Public Health Agency of Canada’s COVID-19 Response: Lessons Learned

The complete "Public Health Agency of Canada's COVID-19 Response: Lessons Learned" report is available in PDF format upon request. Please send an email to oae-bae@phac-aspc.gc.ca.

Executive Summary

Prepared by the Office of Audit and Evaluation
Public Health Agency of Canada

November 2023

Table of contents

• List of acronyms
• Executive summary
  • Context
  • Purpose
  • PHAC's role
  • Key actions taken
• Lessons learned
• Canada's response compared to other countries
• End notes

List of acronyms

CCMOH

Council of Chief Medical Officers of Health

CPHO

Chief Public Health Officer

FPT

Federal/provincial/territorial

GPHIN

Global Public Health Intelligence Network

IANPHI

International Association of National Public Health Institutes

NML

National Microbiology Laboratory

NPHI

National Public Health Institutes

PHAC

Public Health Agency of Canada

PHN

Public Health Network

PPE

Personal protective equipment

SGBA+

Sex and Gender-Based Analysis Plus

WHO

World Health Organization

Executive summary

Context

On December 31, 2019, the Public Health Agency of Canada's (PHAC) Global Public Health Intelligence Network (GPHIN) detected a pneumonia-like illness of unknown cause originating in Wuhan, China. The next day, on January 1, 2020, the PHAC President alerted key federal departments, including Health Canada, Global Affairs Canada, Privy Council Office, Public Safety Canada, as well as the Minister of Health's staff about this signal. The Chief Public Health Officer (CPHO) alerted all members of the Council of Chief Medical Officers of Health (CCMOH) on January 2, 2020. The National Microbiology Laboratory (NML) sent an alert across the Canadian Public Health Laboratory Network on the same day.

PHAC initiated regular communications with federal, provincial, and territorial partners starting in early January 2020. On January 7, 2020, PHAC started preparing situational reports to provide key information on the evolving situation.

The Health Portfolio Operations Centre activated to a Level 2 and set up its Incident Management Structure on January 15, 2020. On January 27, 2020, Canada reported its first confirmed case of COVID-19. On January 28, 2020, the Health Portfolio Operations Centre was officially activated to a level 3, signifying that the impact, or potential impact, of the COVID-19 public health event required greater use of Health Portfolio program resources to support the response.

On January 30, 2020, the World Health Organization (WHO) declared this novel coronavirus outbreak a public emergency of international concern. A few weeks later, on March 11, 2020, it declared COVID-19 as a pandemic. Between the report of the first cases in Wuhan, China, on December 31, 2019, and the official announcement of the end of COVID-19 as a global health emergency by the WHO on May 5, 2023, Canada experienced a series of waves characterized by spikes in cases, hospitalizations, and deaths. Addressing the health, social, and economic impacts of the pandemic required a whole-of-government response that was scaled and adapted as the epidemiological situation evolved in Canada.

Purpose

This report compiles key actions and measures implemented by PHAC to address the COVID-19 pandemic and discusses related lessons learned. Being internally focused, it documents lessons learned from the response provided by PHAC as the Government of Canada's lead on public health responses. It also documents areas for improvement to help the Agency prepare for the next public health emergency. The information presented is based on interviews with senior officials who worked at PHAC during the pandemic, as well as internal documents and externally-led reviews. Most of the data collection work was completed in summer 2022, with updates made in summer 2023. This report does not discuss measures that fall within the mandate of provinces and territories, such as health care, or other federal government departments, such as social transfers and economic policies.

