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

December 9, 2009

Table of Contents

• Executive Summary
  • Purpose
  • Background on the Pandemic (H1N1) 2009 Outbreak
  • Considerations for People Living in Remote and Isolated Communities
  • Preparedness Challenges for Remote and Isolated Communities
  • Considerations for Special Populations in Remote and Isolated Communities
  • Training And Education For Health Care Professionals
  • Working Together and Research Need
• 1.0 Purpose
• 2.0 Background on the Pandemic (H1N1) 2009 Outbreak
• 3.0 Considerations for People Living in RI Communities
• 4.0 Preparedness Challenges for RI Communities
  • 4.1 Surveillance in RI Communities
  • 4.2  Clinical Care in RI Communities
    • 4.2.1  Self-assessment and Initial Triage in RI Communities
    • 4.2.2  Primary Assessment of Patients with Ili In RI Communities
    • 4.2.3  Secondary Assessment Of Patients With Ili In RI Communities
    • 4.2.4  Close Contacts of Cases in RI Communities
    • 4.2.5  Therapeutic Management, Including the Use of Antiviral Drugs in RI Communities
    • 4.2.6 Air or Ground Transfer from a RI Community
  • 4.3 Maintaining Health Services in RI Communities
    • 4.3.1 Maintaining Essential Clinic Services
    • 4.3.2 Supplies and Equipment
  • 4.4 Vaccine in RI Communities
  • 4.5 Public Health Measures in RI Communities
  • 4.6 Managing Excess Mortality in RI Communities
• 5.0 Considerations for Special Populations in RI Communities
  • 5.1 Pregnant, Breastfeeding, and Post-partum Women
  • 5.2 Emergency use of Oseltamivir in Children <1 Year of Age
• 6.0 Training and Education for Health Care Professionals
• 7.0 Working Together
• 8.0 Research Needs
• 9.0 Definitions
• 10.0 Abbreviations
• APPENDIX A: At-home Emergency Supply Checklist
• APPENDIX B: Remote and Isolated Communities Task Group Membership List
• References

Executive Summary

Purpose

The Guidance for Remote and Isolated (RI) Communities in the context of the Pandemic (H1N1) 2009 Outbreak is intended to identify the unique challenges of remote and isolated communities in relation to public health planning, response and health service delivery during a pandemic. As a result of the challenges faced, guidelines and strategies are identified for the purposes of planning and responding to pandemic (H1N1) 2009. This document can be used by community health planners, public health departments, regional health authorities and the provinces and territories, as well as health care providers who work with remote and isolated communities.

Background on the Pandemic (H1N1) 2009 Outbreak

Pandemic (H1N1) 2009 has spread rapidly worldwide since the spring of 2009. The virus spreads mainly from person-to-person in the community setting, through droplets from coughing or sneezing or through direct and indirect contact with hands/surfaces.  Current data suggests that the time from infection with H1N1 virus to the development of symptoms is on average 4 days, and a person who has untreated H1N1 can be contagious for up to one day prior to symptom onset until 7 days after illness onset.  Individuals who are severely ill or immunocompromised, and children may shed virus for longer (up to 10 days for children or weeks to months for the immunocompromised)ⁱ .  This being said, most cases of pandemic (H1N1) 2009 have been relatively mild. However, people living in remote and isolated communities in Canada may experience challenges with access to timely medical care in Canada and have experienced more severe disease than averageⁱⁱ, ⁱⁱⁱ.

Considerations for People Living in Remote and Isolated Communities

The overall health of Canadians living in remote and isolated communities can be affected by social, environmental and economic factors, including housing, water, food security, pre-existing health conditions, education and income. These factors, in addition to limited accessibility to health care due to geographical considerations are important to consider when planning for and responding to pandemic (H1N1) 2009 in remote and isolated communities.

Preparedness Challenges for Remote and Isolated Communities

Remote and isolated communities face many challenges in regards to pandemic planning.  The following areas will be addressed in the document, outlining the specific challenges for each, as well as providing strategies to consider for addressing the challenges.

• Surveillance
• Clinical care
• Maintaining health services
• Vaccine
• Public health measures
• Managing excess mortality

Considerations for Special Populations in Remote and Isolated Communities

Pregnant, breastfeeding and post-partum women and children under the age of five (especially those under age 2), in addition to those with underlying medical conditions, have seen a greater impact due to pandemic (H1N1) 2009 compared to the rest of the Canadian population. These groups are at greater risk for influenza-related complications and hospitalization due to influenza. Thus, pandemic planners and health care providers may wish to consider the unique attributes of these population groups in the context of pandemic (H1N1) 2009 in remote and isolated communities.

Training and Education for Health Care Professionals

This document recognizes that ongoing or specialized training may be difficult to obtain by professionals living and working in remote and isolated communities.  Efforts are made to provide readers with information about where to obtain information, resources and on-line training where remote internet access is available.

Working Together and Research Needs

A coordinated response to pandemic influenza will be facilitated by collaboration between all levels of government and key stakeholders.  The Canadian Pandemic Influenza Plan for the Health Sector (CPIP) outlines the roles and responsibilities of those that would be involved in a public health emergency.  Local public health authorities should also be involved in planning and responding to a pandemic.

In conclusion, a number of research needs have been identified that will be important to address in ongoing planning for pandemic influenza in relation to remote and isolated communities.

1.0 Purpose

The purpose of this document is to identify planning considerations for pandemic planners at all levels of government, specific to remote and isolated (RI) communities, in response to pandemic influenza (H1N1) 2009 (hereafter referred to as pH1N1).  These communities face unique challenges in providing health care to Canadians during the pandemic.  This document addresses the unique aspects of the public health planning, response and delivery of health services during the pandemic to RI communities and how these activities may need to be tailored as the pandemic progresses. 

