Guidance for Remote and Isolated (RI) Communities in the context of the pandemic (H1N1) 2009 outbreak

5.0 Considerations for Special Populations in RI Communities

5.1 Pregnant, Breastfeeding, and Post-partum Women

Among pregnant women with pH1N1, there is a higher proportion of First Nations, Inuit and Métis people (29.5% vs. 11.1%), and a higher proportion of hospitalization (85.3% vs. 19.3%) compared to the rest of the population^xxvi.   Pregnant women, women 6 weeks post-partum, and breastfeeding women in RI communities should be followed closely and considered for antiviral therapy in a manner consistent with those in high risk groups.  Clinical Guidance for Pregnant and Breastfeeding Women with ILI in the context of pandemic (H1N1) 2009 is available at http://www.phac-aspc.gc.ca/alert-alerte/h1n1/guidance-orientation-07-09-eng.php.  RI communities may wish to create a roster with a list of due dates and delivery dates for advance planning for possible evacuation taking potential transportation and weather factors into consideration.  This roster may be useful when considering individuals at increased risk should a community outbreak occur.  The return of mothers who are 6 weeks post-partum to a community where there is an outbreak may need to be delayed, if possible.

5.2 Emergency use of Oseltamivir in Children <1 year of age

All healthy children under 24 months of age and children with certain chronic health conditions are at increased risk of influenza-related complications and hospitalization from influenza. Under normal circumstances, the use of antivirals in children under one year of age is not an approved use of the medication.  After careful review of the evidence, Health Canada has approved, in the context of pH1N1, emergency use of antivirals (oseltamivir) in children <1 year.  This use is permitted after a careful risk-benefit analysis.  Normally these children would be managed in an acute care facility in consultation with paediatric infectious disease specialists.  Consideration should be given for antiviral treatment of children <1 year of age in a RI community where delays to access to acute care could negatively impact the health of the child and delay early treatment.  Preferably, this should be done in consultation with a physician. Guidance for expanded use of oseltamivir (Tamiflu®) in children under one year of age in the context of Pandemic (H1N1) 2009 is available at http://www.phac-aspc.gc.ca/alert-alerte/h1n1/guidance_lignesdirectrices/guidance-tamiflu-eng.php.

6.0 Training and Education for Health Care Professionals

Specific RI challenges to consider include difficulties accessing training due to geographical isolation and differing staff workloads, experience and skills. Training for the primary health care workforce (in the use of PPE, infection control, testing and other pandemic-related measures) is currently being provided in the online course entitled Infectious Disease Outbreaks: Tools and Strategies for Front-Line Clinicians.

Other educational material and resources for the public and health professionals are available through the www.fightflu.ca website.  This website includes educational materials in English, French, and some in Baffin syllabics, Nunavik syllabics, Inuktitut, and Inuinnaqtun.

Advanced education for the major referral centers about the unique circumstances/ guidelines for this pandemic in R&I communities may be helpful.

PHAC has worked with mdBriefCase to develop an online learning program based on the recommendation/statement for H1N1 Vaccine.   This online program will be available in both official languages. It will require approximately one (1) hour for health professionals to complete and is an accredited course for physicians, medical specialists, and pharmacists (CME/CE).  The online course is available at www.mdbriefcase.com

7.0 Working Together

A coordinated response to pandemic influenza in Canada requires collective planning and response between federal, provincial, territorial and local governments, health authorities and key public health partners. 

The CPIP maps out how the health sector can prepare for and respond to pandemic influenza in Canada.  It does so by outlining the actions that should be taken during each pandemic phase and clarifying the roles and responsibilities of those who would be involved in a public health emergency – governments at all levels, non-government organizations, public health officials, and front-line health care workers.   A summary of the roles and responsibilities of various government departments in pandemic response pertaining to On-Reserve First Nations communities is located in Annex B (Influenza Pandemic Planning Considerations in On Reserve First Nations Communities) of the CPIP.

Provincial and territorial governments have pandemic plans which include primary health care services.  Local communities, including RI communities should continue to work with local public health authorities to ensure a coordinated and comprehensive pandemic plan that addresses their specific needs. 

Information (including updates and pandemic plans) from provinces and territories is located at http://www.fightflu.ca/province_territory-eng.html.

8.0 Research Needs

The following list of research needs was identified by members of the RITG.  It is recommended that representatives from RI communities are involved in these studies, where possible. 