At the outset of the pandemic, existing emergency plans and guidance documents, such as the Health Portfolio Emergency Response Plan, the Health Portfolio Strategic Emergency Management Plan, the Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector^{Footnote 1}, and the Federal/Provincial/Territorial Public Health Response Plan for Biological Events^{Footnote 2} provided a framework to guide PHAC's response and coordination with provincial and territorial public health units. Due to the unprecedented magnitude and scope of the COVID-19 pandemic, there was a need for a forward planning approach to ongoing management of COVID-19. This led to the creation of a COVID-specific federal/provincial/territorial response plan^{Footnote 3} that was first published in 2020, with the latest updates dating from 2022. This plan outlines key components for transitioning from an acute response towards a more sustainable long-term response to the ongoing presence of COVID-19. These components, along with other key elements that are internal to PHAC, such as workforce mobilization and surge capacity, and specific to PHAC's role as the Government of Canada public health lead, such as coordination within the Health Portfolio, were used as a framework to structure this report. Key response components discussed in the report are as follows:

• National Emergency Stockpiling of Medical Assets;
• International Border and Travel Health Measures;
• Testing and Laboratory Services;
• Surveillance and Data;
• Vaccination;
• Guidance and Advice;
• Science, Research, and Innovation;
• Risk Communications and Outreach;
• Addressing Disproportionate Impacts due to Existing Health Inequities and Inequalities;
• Collaboration and Coordination with other Public Health Organizations and Health Professional Groups; and
• Internal Capacity.

PHAC's role

In broad terms, the Public Health Agency of Canada Act^{Footnote 4} considers that the creation of PHAC and the appointment of the CPHO "contribute to federal efforts to identify and reduce public health risk factors and to support national readiness for public health threats." The Act outlines responsibilities for public health measures related to health protection and promotion, health surveillance, emergency preparedness and response, collaboration within the public health field, coordination of federal policies, federal/provincial/territorial cooperation, and international cooperation. While the core mandate of PHAC did not change, the unprecedented magnitude of the COVID-19 pandemic response required significant scale up and expansion of the scope of activities required to lead and support Canada's COVID-19 response.

As public health is a shared federal/provincial/territorial (FPT) responsibility, a time-limited governance structure was established in January 2020 under the Public Health Network (PHN), as per the FPT Response Plan for Biological Events, to support the coordination of the pan-Canadian response. This included the Special Advisory Committee on COVID-19 and its related advisory committees, the Technical Advisory Committee, the Logistic Advisory Committee, the Public Health Network Communications Group, and the Public Health Working Group on Remote and Isolated Communities. The Special Advisory Committee on COVID-19 was composed of members of both the PHN Council and the CCMOH, and was accountable for providing advice to the Conference of FPT Deputy Ministers of Health on coordination, public health policy, and technical content related to the COVID-19 pandemic.

Key actions taken

Some of the most salient actions implemented by PHAC to address COVID-19 included:

National emergency stockpiling of medical assets

• Bulk procurement, distribution, and management of an unprecedented amount of personal protective equipment (PPE), vaccine ancillary supplies, and biomedical equipment, along with vaccines, therapeutics, and testing supplies on behalf of provinces and territories, in response to global supply disruptions. For example, PHAC purchased over 530 million needles and syringes of various sizes to advance vaccine rollout during the pandemic.

International border and travel health measures

• Supporting five repatriation flights, as well as the reception and quarantines of repatriated Canadian citizens and permanent residents in February and March 2020.
• Leading the development and approval of 83 Emergency Orders-in-Council, pursuant to the Quarantine Act, to limit the introduction and spread of COVID-19 into Canada. PHAC expanded its border presence through the provision of front-line public health services. This included, among other things, establishing designated quarantine facilities, implementing compliance and enforcement mechanisms, as well as designing, overseeing, and deploying COVID-19 testing at ports of entry, including air and land.

Testing and laboratory services

• Working with the Canadian Public Health Laboratory Network to support testing capabilities for COVID-19 testing across the country. The NML established a network of federal surge laboratories that provided additional support for provinces and territories, as well as for border testing. Also, PHAC increased access to diagnostic testing for northern, remote, and isolated communities.

Surveillance and data

• Working with provinces and territories to support the collection of COVID-19 case surveillance data. PHAC worked with provinces and territories to create a national COVID-19 vaccine surveillance system to track coverage rates in Canada and to scale up an existing post-market vaccine surveillance system to monitor reported side effects. Supporting the development of a whole genome sequencing network for COVID-19 and the delivery of dedicated technical capacity to provincial and territorial partners for genome sequencing.
• Developing a Pan-Canadian Wastewater Surveillance Network with key partners and programs across different government levels (federal, provincial, territorial, and municipal), as well as with academia to sample and test wastewater for COVID-19 from a large number of municipalities across Canada.