The definition of the terms “remote” and/or “isolated” should be developed by jurisdictions in consultation with stakeholders and communities.  The Remote and Isolated Task Group (RITG) Terms of Reference includes the planning definition that has been adapted from Annex B (Influenza Pandemic Planning Considerations in On Reserve First Nations Communities) of the Canadian Pandemic Influenza Plan for the Health Sector (CPIP).  It should not preclude jurisdictional definitions of a RI community for pandemic planning purposes.  For discussion and optional definitions for RI, including acute care centre versus service centre as a point of reference, refer to the document entitled Considerations for Definitions of “Remote” and “Isolated”in the Context of Pandemic (H1N1) 2009^iv. 

The Terms of Reference for the Remote and Isolated Communities Task Group (RITG) defines a RI community as^v:

Since many variations exist among provinces/territories across Canada in the delivery of health care service for RI communities, it is recommended that this guidance be considered in conjunction with relevant federal, provincial and territorial guidance and planning documents.  This document is consistent with the guidelines contained in Annex B of the CPIP, and other Annexes of the CPIP.  Other references used in its development include national public health reports and guidance documents located at www.fightflu.ca, and other international consultation^vi and guidance documents^vii.

This guidance document is intended for community health planners, public health departments, regional health authorities and the provinces and territories, as well as health care providers who deliver services to RI communities.  It is also intended to provide general principles rather than replace federal, provincial, territorial, and local guidelines that have been developed for pandemic planning and response and clinical management of patients.  The suggested strategies listed in this document are not all-inclusive and individuals identified as responsible for the strategies may vary depending on the setting.  Regional variations with respect to infrastructure, human resource capacity, and planning principles should be taken into account when reading this document.

2.0 Background on the Pandemic (H1N1) 2009 Outbreak

The pH1N1 virus has rapidly spread across the world. At this point, viral spread has been almost exclusively in the community and from person-to-person through droplets from coughing or sneezing.  Like seasonal influenza, indirect transmission can occur after contact with surfaces or objects contaminated with the virus from infected persons and in some cases, during a procedure carried out on a patient that can induce the production of aerosols (e.g. during procedures such as intubation, bronchoscopy, closed endotrachial suctioning)^viii.

The typical incubation period (the time from exposure to the development of symptoms) for seasonal influenza is 1-4 days.  At this time, the epidemiologic data suggests that the incubation period for pH1N1 is an average of 4 days.  The period of communicability (the time that an individual is infectious) in untreated individuals is up to 7 days from onset of symptoms in uncomplicated cases; this may be longer (up to 10 days) in individuals with severe illness and children in whom symptoms and virus shedding may persist.  This information will be reviewed by the Public Health Agency of Canada and updated if necessary. 

In Canada, most cases from the first wave of pH1N1 were relatively mild with most individuals experiencing self-limiting illness and recovering quickly.  However, some people living in RI communities have experienced a more significant impact compared to the rest of the Canadian population^ix.  For example, a large number of First Nations and Métis people live in RI communities in Manitoba.  Although the total population of Manitoba is approximately 15.5%, as of September 2009, 38% of confirmed cases were people with Aboriginal ethnicity^x    

Internationally, similar situations to Canada have been reported.  In Australia, as of September 24 2009, 13.55% of the deaths due to pH1N1 were Indigenous persons^xi, where across Australia, indigenous people represent 2% of the total population^xii.  Moreover, indigenous people make up 24% of Australians living in remote or very remote areas and just 1% of those living in major cities^xiii.

Like seasonal flu, pH1N1 infection in humans can vary in severity from mild to severe, with the most severe disease occurring in those considered at risk of complications.  Those at higher risk of complications^xiv include:

• 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)

Women in the immediate post-partum period (up to 6 weeks) are also considered at higher risk of developing complications from H1N1^xv.Those living in remote and isolated communities or people who are First Nations, Inuit or Métis may also be at higher risk for complications. 
In the first wave of pH1N1, people 55 and older and particularly those >65 were less likely to become infected than adults under 55.  However, when infected, older people had a proportionately higher risk of being hospitalized and dying.

3.0 Considerations for People Living in RI Communities

Illness outbreaks due to pH1N1 influenza have occurred throughout Canada.  In addition to geographic considerations, there are a number of other factors including health, social, environmental and economic considerations that may affect the health status of individuals living in a RI community beyond those of the general population. 

Canadians in RI communities may face difficulties accessing the health care system. In the Northwest Territories, both Aboriginal (59%) and non-Aboriginal (76%) populations report lower rates of contact with a health care professional than the broader Canadian population (79%)^xvi.

Additionally, the Aboriginal population in Canada is younger than the non-Aboriginal population. Almost half (48%) of the Aboriginal population consists of children and youth aged 24 and under, compared with 31% of the non-Aboriginal population^xvii.   This demographic shift has significance in planning considerations such as how much and what type of antivirals a RI community may need to stockpile.

The social circumstances and needs of people living in RI communities may also differ from other Canadians in the following ways:  

There are a variety of ethical principles that guide decision-making during a pandemic, and those used to inform this document are the principles that were used to inform the development of the CPIP.

It is important that health professionals, particularly those providing care to Canadians living in RI communities, keep the above concepts in mind when assessing and treating any patients who they suspect may have pH1N1 infection.  It is important that planners and policy makers consider these determinants of health in RI communities for the inter-pandemic period in order to prepare for the next phase of the pandemic or future pandemics.