• Evaluation of the epidemiology to determine if genetics (vs. social determinants) are a predisposing factor to severe illness in RI communities:
  • Apparent increased attack rate and transmission
  • Apparent increased disease severity and associated risk factors
  • Unusual or atypical presentations/clusters

• Evaluation of antiviral use in RI communities; 
  • Comparative analysis of regional use across the country
  • Assessment of antiviral effectiveness, adverse events, and resistance.

• Consideration of the factors (e.g. social determinants, geography, ethnicity) that define a “remote” and “isolated” community.

• Quantitative and qualitative comparative analysis of how RI versus urban communities coped with the pandemic, for example rate of utilization of health care/mental health services, ethical perspectives, and lived experiences.

• Research into the compounding effects of an already vulnerable population within a RI community, such as the ability of a person with an underlying medical condition who is living in an overcrowded house to cope with a pandemic.
  • Evaluation and gap analysis of existing public policy for vulnerable groups.
  • Recommendation for future policy development regarding vulnerable groups and communicable disease outbreaks.
  • Evaluation of communication strategies and barriers to access by vulnerable groups.

• Evaluation of the effectiveness and application of the guidance documents provided on the PHAC website for remote and isolated communities. 

• Public opinion research on people’s values related to H1N1 vaccine sequencing and age distribution recommendations.   

9.0 Definitions

Term	Definition
Aboriginal	The term "Aboriginal" describes a descendant of the original inhabitants of North America. The Canadian Constitution recognizes three groups of Aboriginal people – First Nations, Métis and Inuit. These are three separate peoples with unique heritages, languages, cultural practices and spiritual beliefs.
Alternative care site	An alternative care site is a site that is currently not an established health care site, or is an established health care site that usually offers a different type or level of care.
At-Risk Populations (in the context of wave 1 of the pandemic (H1N1) 2009	children under 5 years of age (especially those under 2), women who are pregnant (especially 2nd and 3rd trimester) people with asthma and other chronic respiratory diseases; diabetes and other metabolic disorders; cardiac disease; immunocompromised, immunosuppressed; blood disorders (including anemia and sickle cell anemia); neurologic and neurodevelopmental disorders (that affect swallowing and breathing) people with morbid obesity (BMI>35) Other considerations are those living in remote and isolated communities or people who are First Nations, Inuit or Métisix
Closed Facility	Fixed residential population with limited turnover, or in the case of a hospital, has units or wards that are, or can be, closedxxvii.  Other considerations, apart from being a closed facility, used to decide whether facilities are eligible for antiviral outbreak control are: The facility has high-risk patients/residents; There is ongoing surveillance to detect influenza activity and outbreaks in the facility; It would be difficult to manage an outbreak in the setting; Outbreak control would reduce the burden on the health care system (e.g. prevent hospitalization or further morbidity and mortality in already-hospitalized patients); and The facility is able to manage an antiviral regimen with adequate medical expertise and minimal public health assistance.
First Nations	The term "First Nations" came into common usage in the late 1970s to replace the word "Indian", which many people found offensive. Although the term "First Nations" is widely used, no legal definition of it exists. The term "First Nations" has also been adopted to replace the word "Band" in community names. Both status and non-status Indian people in Canada are referred to as First Nations people(s).
Health Centre	A health centre is a field unit staffed by one or more community health nurses and support personnel to carry out disease prevention and health promotion activities in the community. A health centre is normally located in a non-isolated community.
Health Care Providers	Those who provide front line primary health care or patient care (e.g. clinicians (nurses, physicians), midwives, community health rep, paramedic).
Health Service Planners	Those who plan and coordinate emergency management, including that provided during a pandemic (e.g. provincial EPR coordinators)
Nursing Station	A nursing station is a field unit located in an isolated community where there is no road access to other health care facilities. Nursing stations house field unit staff of two or more community health nurses and other support and primary health care staff organized to carry out primary health care services, including urgent care, short-term in-patient care and public/community health care.
Medical Officer of Health	A Medical Officer of Health is a physician who is appointed by a regional health authority or designated by a provincial Minister pursuant to statute as a Medical Officer of Health, and includes the Chief Medical Officer and the Deputy Chief Medical Officer.
Pandemic influenza	Pandemic influenza refers to an influenza virus changing and becoming a new strain against which people have little or no immunity; this new strain is easily spread from person to person.
Primary care	Primary care is the element within primary health care that focuses on health care services, including health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury.
Public Health Planners	Those who plan, coordinate and deliver tertiary health care (e.g. community health managers, F/P/T/L public health staff)
Reserve	The term "reserve" is used to designate an area of land set aside by the federal government for the use and occupancy of a First Nations group or band.