Vaccination

• Supporting the rollout of the largest vaccination campaign in Canada's history through the bulk procurement, as well as the distribution of vaccines and related enabling equipment, in partnership with the Canadian Armed Forces. PHAC launched the Vaccine Connect IT System to help provide logistical support for vaccine administration across Canada.
• Conducting research, deploying toolkits, establishing partnerships with community organizations, and conducting advertisement campaigns to support vaccine confidence and uptake.
• Establishing a federal Vaccine Injury Support Program to ensure that all people in Canada who have experienced a serious and permanent injury as a result of receiving a Health Canada authorized vaccine administered in Canada, have fair and timely access to financial support.

Guidance and advice

• Developing guidance documents on a variety of subjects, including infection prevention and control, clinical guidance, and advice on vaccine use. PHAC's guidance and tools were designed for various audiences, including the public, public health authorities, schools, and establishments (e.g., tool for operators). PHAC COVID-19 guidance documents underwent a Sex and Gender-Based Analysis Plus (SGBA+) review to consider the specific needs and circumstances of different groups of people living in Canada.
• Providing online courses and webinars for Canadian public health organizations and health care providers on subjects such as vaccination and contact tracing.
• Deploying federal field staff in local, provincial, and territorial public health organizations to bolster day-to-day surveillance and response activities, including 12 COVID-19 Public Health Officers and four Vaccine Safety Public Health Officers. In addition, PHAC deployed 91 epidemiologists to 11 provinces and territories between January 2020 and December 2022 in response to 63 requests for short-term surge support, including 18 requests for non-COVID-19 public health threats.

Science, research and innovation

• Rapidly strengthening scientific capacity, collaboration, and evidence-based decision making. This included rapid investment in scientific research as well as establishing and bolstering many bodies for science advice. PHAC also implemented a new scientific collaboration governance approaches and new tools for knowledge synthesis and mobilization.
• Developing additional science capabilities to support policy development, such as the establishment of a modelling team and Behavioral Science Office (BeSciO).
• Coordinating evidence synthesis and mobilization activities related to COVID-19, including 62 unique evidence syntheses produced by COVID-END and other evidence producers, as well as 15 expert consultations and engagements on a wide range of emerging and complex COVID-19 topics in collaboration with the CanCOVID network.

Risk communications and outreach

• Engaging in substantial media activities, including responding to 14,937 media requests between January 2020 and September 2022. The Minister of Health, the CPHO, the Deputy CPHO, and other PHAC officials offered 669 media availabilities, including conferences, media scrums, interviews, and technical briefings. In addition, from January 2020 to September 2022, content on ca/coronavirus received 619,602,756 web visits. Between March 1, 2020, and September 2022, 1,596,763 calls were answered via the dedicated 1-800 COVID-19 information line.
• Scaling up risk communications and maintaining ongoing public outreach through media and social media campaigns, as well as through partnerships with influencers and community organizations to communicate proactively with people living in Canada and partners across the system on health risks and methods to protect the health of the Canadian population.
• Conducting research using behavioral science and leveraging partnerships with a variety of organizations to address misinformation.

Addressing the disproportionate impacts due to existing health inequities and inequalities

• Leveraging partnerships with PHAC's community-based programs to distribute vital public health information about COVID-19, and to direct participants to local public health authorities for regional guidance.
• Conducting analysis on the wider health impacts of COVID-19, with a focus on mental health, the ongoing increase in opioid-related harms and deaths, chronic diseases, post-COVID-19 conditions, children, and seniors. For example, PHAC supported recipients of its community-based programs, such as the Community Action Program for Children, the Canada Prenatal Nutrition Program, the Mental Health Promotion Innovation Fund, and the Aboriginal Head Start in Urban and Northern Communities Program to adapt their project activities to continue supporting at-risk children and families during the pandemic.
• Leading the federally funded and locally operated Safe Voluntary Isolation Sites Program.
• Establishing an Immunization Partnership Fund to support vaccination in communities.

