When the next pandemic arrives (and it will!) Canada will once again face urgent questions: Which treatments work? For whom? At what dose? And how quickly should we act?
During the COVID pandemic, we had to answer these questions without a reliable way to rapidly test outpatient treatments in community settings. Instead, we relied heavily on data from pharmaceutical-sponsored studies that often left significant ambiguity about how well a therapy would work in general populations. That uncertainty shaped billion-dollar procurement decisions and left health-care providers without clear guidance.
We now have an opportunity to change this.
A ready-to-run adaptive platform trial that stays in place to evaluate multiple treatments as soon as a threat emerges could ensure that Canada is no longer caught unprepared or dependent on evidence from elsewhere. This type of platform trial would be permanent, “always on” infrastructure to rapidly assess multiple treatments in real-world settings.
The Paxlovid story is a telling example. Canada purchased large quantities based on early trial data sponsored by the manufacturer. Those trials, while important, did not reflect the realities of outpatient care in Canada, where patients had different levels of vaccination, comorbidities and health-system access. It later became clear, only after additional data were released by the manufacturer, that the benefits were smaller than initially expected, especially for lower-risk groups.
This is not about criticizing any one trial. It is about recognizing that Canada had no mechanism to answer these questions for itself, quickly and independently. Without a rapid way to evaluate effectiveness in our own communities, governments had to make decisions with wide uncertainty and limited local data.
That vulnerability is still with us today.
Canada faces two structural challenges during health emergencies:
1- We do not have a rapid method to evaluate outpatient treatments. Most people with acute respiratory infections, whether COVID, flu, RSV or a future pathogen, are treated in primary care and emergency departments, not hospitals. Yet our research infrastructure has traditionally focused on acute care settings. This leaves us unable to quickly test therapies where they matter most.
2- We rebuild research infrastructure from scratch every time. Each new pandemic or emerging infection requires new teams, contracts, ethics approvals, data capture systems and protocols. This delays the start of trial by weeks or months; the exact period when governments are making critical decisions about what to purchase and how to deploy it.
The result?
Canada ends up making high-stakes clinical and procurement choices with limited local evidence. That is a fundamental vulnerability.
A ready-to-run platform trial can address this gap. The platform does not shut down between pandemics, it stays active, even at low intensity. When a new virus emerges or new therapy becomes available, enrolment can ramp up immediately, avoiding delays that come from reinventing the wheel.
It can test more than one treatment at a time. Instead of running separate trials, an adaptive platform can evaluate several therapies in parallel under one master protocol. This reduces cost, improves efficiency and accelerates decision making.
The adaptive platform evolves as evidence evolves; it allows ineffective treatments to be dropped and promising ones to be added. The trial adapts to changing variants, patient needs and scientific priorities.
Major international trials (such as RECOVERY and PANORAMIC in the United Kingdom and REMAP-CAP globally) showed how quickly adaptive platforms can produce reliable answers.
The next pandemic will not begin in hospitals. It will begin in walk-in clinics, family practices, urgent care centres and emergency departments. That is where clinicians see the earliest cases, and where early treatment decisions shape outcomes.
Evaluating treatments in these settings matters because:
1- Effectiveness varies based on timing of treatment and patient characteristics.
2- Many high-risk groups, including people facing economic insecurity, newcomers, and those without access to regular primary care, receive care in outpatient settings.
3- Early treatment can prevent hospital admissions and reduce pressure on emergency rooms.
Early steps are already underway. TreatResp (adapted from CanTreatCOVID, one of the largest outpatient trials conducted in Canada with 800 participants) offers an initial demonstration of how this model can work in community settings. But efforts like this will only reach their potential if they are treated as national infrastructure rather than short-term projects.
A standing trial embedded in community settings strengthens the entire system, not just hospitals. It also supports more responsible public spending. A standing platform would give decision-makers early signals about which drugs are effective, which groups benefit most and rapid data to support or revise guidelines.
In other words: better data, fewer costly mistakes.
There is growing recognition across health systems that preparedness cannot focus solely on stockpiles, vaccines or hospital surge plans. We also need the capacity to generate evidence, rapidly, locally and independently.
The window to build this is open today. Once the sense of urgency fades, it will be much harder to create sustained funding and political support. If we want to avoid repeating the uncertainty of the last pandemic, we need to act now.
Conflict of interest disclosure: Dr. Andrew Pinto is the Principal Investigator for CanTreatCOVID and TreatResp. Dr. Benita Hosseini is the co-Principal Investigator for CanTreatCOVID and TreatResp.
