RI Challenge: Difficulty obtaining surveillance data
Due to limited capacity in a RI community, privacy concerns of some First Nations, Inuit and Métis peoples, and complicated reporting forms, there is difficulty obtaining surveillance data from RI communities.

Strategies to consider:

• Public health planners involve front-line health care providers from RI communities in the development of simplified reporting forms.
• Health care providers delegate the submission of surveillance data to support staff.
• Public health planners should actively involve schools in surveillance to identify cases before an outbreak occurs. Tools such as tracking forms and fact sheets for school based ILI surveillance are available in the Influenza Surveillance Guide for First Nation Communities.
• Health care providers train staff on the mechanisms for reporting possible and probable cases.
• Public health planners work with local governments on surveillance strategies
• Public health planners work to improve communication from referral hospital back to the community with relevant epidemiological information (e.g. diagnosis of H1N1 to determine presence of H1N1 virus in the community)

RI Challenge: Inconsistency with reporting.

Strategies to consider:

• Public health planners encourage use of national case definitions rather than regional variations to avoid confusion between RI communities that border on two provinces/territories.
• Health care providers ensure information collected at the service level is as complete and detailed as possible.

4.2.1 Self-Assessment and Initial Triage in RI Communities

The objectives of triage are to identify suspected cases of pH1N1 for clinical management and to decrease the risk of transmission of the virus to patients and health care workers in health care facilities.

Public education may help people do their own personal self-assessment and thus reduce unnecessary strain on the health care system. Many jurisdictions are planning to implement special measures (e.g. initial assessment over the phone) to: determine whether a patient has influenza and can stay at home; to determine whether he/she needs to be seen by a clinician for further assessment; and to determine whether he/she may meet the criteria for early antiviral treatment, such as the criteria outlined in the algorithm at: http://www.phac-aspc.gc.ca/alert-alerte/h1n1/tools_outils-eng.php.

Many jurisdictions are using algorithms for use during telephone triage to determine whether or not a patient should be seen by a clinician. If it is determined that a clinical assessment is not needed at that time, the person may be given guidance on self-care measures and advice on when to contact a clinician again should symptoms worsen or persist. Suggestions for supplies people may consider stockpiling at home (e.g. symptom relief products) for self-care management are listed in Appendix A, and general advice for H1N1 preparedness at home can be found in Your H1N1 Preparedness Guide, available at: http://www.phac-aspc.gc.ca/alert-alerte/h1n1/guide/index-eng.php

It is recommended that all patients who present to a clinic or assessment centre be screened for cough and fever, ideally by the first person who is expected to have contact with the patient (i.e. a receptionist). If cough and fever are present, the patient may be instructed to clean his or her hands with a 60%-90% alcohol-based hand rub or soap and water, put on a surgical or high-quality procedure mask and if possible be seated at least two (2) meters (6-7 feet) away from others. Additional information on infection prevention and control in a RI community clinic setting is available in Guidance for Clinical Management of Patients with ILI in the context of pandemic (H1N1) 2009 in Remote and Isolated Communities

RI Challenge: Lack of access to culturally appropriate information
Public education for RI community residents that encourages personal assessment prior to accessing care may be challenging due to the lack of access to culturally appropriate information, and lack of telephone access in the home.

Strategies to consider:

• Public health planners strategically place/position communication tools within a community which reflect the diverse linguistic, literacy and cultural characteristics and needs of the community. When such materials are not available, adequate resources are provided at the appropriate local or regional level to develop them.
• Public health planners utilize multimedia approaches, such as posters, community radio, Public Service Messages, print material, and flyers delivered to homes.
• Promotional materials include Service Canada’s toll-free Flu Hotline, available for the general public in English and French, at 1-800-O-CANADA or TTY 1-800-465-7735. Planners may wish to consider paid interpretation services to provide health advice over the phone in other languages.
• Health care providers consider telephone triage services, if feasible.
• Public health planners gather FNIH contact information for First Nations communities.

4.2.2 Primary Assessment of Patients with ILI in RI Communities

Primary assessment includes history-taking (signs/symptoms, underlying medical conditions) and a physical examination with a focus on vital signs, mental status, the cardiorespiratory system and functional status.

Infection with pH1N1 results in influenza-like illness (ILI) similar to seasonal influenza. For the purpose of pH1N1, the following screening criteria may be used for patient assessment/triage and is based on evidence known to date:^xx

RI Challenge: Nurses working in isolation
Nurses work independently in many RI communities and will likely need to make clinical decisions, possibly without a consultation.