Collaboration and coordination with other public health organizations and health professional groups

• Supporting 238 meetings of the FPT Special Advisory Committee on COVID-19 and 78 Chief Medical Officers of Health meetings.
• Hosting over 50 bilateral and multilateral engagements with provinces and territories, and five federal, provincial, territorial, and Indigenous summits to discuss various aspects of vaccine rollout and facilitate the sharing of best practices and lessons learned.

Lessons learned

The COVID-19 pandemic highlighted the key role of PHAC in preparing for and responding to public health emergencies in support of population health and well-being. It also stressed the importance of PHAC's CPHO as a trusted scientific adviser to the governments and the public. Through its COVID-19 response, PHAC gained knowledge and experience which should be taken into consideration as PHAC positions itself to respond to future emergencies.

This review identifies several cross-cutting lessons.

Lesson 1: As a pandemic evolves, it is critical to rapidly adapt the response in light of evolving science and to provide real-time communication about activities and new emerging evidence.

The COVID-19 pandemic exposed the necessity of nimbleness in a public health response. This includes the recognition that a pandemic will not resemble what has occurred in previous emergencies and that the response will most likely change as the science evolves, or as new challenges arise.

There was an overwhelming recognition that the COVID-19 pandemic was unprecedented in both complexity and scale. Activities critical at the beginning of the response, such as ensuring the availability of PPE and the development of diagnostic tests, evolved into other challenges, including the development of a vaccine. Meanwhile, some activities were ongoing, like ensuring the availability of data and testing capacity across the country. The magnitude of measures and programs implemented by PHAC was unforeseen and many of those measures evolved as new science became available. Additionally, the evolution of the virus itself required changes to response measures.

Communicating about evolving scientific evidence, as well as how the Agency is adapting its response to partners, stakeholders, decision makers, and Canadians in "real time" is critical, as this information builds trust and allows others to plan or implement their own activities. Ensuring that information is interpreted and mobilized in a way that makes it useful to specific audiences is important. This includes considering the broader context in which information is used and ensuring that science and evidence is developed in a way that makes it accessible and relevant to decision makers. Enhanced capacity for risk communication is important.

Lesson 2: Misinformation and disinformation present a significant challenge to public policy making and public health interventions during a pandemic. To prepare for future emergencies, it will be critical to find targeted and innovative approaches to build and maintain trust in public health advice.

When COVID-19 started to spread around the world, little scientific information was available about the virus and its transmission patterns. The absence of scientific certainty upon which to base advice and support communications to the public, or in some cases, the lack of timeliness in providing advice or communicating uncertainty left space for mis- and disinformation and non-reputable sources emerged domestically and globally to fill that void.

Maintaining transparent and timely risk communications as the public health event evolves is essential, as well as communicating to the public that our knowledge of the situation, based on the evolving science and data, will continue to change. PHAC, like other public health agencies around the world, must find ways to address this and ensure to remain trusted and go-to sources of credible information. Addressing mis- and disinformation will require continuous attention and new capacity.

Work is required to build capacity within the Agency to use the most effective and appropriate communication strategies to support behavioural change and maintain it. The creation of the Behavioural Science Office (BeSciO) within PHAC and ongoing research to better understand misinformation and disinformation has been a step forward in developing this capacity. Both ongoing and innovative approaches will also be required to help build and maintain trust in public health advice. Many partnerships with community groups and innovative approaches tailored to various segments of the population were successful during the pandemic. These should be a part of the Agency's toolkit moving forward.

Lesson 3: In collaboration with public health partners, strengthen surveillance systems to access comprehensive, quality, and timely data to support public health decision making. This includes leveraging traditional types of surveillance data, as well as innovative and non-traditional sources of information such as wastewater surveillance, modelling, and anonymized mobility data. It also includes collecting disaggregated data on race, ethnicity, and socio-economic conditions to better understand how some population groups are disproportionality affected by public health emergencies and inform responses accordingly to address inequities. Finally, improving the compatibility of the data collected from various sources is also essential to maximize its usefulness.