10.0 Abbreviations

Abbreviation	Description
AV/CC	Antiviral/Clinical Care (Task Group)
CPIP	Canadian Pandemic Influenza Plan for the Health Sector
F/P/T/L	Federal, provincial, territorial, local
HC	Health Canada
HCW	Health care worker
ILI	Influenza-like illness
MOH	Medical Officer of Health
NAS	National Antiviral Stockpile
PPE	Personal protective equipment
PHAC	Public Health Agency of Canada
RI	Remote and Isolated
RITG	Remote and Isolated Task Group, task group of the pandemic (H1N1) task force, Public Health Agency of Canada

APPENDIX A: At-Home Emergency Supply Checklist

Non-perishable food and fluids

• Canned soups
• Frozen or canned fruits, vegetables, meats and fish
• Frozen or canned juices, tea bags
• Easy dinners, such as spaghetti and tomato sauce
• Breakfast cereals, honey, sugar or sweetener
• Bottled water, Tetra Pak milk or soy milk
• Baby food/formula
• Pet food

Health and cleaning supplies

• Thermometer
• Hand soap
• Pain and fever medication (e.g. acetaminophen, for example Tylenol, or ibuprofen, for example Advil)
• Supply of prescription medications
• Masks (optional)
• Alcohol-based hand sanitizer with at least 60% alcohol
• Cough suppressants, cough lozenges (not for children under 6 years old)
• Laundry detergent
• Garbage bags
• Household cleaning supplies
• Tissues, toilet paper
• Feminine hygiene products, diapers and wipes

APPENDIX B: Remote and Isolated Communities Task Group Membership List

The Remote and Isolated Communities Task Group is comprised of 25 members with a broad range of expertise.  The Task Group represents the interest of at least 130 remote and/or isolated communities in Canada.  Some of these are Aboriginal (First Nations, Inuit, and Métis) however, others are from small settlements (e.g. mining sites, working camps).  They face common challenges and share similar strategies.

This group is comprised of representatives from:

• Federal government (INAC, HC, PHAC)
• Council of Health Emergency Management Directors
• Council of Emergency Social Services Directors
• Assembly of First Nations
• Government: Alberta, Nunavut, Ontario, Saskatchewan, Manitoba, Quebec’ Nunavik region, Yukon, Newfoundland and Labrador’s Nunatsiavut region

List of Members

Co-Chairs
Corriveau, Dr. André	Alberta Health & Wellness
Woods, Shelagh Jane	First Nations and Inuit Health Branch (FNIHB), Health Canada (HC)
Barker, Dr. Kim	Assembly of First Nations (AFN)
Belfer, Heather	Public Health Agency of Canada (PHAC)
Breen, Mark	Ontario Ministry of Aboriginal Affairs
Brunet, Stephanie	First Nations and Inuit Health Branch (FNIHB), Health Canada (HC)
Bruyere, Dawn	First Nations and Inuit Health Branch (FNIHB), Health Canada (HC)
Bulych, Cathy	Council of Emergency Social Services Directors (CESSD)
Champagne-Shields, Isabelle	Public Health Agency of Canada (PHAC)
Clegg, Cindy	Public Health Agency of Canada (PHAC)
Déry, Dr. Serge	Government of Nunavik
House, Althea	Public Health Agency of Canada (PHAC)
Jakielaszek, Fiona	First Nations and Inuit Health (FNIH), Health Canada (HC)
Ladouceur, Luc	Indian and Northern Affairs (INAC)
Leeder, Ross	Health Canada (HC)
Leinan, Val	Public Health Agency of Canada (PHAC)
Lem, Dr. Marcus	First Nations and Inuit Health (FNIH), Health Canada (HC)
Matchett, Garnet	Council of Health Emergency Management Directors (CHEMD)
Melanson, Ron	Government of Yukon
Michie, Olga	Public Health Agency of Canada (PHAC)
Olsen, Sue	Public Health Agency of Canada (PHAC)
Sarin, Dr. Chris	First Nations and Inuit Health Branch (FNIHB), Health Canada (HC)
Sobol, Dr. Isaac	Government of Nunavut
Trimp, Rick	Saskatchewan Ministry of Health
Turner, Gail	Nunatsiavut Government
Weiss, Dr. Elise	Assiniboine & Brandon Regional Health Authorities

PHAC Secretariat

Jennifer Allison, Debbie Arnold, Claudia Brown, Beverly Campbell, Kim Daly, Jennifer Smalley.

Authors

Althea House, Lisa Paddle