Strategies to consider:

• Clinical presentation assessed by triage personnel who are equipped with and educated regarding the use of jurisdiction-specific algorithms to decide when patients can be sent home with instruction and follow-up, managed in the community, or considered for Med-Evac after a primary assessment (see section 4.2.6 of this document for considerations for air or ground transfer).
• Nurses may Med-Evac patients out sooner rather than later when bad weather is forecasted or during winter when forecasts and weather are often unpredictable.
• Education or policy development at referral centres in advance on the circumstances for transferring ‘less sick’ patients to acute care facilities.
• Health care providers use other reliable means of communication (e.g. satellite phones, email in addition to land line phone service) for consultation with physician staff.
• Planners should consider a consolidated centralized resource (e.g. Telehealth) for support with clinical decision-making.
• Health care providers organize a short-term observation unit for patients whose clinical prognosis is still in question before deciding to send patients home with instructions, to treat the patients, or Med-Evac patients out.
• Communities develop guidance for managing illness when nurses are not available. Additional information can be found in the Guidance: Looking after someone at home with H1N1 flu virus in a remote or isolated community.

RI Challenge: Higher attack and severity rates
There is evidence for increased attack rates and a higher incidence of risk conditions for severe illness in RI communities. Many of these risk conditions may be undiagnosed.

Strategies to consider:

• Health care providers’ primary assessment take into account high prevalence of chronic diseases in people living in RI communities and the likelihood of overcrowded living conditions.
• Health care providers offer treatment with antivirals to all individuals with ILI seeking medical care once pH1N1 has been detected in a remote and isolated community regardless of disease severity or the presence of risk factors for severe disease.^xxi
• Health care providers follow up with patients receiving treatment within 24-48 hours of treatment initiation to assess clinical improvement. This may be done by administrative staff or local community members, with clear guidance on when to ask patients to return for further assessment.

RI Challenge: Limited human health resources and care sites
There may be limited capacity in which to conduct clinical assessment in an existing health care facility in a RI community.

Strategies to consider:

• Health care providers group patients with ILI symptoms (e.g. see these patients in the afternoons) to prevent the need for non-flu patients to be exposed to the virus in the clinic at that time. Refer to infection prevention and control guidance documents for advice on measures to protect health care workers.
• Public health planners establish alternative care sites (e.g. schools, community centres). For a more in-depth discussion on alternative sites, refer to Annex J (Guidelines for Non-traditional Sites and Workers) of the CPIP.
• Public health planners establish agreements with alternative care sites in advance, taking supply needs into consideration.
• Health care providers and public health planners develop a roster of trained volunteers, alternative workers, etc., to assist in the management of ILI patients in alternative facilities and health care centres. Refer to Section 6.0 of this document for information on training.
• Public health planners establish Mutual Aid agreements with neighbouring jurisdictions/communities for support.

4.2.3 Secondary Assessment of Patients with ILI in RI Communities

Secondary assessment, if required, involves laboratory studies such as testing of nasopharyngeal swab specimens to further the assessment and evaluation of patients. However, once the presence of influenza in a community is established, the decision to treat or not treat should NOT be based on a point-of-care test result but rather on the clinical assessment and the patient’s underlying risk conditions. Advice regarding which tests may be considered are in Annex G (Clinical Care Guidelines and Tools) of the CPIP, located at http://www.phac-aspc.gc.ca/cpip-pclcpi/ann-g-eng.php, and relevant laboratory guidelines and nasopharyngeal swab protocol can be found in Annex C (Pandemic Influenza Laboratory Guidelines) of the CPIP, located at http://www.phac-aspc.gc.ca/cpip-pclcpi/pdf-e/annex_c-eng.pdf and the Interim Guidance for Laboratory Testing for Detection and Characterization of Pandemic H1N1 (2009) Virus.

As outlined above, RI communities have difficulty getting timely access to influenza diagnostics. For clinical decision-making, clinical assessment and the patients underlying risk conditions may drive treatment decisions. Although the performance characteristics of the currently available rapid antigen detection or Point of Care (POC) tests are poor, they may be the only option for diagnostic testing in RI communities. Given the very poor sensitivity (15%-60%) of these tests and the potential for false positive test results (especially if the tester is inexperienced), these tests are not recommended to make clinical decisions about diagnosis and treatment in individual patients.

Extreme temperature fluctuations and time delays in transporting specimens from RI communities may adversely affect laboratory test results (e.g. if a specimen is frozen and thawed, PCR testing may be falsely negative). It is advised that every effort be made to transport specimens without delay.

Guidelines for infection prevention and control, laboratory best practices and clinical assessment/management of people in a RI community is included in: Guidance for Clinical Management of Patients with ILI in the context of pandemic (H1N1) 2009 in Remote and Isolated Communities, located at http://www.phac-aspc.gc.ca/alert-alerte/h1n1/hp-ps/guideili-ldsg09-eng.php. It is recommended that specimens collected by clinicians in RI communities be collected and handled as per the recommendations in these guidelines.