The availability of surveillance information is critical to supporting PHAC's capacity to provide information to partners, stakeholders, decision makers, and Canadians. However, there are long-standing and well-documented challenges facing traditional forms of surveillance data, which affected PHAC's ability to provide such critical information. For example:

• lack of timeliness in information affected its usefulness;
• differences across PHAC's branches and in provinces and territories in how data is gathered, stored, and shared;
• limited longitudinal and disaggregated data, especially on age, ethnicity, identity, and socio-economic conditions; and
• challenges related to technological infrastructure, including lack of compatibility across databases, connectivity across genomic clinical data, and IT solutions to collect data in real-time or close to real-time, as well as varied capacity across existing systems.

In addition, during the COVID-19 pandemic, non-traditional forms of public health evidence, such as wastewater analysis, modelling, and the use of anonymized mobility data, added value to more traditional public health surveillance data. There is an opportunity to continue exploring such alternatives and innovate in that space. COVID-19 highlighted a need to tap into all relevant data sources available to support effective decision making.

The border testing program was the largest public health surveillance program implemented in PHAC's history. Generally, the Agency does not collect this type of data. However, work undertaken under this program showed that, in areas of federal domain like borders, data collection from the Agency can complement data collected by provinces and territories.

Finally, the pandemic has highlighted the importance of adapting public health measures to the specific circumstances of population groups disproportionately affected by public health emergencies or diseases. This requires having sufficient and timely data on race, ethnicity, and socio-economic conditions in order to better understand those impacts and inform decision making.

Lesson 4: The rapid availability, contextualization, and mobilization of evolving scientific evidence is foundational for response activities and should be built into emergency planning.

The pandemic response spurred additional scientific and technological capabilities, including the following:

• laboratory capacity;
• genomics;
• modelling;
• alternative surveillance systems, like wastewater, seroprevalence monitoring, and random testing;
• applied public health studies;
• population health survey;
• social and equity science; and
• behavioral science.

All of these allowed the Agency to obtain critical evidence-based data to inform its activities.

Maintaining a variety of scientific approaches, as well as the skills necessary to make effective use of them, are essential in ensuring proper preparedness and response. For example, the World Health Organization (WHO), the G7, and the G20 all have identified that accessible genomic surveillance is a critical element of future planning, preparedness, and response. In addition, the pandemic response highlighted the importance of applied public health studies in community and specialized settings. A better understanding of transmission dynamics, as well as the effectiveness and negative impacts of preventive measures in community and specific settings such as schools, long-term care homes, food production plants, and hospitals, as well as of immunity (seroprevalence studies) and risk factors (studies of severe vs non-severe cases) are critical to response management and resource placement. This type of evidence and data can help mitigate harm to the population and sub-populations.

Similarly, during the COVID-19 pandemic, scientific evidence accumulated at an unprecedented rate. This resulted in the need for dedicated expertise and capacity to monitor, assess, and synthesize the science available to inform decision making. Given the rapidly emerging evidence, and a large number of unknowns as the pandemic unfolded, expert engagement and advice was essential for interpreting emerging scientific evidence and guiding recommendations and actions. Various advisory bodies were established to support the pandemic response, but there was an unevenness in the effectiveness and robustness of advisory approaches.

Moving forward, there is an opportunity to formalize and build on the mechanisms for rapid evidence synthesis and scientific expert engagement that were established during the pandemic to ensure ongoing capacity for evidence-informed decision making. There is also an opportunity to examine how to support a strong use and mobilization of scientific evidence, such as developing a roster of experts and having a more structured approach to advisory bodies.

Continued investment in science, applied public health studies, and technology should not only enhance PHAC's ability to face health emergencies, but also to address the long-term impacts arising from public health emergencies.

Lesson 5: Health equity needs to be at the centre of future response and recovery activities.

