply meta tags to collections of articles in the database, specific to a particular audience, so that a subscriber can browse filtered articles pre‑selected by analysts. However, a subscriber would generally need to have a specific query in mind in order to use the database effectively.

COVID‑19 and GPHIN: Timeline of early events following initial detection

Global Public Health Intelligence Network

Documents provided to the Panel show GPHIN initially detected signals of what would become the COVID‑19 pandemic on December 30, 2019, at 10:30 pm, Eastern time, by the GPHIN analyst on duty. The signal, which detected the outbreak of pneumonia in Wuhan, was distributed the following morning in the Daily Report for December 31, 2019, which cited an article published by Agence France‑Press and an article published by the South China Morning Post.

Supplemental monitoring was immediately initiated, and GPHIN issued its first Special ReportFootnote 12 highlighting an outbreak of viral pneumonia in China, on January 1, 2020. Stand‑alone Special Reports continued until February 4. Thereafter, Daily Reports also included a new Special Section on COVID‑19.

Public Health Agency of Canada

Documents received by the Panel show that both PHAC’s President, Tina Namiesniowski, and Chief Public Health Officer (CPHO), Dr. Theresa Tam, took action upon receipt of the January 1 Special Report from GPHIN’s management shortly after 9:00 am that day. The President shared information with the Minister of Health’s office, as well as counterparts at the Privy Council Office (PCO), Global Affairs Canada (GAC) and Public Safety Canada (PSC).

The following day, January 2, the CPHO notified the Council of Chief Medical Officers of Health (CCMOH), and PHAC alerted the federal/provincial/territorial (F/P/T) Public Health Network Communications Group and the Canadian Public Health Laboratory Network (CPHLN). The first meeting of CCMOH related to this viral pneumonia outbreak took place on January 14.

From January 8 to 15, GPHIN Special Reports were included as an input for PHAC’s informal situational reporting. Upon Level 2 activation of HPOC on January 16, GPHIN Special Reports became an input into official Situation Reports, distributed by HPOC to a broader internal audience, as well as CCMOH and other external partners.

International

On January 3, PHAC sent an official request to the WHO for additional information regarding the evolving outbreak in Wuhan. On January 5, the WHO posted its first event notification on its secure Event Information Site (EIS), a secure portal through which information, including risk assessment and advice, is shared with IHR National Focal Points.Footnote 13 At that moment, the WHO found that there was limited information to determine overall risk and advised against the application of any travel or trade restrictions against China. A subsequent EIS update on January 12 stated “a new type of coronavirus has been detected and the entire genome sequence of the virus has been obtained.”Footnote 14

Overview of key milestones and events post‑detection

Initial conclusions

The Panel finds that:

Looking forward

That GPHIN identified early open‑source signals of what would become COVID‑19 and promptly alerted senior management does not mean that the system is operating as smoothly or as clearly as it could and should.

As we highlighted earlier, there is an important discussion to be had about the intended and perceived purpose of Alerts. GPHIN did not issue an Alert for COVID‑19, though we have nonetheless concluded that Canada’s response followed promptly upon detection. However, as international subscribers only receive Alerts, some jurisdictions did not receive an early signal directly from GPHIN and would have relied upon other EBS notifications to inform their risk assessment and future action. To what extent GPHIN can or should be providing early signals to international partners and the potential for value‑added risk assessment embedded into the Alerting process will factor into the next phase of our review.

The Panel will also be carefully considering the operational context for GPHIN based on findings to date, which confirm a high degree of management turnover, a decline in the number of internal experts with public health credentials in both branches within which GPHIN has been located in recent years, and evidence of less‑than‑optimal integration of GPHIN with PHAC’s other operations.

This second phase will also consider lessons learned from COVID‑19, opportunities to improve the system, advice on the next generation of public health intelligence systems and how best to position public health surveillance in Canada to respond appropriately to public health events in the future.

We have observed the following key areas that merit further consideration:

1) GPHIN’s role and mandate within PHAC and within the broader government context. This line of inquiry will consider GPHIN’s capabilities in greater detail, whether it has a clear and relevant mandate, how it contributes to both public health surveillance and public health intelligence, and how it supports PHAC’s mandate.

The Panel also intends to examine the state of risk assessment at PHAC, whether GPHIN is being calibrated to support assessments carried out across program areas and to what extent GPHIN could contribute more to that function. The Panel will consider whether early detection of signals is leading to verification, followed by rapid risk assessment, decisions and appropriate response. We will also examine to what extent PHAC is providing useful public health intelligence to other stakeholders across Canada and internationally.

2) The state of governance structures that support and enable GPHIN—including consideration of the public health skills and experience required of GPHIN analysts, mid‑level managers and senior executives—in order to take full advantage of GPHIN’s intelligence and potential.

3) Partnerships and flows of information between GPHIN and stakeholders within and outside of government, across Canada and around the world. The Panel will assess whether existing flows of information are sufficient and codified, and what opportunities exist to increase the efficacy and reach of GPHIN products and database. The Panel will also consider both public health surveillance and public health intelligence, examining whether there is an effective approach currently in place at PHAC, and whether GPHIN products are being appropriately used and fully integrated into PHAC’s core functions. The Panel will also carefully consider the links between EBS and IBS, risk assessment and Alerts, and whether PHAC has the capacity to manage epidemic intelligence effectively.