RI Challenge: Delays in diagnostic results
Although it is generally recommended to collect a nasophyaryngeal swab on patients for surveillance purposes and may be warranted in certain clinical situations (e.g. patients with severe illness requiring hospitalization, for outbreak investigation), there may be delays in receiving test results. It is important that clinicians do not delay treatment decisions in suspect cases while awaiting laboratory results.

Strategies to consider:

• Health care providers in RI communities have access to expert consultation via phone/email (or other reliable means of communication) to support clinical decision-making throughout a pandemic.

Public Health planners develop a testing strategy prior to the next wave.

4.2.4 Close Contacts of Cases in RI Communities

After the pandemic has become established, contact tracing for surveillance purposes is not recommended. Due to widespread community spread of pH1N1 and to minimize the risk of antiviral resistance, close contacts² are not routinely offered post-exposure antiviral prophylaxis (prevention). However, they may be educated and instructed to seek early treatment if they develop ILI symptoms.

RI Challenge: Overcrowding and isolation of cases
Generally, it is recommended to isolate cases from those who are at-risk and for sick individuals to keep a distance of two meters (6-7 feet) from others. This may be challenging in situations of overcrowding.

Strategies to consider:

• Health care providers educate all close contacts of cases to seek assessment and early treatment if they develop ILI and live with a sick individual.
• Health care providers recommend other measures, such as when an ill patient cannot perform proper cough etiquette they wear a surgical or high-quality procedure mask when healthy individuals are in the room. Having said this, there is limited evidence to support the use of masks in households as a means to reduce influenza transmission in the household. Advice on the proper use of masks in the home can be found in the guidance at: http://www.phac-aspc.gc.ca/alert-alerte/h1n1/rem-iso/guid_home-maison-eng.php
• Public health planners and health care providers provide information on hand hygiene (alternative means for effective hand washing if they are without clean running water) and cough etiquette for patients, their contacts and the broader community (see www.fightflu.ca).

Information for caregivers is included in Guidance: Looking after someone at home with H1N1 flu virus in a remote or isolated community.

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4.2.5 Therapeutic Management, including the use of Antiviral Drugs in RI Communities

General advice regarding antiviral therapy is located in Annex E (The Use of Antiviral Drugs During a Pandemic) of the CPIP. Additional advice on the clinical management of patients in a RI setting is located in Guidance for Clinical Management of Patients with ILI in the context of Pandemic (H1N1) 2009 in a Remote and Isolated Communit.

Advice on outbreak management in a remote and isolated community is located in Guidance for the Management of Pandemic (H1N1) 2009 Outbreaks in Residential Facilities in Remote and Isolated Communities.

While not all individuals in RI communities are considered more at risk for influenza complications, it is recommended that the treating clinician be aware of what can place individuals at a higher risk (e.g. underlying chronic medical conditions, pregnancy, children less than 5 years of age), which can in turn impact the need for investigation and clinical judgment.

Experience thus far with the pH1N1 outbreak supports early assessment and treatment of those in the general population with ILI who are at-risk of complications to reduce overall morbidity and mortality. Due to the circumstances in a RI community, it is recommended that early treatment be considered for those with ILI regardless of disease severity or underlying medical conditions. Should a patient be placed on antiviral therapy and is not responding well, antiviral resistance could be suspected and discussed with local public health authorities.

RI Challenge: Availability of Antivirals
The availability of antivirals in a RI community may be impacted by transportation and weather issues which could delay the initiation of early (within 24-48 hours of symptom onset) treatment.

Strategies to consider:

• Health planners work with their province/territory and/or FNIH to preposition a supply of antivirals in a RI community at an amount equal to at least 17.5% of the population in that community. It is possible that pH1N1 could spread rapidly in some remote and isolated communities and there may be a need for additional antivirals (beyond the 17.5%). Consideration should be given to increase the antiviral stockpile where delays of more than 48 hours can be expected.
• Health planners take into account the unique demographics in many RI communities and the appropriate proportion of antivirals needed (i.e. higher proportion of doses for children than in urban Canadian communities)
• Health planners consider issues such as storage space and security of supplies when prepositioning antivirals. Other important considerations include inventory maintenance, stock replenishment, and return/rotation of expiring stock, using soon-to-expire drugs first. Additional information on management of antiviral stockpiles can be located in the Management of the National Antiviral Stockpile: Options Report.
• Health care providers should regularly monitor the rate of depletion of antivirals from their stockpile and report this usage trend to regional health authorities in order to ensure an ample supply can be replenished.