The COVID-19 pandemic and response illuminated and amplified existing social, economic, and health inequities in Canada and globally. To address inequities, PHAC was able to capitalize on its long-standing relationships with community organizations to connect with populations in situations of vulnerability and provide adapted services and information. New tools were also developed, such as the Immunization Partnership Fund.

Many of the lessons learned during the pandemic reflect the need to integrate equity considerations within future public health emergency planning and decision making to avoid unintended harm and consequences to populations already experiencing inequities and to support equitable outcomes for all people. As such, PHAC needs to continue and further integrate actions to improve health equity within all its activities, including measuring and monitoring the direct and indirect impacts of its response on different populations living in Canada. In addition, PHAC needs to work across the federal government to collaborate on policies and programs that reduce social and economic disparities as key factors that influence health inequalities. Tools and mechanisms to fund community organizations that support vulnerable populations are critical to extending the reach of public health activities in an emergency. Reducing inequalities writ large, outside of a pandemic context, will build greater resilience in the population to minimize disproportionate impacts from future public health emergencies.

Lesson 6: To prepare for future emergencies, PHAC needs a robust mobilization strategy that can support the quick deployment of a surge capacity and the appropriate support to sustain this capacity in the longer term. This strategy should provide a foundation to:

• Ensure that PHAC has the right blend of operational capacity and science-based expertise built in and ready to address future challenges.
• Allow for the quick mobilization of additional capacity and expertise within the Agency and the rest of the federal government that could include having an inventory of expertise in core areas.
• Support the well-being of mobilized employees throughout the response.
• Build the foundation to quickly ramp up support functions, including staffing, financial management, procurement, and IT systems.

The Agency's ultimate strength during the COVID-19 response came from its workforce's expertise and dedication. At the same time, the expectation that PHAC employees, at all levels, could continue to work at the pace and scale required by the COVID-19 response over multiple years was not sustainable. This should be addressed prior to the next large-scale public health emergency.

In addition to workload, other factors that challenged employees' well-being, included threats to personal security, negative treatment of front line workers by the public, difficult working conditions, equipment availability, and, a lack of previous experience or training for new tasks that emerged such as border operations.

To help cope with the demands, PHAC employees were invited to access a wide variety of mental health information resources and support services. Starting in January of 2021, the suite of Culture of Care psycho-social support services was also offered to pandemic responders.

The COVID-19 response, like other past public health emergency responses such as H1N1, showed that having the appropriate tools to support employee well-being must remain a priority. The many supports benefitted frontline responders, but should be in place at the onset of any major event.

Overall, the COVID-19 pandemic demonstrated the importance of being able to mobilize the necessary staff and expertise to sustain a large-scale response over the longer term. This includes having sufficient scientific and public health background knowledge, and pairing scientific expertise with policy development and knowledge translation. It highlighted the importance of having a strong mobilization strategy that recognizes the need for technical and medical expertise to develop science-based guidance and advice, and to provide laboratory services, but also a strong operational base to implement measures on the ground. There is also a need to re-evaluate core competencies for public health and ensure PHAC is equipped with a stable capacity to meet future challenges. Many suggestions heard in interviews outlined numerous considerations, including a government-wide approach to mobilization, dedicated HR capacity to support mobilization, talent pipelines, and psychological support preceding, during, and following the event, among others. Leveraging existing flexibilities in staffing processes to quickly bring in new employees to the Agency is also important.

Similarly, the response required the Agency to double in size, significantly increase its budget, implement massive bulk procurement of medical equipment, supplies, and services, and rapidly deploy IT solutions. It highlighted the importance of having a mobilized corporate expertise in the functional areas of workforce and staffing, financial management, contracting and procurement support, and IT. Planning for the next emergency will also require maintaining adequate capacity and expertise in those areas, as well as proactively developing the tools, authorities, and procedures required to respond to emergencies.