4) Technology and the future of surveillance tools. Much like the circumstances that gave rise to GPHIN two decades ago, the information landscape is rapidly evolving; information is now expanding exponentially due to the proliferation of social networks. Machine learning and AI are evolving quickly, and the rise of big data in all sectors, and especially in health, present unique new challenges and opportunities to global public health surveillance. In this section, we hope to provide a clear assessment of GPHIN’s current system, taking into consideration the system’s existing abilities, and the two‑step structure that depends on both the platform and the existing strengths and specialized expertise of the GPHIN team. We aim to present an approach to technological renewal that is not exclusively focused on acquiring the most cutting‑edge tools, but nonetheless evolves over time to respond to new open sources.

The Panel will also consider findings of PHAC’s internal assessment and Lessons Learned from the Public Health Agency of Canada’s COVID‑19 Response (Phase One) report, and will take note of any relevant recommendations related to both international surveillance and risk assessment. The Lessons Learned report has already identified surveillance as a key function that could be improved, and that teams involved in surveillance lack coordination and common purpose.

We remain open to new evidence that could help evolve our scope and approach. We are confident we will be able to provide recommendations that will ensure GPHIN is fit for purpose and contributes to PHAC fulfilling its mandate.

The work ahead

To date, the Panel has relied on first‑person interviews and primary source documents and reports to collect the vast range of perspectives and stakeholders who interact with and rely upon GPHIN day‑to‑day. In the second phase of our work, we will continue to draw on experts to help refine future recommendations and make sure they are realistic, actionable and within scope. We will provide our recommendations to you in a final report in May 2021.

The Panel wishes to acknowledge the PHAC officials who have been instrumental in providing first‑person testimony and in responding to requests for documents and records, and to thank them for their responsiveness and cooperation during a time when they are managing very large work loads and great stress. Our work would not have been possible without their willing collaboration. We are particularly recognizant of their help in light of Canada’s ongoing pandemic response and in the face of the most complex global pandemic in history.

The Panel has been very ably supported in its work by the very dedicated and professional secretariat, and wishes to thank Brian Pagan, John Ryan, and Kym Shumsky for their excellent work and contribution. We would not be able to conduct this review without their efforts.

Acronyms

CCMOH
Council of Chief Medical Officers of Health
CEPR
Centre for Emergency Preparedness and Response
COVID 19
coronavirus disease 2019
CNPHI
Canadian Network for Public Health Intelligence
CPHLN
Canadian Public Health Laboratory Network
CPHO
Chief Public Health Officer
CRA
Collaborative Research Agreement
EBS
event based surveillance
EIOS
Epidemic Intelligence from Open Sources
EIS
Event Information Site
EMB
Emergency Management Branch
EWAR
early warning and response
F/P/T
federal, provincial and territorial
GAC
Global Affairs Canada
GOC
Government Operations Centre
GPHIN
Global Public Health Intelligence Network
GRP
GPHIN Renewal Project
HPOC
Health Portfolio Operations Centre
HSIB
Health Security and Infrastructure Branch
IBS
indicator based surveillance
IHR
International Health Regulations
IMS
Incident management structure
JEE
Joint External Evaluation
LAC
Logistical Advisory Committee
MERS
Middle Eastern Respiratory Syndrome
NRC
National Research Council Canada
NTI
Nuclear Threat Initiative
OSA
Office of Situational Awareness
PCO
Privy Council Office
PHAC
Public Health Agency of Canada
PHEIC
Public Health Emergency of International Concern
PSC
Public Safety Canada
SAC
Special Advisory Committee
SARS
severe acute respiratory syndrome
SOP
standard operating procedures
TAC
Technical Advisory Committee
WHO
World Health Organization
Footnote 1

WHO, 2014: Implementation of early warning and response with a focus on event‑based surveillance

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Footnote 2

CEPR was moved from Health Security and Infrastructure Branch (HSIB) in November 2020, as part of an organizational realignment.

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Footnote 3

IHR (2005), Foreword

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Footnote 4

WHO, 2019: Joint external evaluation of IHR core capacities of Canada: Mission report

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Footnote 5

WHO, 2014: Implementation of early warning and response with a focus on event‑based surveillance

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Footnote 6

Alis Technologies Inc. filed for bankruptcy in 2003, but another Canadian firm, Nstein Technologies Inc., which had been involved in some of the prototyping, was able to continue the development work in the interim and entered into a new CRA with GPHIN in 2004.

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Footnote 7

WHO, 2014: Implementation of early warning and response with a focus on event‑based surveillance

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Footnote 8

IHR (2005), Foreword

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Footnote 9

New domestic events, New international events, Update on domestic events, Update on international events, and Research, policies and guidelines of interest.

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Footnote 10

WHO, 2014: Implementation of early warning and response with a focus on event‑based surveillance

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Footnote 11

HPOC is a permanent 24/7 command and control platform for PHAC and Health Canada, responsible for carrying out the principles of emergency preparedness and emergency management functions at an operational level. It is structured around activities: single-window, mobilizations, response planning, information management, stakeholder coordination and engagement. There are four levels of activation: 1‑Routine, 2‑Heightened, 3‑Escalated and 4‑Emergency; the IMS is usually activated when a situation reaches level 2, 3 or 4. During an activation, HPOC is responsible for supporting the coordination and logistics of the IMS and for continuing its “single‑window” role (for non‑event issues).

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Footnote 12

Daily Reports are not published on statutory holidays.

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Footnote 13

The IHR Focal Point for Canada is the Director of the OSA.

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Footnote 14

From the Event Information Site for IRH National Focal Points, first posted January 5, 2020, and updated January 12, 2020. (Not publicly accessible.)

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