New processes, governance, and partnerships with other federal departments like Public Services and Procurement Canada had to be quickly defined and implemented to enable these corporate functions. Plans for the next emergencies need to account for the lessons learned from the COVID-19 response and build a foundation for the fast deployment of procurement and IT solutions. This would include identifying the governance mechanisms required to support coordination within these areas, having procurement plans in place, and exploring the feasibility of having pre-established standing offers and contracts. In some areas, PHAC's current IT systems and infrastructure led to difficulties in the response, such as with bulk purchasing of medical equipment and supplies, as well as stockpile management. While PHAC had robust enough controls in place to support the sound management of purchases made, relevant IT systems, including those related to inventory management, financial systems, and procurement, did not have a common interface, which made processes complicated and inefficient. Aging IT systems and infrastructure also affected efficient quarantine enforcement and isolation measures. Investments were made to develop IT systems to support the response. This showed that having efficient IT systems and infrastructure would help support an effective and resilient response to future public health emergencies.

Lesson 7: Strong strategic planning capacity is required to ensure preparedness and response.

Large-scale public health emergencies require the prioritization of activities that are critical for the response and of core non-pandemic activities that must continue. PHAC is an organization with various roles and responsibilities. Strong planning and prioritization allow the organization to find and allocate resources where most needed, while ensuring that work on other priority files remains ongoing as appropriate. This must take into consideration the main public health event, as well as potential wider health impacts. Exercising this capacity when the Agency is in a preparedness posture is equally important.

PHAC needs to continue its work on strengthening its strategic planning systems, as this will allow the Agency to move from a reactive position to a proactive state when addressing an emergency. There should be a clear identification of which governance tables have the role to lead PHAC's strategic planning for response prioritization, as well as non-response activities. Roles, responsibilities, and accountabilities of these tables should be made clear to ensure their effectiveness in supporting PHAC's strategic planning.

Lesson 8: Future event planning should consider that a response may continue for an extended period of time beyond the vaccination of the population, and address secondary effects that may last over time. Preparedness measures need to support a phased and prolonged response that needs to take longer-term impacts into account.

The vaccination rollout was instrumental in the response to COVID-19, saving lives and providing hope for an eventual return to normal life. The distribution and administration of COVID-19 vaccines was the largest and most complex vaccination program Canada has ever implemented. Canada's percentage of the population receiving two doses of a SARS-CoV-2 vaccine was higher than any other comparable country.

Unlike past emergencies like H1N1, the pandemic did not end shortly after the distribution of the first vaccine doses. For example, the first doses of COVID-19 vaccine were delivered in Canada in December 2020, approximately two and a half years before the WHO declared the end of COVID-19 as a global health emergency in May 2023. This underlines the importance of being prepared to lead response that may continue for an extended period of time and effectively communicate this.

Given that COVID-19 pandemic also has had secondary effects that will likely last beyond the emergency phase of the pandemic itself, attention to longer-term impacts needs to be built into the response (for example, there were mental health impacts on various population groups). As such, PHAC needs to be prepared to lead responses that may continue for an extended period of time after the achievement of key milestones, and communicate this reality to affected parties in order to manage expectations.

Scenario-based planning to identify resources, protocols, and processes to ramp up in future emergencies, based on the level of risk of a potential pathogen, would enable a faster and more efficient response and help sustain the response over the longer term. For example, scenario-based planning for future emergencies should account for the necessary protocols, security measures, space requirements, governance structures, and procurement needs that would have to be fulfilled in order to implement public health measures to address both the virus and its longer-term impacts on other aspects of Canadians' health.

Lesson 9: The COVID-19 response required intensive collaboration across the Agency and with federal, provincial, territorial government as well as with other partners. Streamlined governance, clarity, and a collective understanding of roles and responsibilities across and between jurisdictions help support an efficient response. Mechanisms to expand and enhance governance in an emergency should be examined and prepared for.

Clear identification of roles, responsibilities, and accountability is essential for an efficient response. These responsibilities should be communicated and understood by everyone who plays a role in the response. While existing plans and Acts have outlined the roles and responsibilities of federal, provincial, and territorial governments and departments, not all work areas required by the COVID-19 response were accounted for in these plans and required actions outstripped the capacity of many jurisdictions.

PHAC should ensure that all implicated parties are both aware of, and understand, roles during a public health event. This can be achieved through regular employee training and tabletop exercises with stakeholders included in the federal, provincial, and territorial Public Health Response Plan for Biological Events.

In addition, for the COVID-19 response, many internal and external governance tables bringing partners together were created to support response implementation. These tables helped to support the response and leverage the expertise and capabilities of partners, but were built unevenly. A more comprehensive planned governance structure would improve efficiency and avoid gaps and duplication.

Canada's response compared to other countries

Early evidence suggests that Canada's response strategy was effective when compared with peer countries. For example, a July 2022 article was published in the Canadian Medical Association Journal comparing Canada's response in the initial two years of the COVID-19 pandemic with that of ten peer countries^{Footnote 5}. Canada performed better than most in terms of cumulative per capita rate of COVID-19 cases, with most comparable countries having at least two- to threefold higher case counts than Canada. Canada's rate of COVID-19 related deaths was also the second lowest compared to other countries. Also, the percentage of the population receiving two doses of a COVID-19 vaccine was higher than any other comparable countries. The researchers hypothesize that high vaccination rates and good compliance with sustained public health restrictions such as restrictions on public gatherings, internal movement, and school closures, partly explain Canada's robust performance in limiting COVID-19 health burdens.

Similarly, a July-August 2022 study conducted by researchers from PHAC compared Canada's response with those of other countries against a variety of scenarios.^{Footnote 6} These counterfactual scenarios included a scenario with no public health measures or vaccines, and a scenario where public health measures, like lockdowns and masks, would have been lifted earlier. The study showed that the combination of public health measures and vaccinations that occurred in Canada resulted in far fewer infections, hospitalizations, and deaths than the counterfactual scenarios. Simulations also showed that the earlier measures were lifted, the worse the outcomes were in terms of hospitalizations and deaths.

The International Association of National Public Health Institutes (IANPHI) also conducted a lesson learned exercise, based on the responses of National Public Health Institutes (NPHIs), about their role in the COVID-19 response in 2020.^{Footnote 7} It showed that, overall, the experiences and lessons from the various NPHIs were similar to what PHAC and Canada experienced as well.

• As was the case in Canada, many NPHIs were not adequately prepared for such a major public health crisis. COVID-19 rapidly became their primary focus, and all NPHIs had to adapt, reorganize, renegotiate, or even suspend their work to concentrate resources towards the COVID-19 response.
• A majority of NPHIs experienced challenges in developing and accessing human, financial, and material resources like PPE, testing kits, and therapeutics. Many considered themselves chronically underfunded before the pandemic and had a limited reserve and mobilization capacity required for the response.
• NPHIs had to work closely with local authorities and health systems. They had to involve them in the decision-making process, as well as the design and delivery of essential services, including surveillance and response. This includes greater clarity on channels of communication and messages between all the actors involved, and enhanced governance.
• Other NPHIs also faced challenges in scaling up their workforce with adequate skills and capacities in specialized areas, including epidemiology, laboratory, risk assessment, and risk communications, in order to address the COVID-19 pandemic. The review of NPHIs found that there are opportunities for NPHIs to mobilize a wider range of experts and strengthen partnerships with other sectors to support the response to future public health emergencies. The review also found that NPHIs need to develop clear strategic plans for communicating their data, guidance, and advice to decision makers.^{Footnote 8}
• Other countries also faced challenges with the availability and integration of surveillance data.^{Footnote 9} The review of lessons learned from NPHIs noted that the demands of the COVID-19 pandemic revealed the need to improve public health surveillance in the global context. For example, by digitizing systems with unique health identifiers to connect individual-level data and incorporate privacy safeguards.^{Footnote 10}
• Finally, the IANPHI report outlined the criticality of science-based evidence, including how it was collected and the need to document how science advice is used in decisions taken by governments or their respective organizations, noting that the policy measures ultimately taken may be based on a range of factors outside of the advice provided.