RI Challenge: Limited access to Tamiflu^® suspension
RI communities may have limited access to Tamiflu^® for oral suspension for those unable to swallow capsules or for paediatric doses where paediatric capsules are no longer available. The Tamiflu^® Product Monograph^xxii provides instructions for pharmacist-preparation of oral suspension; however, there may not be a pharmacist available in a RI community to reconstitute the drug.

Strategies to consider:

• Where there is no oral suspension Tamiflu^® or paediatric capsules, emergency compounding of adult capsules can be done as outlined in the Product Monograph. Refer to: Guidance for Clinical Management of Patients with ILI in the context of Pandemic (H1N1) 2009 in a Remote and Isolated Community, available at: http://www.phac-aspc.gc.ca/alert-alerte/h1n1/hp-ps/guideili-ldsg09-eng.php for guidance on how to do this.
• Physicians who may be compounding the drug may stockpile assembly kits consisting of mortar/pestle, amber glass or PET bottle, child-resistant caps, and labels.

4.2.6 Air or Ground Transfer from a RI Community

Access to an acute health care facility is a particular challenge for RI communities. In some instances, it may be necessary to transfer a patient to an acute care facility because of the severity of symptoms, the extent of care required and the capacity to provide this care, and/or a lack of appropriate medical equipment and services (e.g. ventilators, oxygen therapy). 

RI Challenges: Transportation issues

Limited flights (e.g. infrequency of flights, unavailability of pilots for Med-Evac due to illness) or inclement weather make the transfer of critically ill patients from a RI community more challenging.

Strategies to consider: 

• Health care providers ensure that contact information for local transportation support services is readily available. 
• Health care providers maintain a roster of ill or at-risk people (e.g. pregnant women) to anticipate potential clinical deterioration and respond early for timely transfers.
• Health care providers ensure they know how to access additional clinical support: within their organization (manager, medical officers of health); and external specialist supports (regional hospitals, laboratory support, infectious disease specialists, pediatricians, public health physicians, nurse practitioners). 
• Referral centers have been educated about clinical guidelines in RI communities, and recommendations for early consultation/ transfer in certain situations (e.g. when bad weather is forecast) 
• Health service planners plan for emergency evacuations by liaising regularly with retrieval services and acute care support services in their jurisdiction.  Ensure a policy/process exists whereby Med-Evac/airline staff are prepared with equipment/supplies to implement appropriate infection control measures for individuals with ILI suspected to have pH1N1 as well as a business continuity plan to ensure the community’s emergency transport services will be maintained. 
• Consider planning options if there are no Med-Evac services (i.e. need to seek DND assistance).
• Health care providers should ensure that enough medical supplies are available to care for patients who require 24 hour care but cannot be Med-Evac’d.

4.3.1 Maintaining essential clinic services

RI Challenges: Lack of human capacity
Existing shortages of staff and the absence of surge capacity present a significant challenge in RI communities. Existing limitations to human resources could be exacerbated during a pandemic by illness-related absenteeism and personal and/or family responsibilities.

Strategies to consider:

• Health care providers receive influenza immunization.
• Public health planners call upon other key community members (elders, traditional healers, other professionals) to help educate the community using approved guidelines and materials and provide information on self-care during a pandemic.
• Public health planners consider recruitment of retired professionals or licensed professionals from other jurisdictions (e.g. nurses licensed in Ontario deployed to Manitoba) to assist.
• Public health planners establish Mutual Aid Agreements with neighbouring health care authorities.
• Public health planners consider new legislation for licensing bodies to allow licensed retirees who still have medical/malpractice insurance to assist during an emergency.
• Health care providers and public health planners reassign public health staff to care for patients with pH1N1.
• Health care providers with medical conditions that place them at high risk for severe disease or complications if infected with influenza, who are symptomatic with ILI should be provided with early treatment with antivirals. During a severe pandemic wave where safe staffing levels may be compromised, early treatment for ill staff without medical conditions may be considered.
• Health care providers, in consultation with infectious disease experts, consider post-exposure prophylaxis for front-line health care workers who have medical conditions placing them at high risk for complications who have had an occupational exposure to pH1N1. This is done on a case-by-case basis or in exceptional circumstances such as staff shortages.
• Public health planners in provinces and territories consider developing policy, in consultation with appropriate colleges or licensing bodies, that extends the right to prepare and dispense medications to other licensed health care providers.

4.3.2 Supplies and equipment

RI Challenges: Lack of availability of clinic supplies
Due to geographical location and weather conditions, there may be challenges with regard to availability of clinic resources (e.g. personal protective equipment, symptomatic relief supplies, oxygen) in RI communities.

Strategies to consider:

• Health care providers contact FNIH or their province/territory for information on access to supplies and equipment stockpiles.
• Health care providers establish a secure and adequate stockpile (4 week supply) of supplies and equipment.
• Health care planners plan to replenish supplies well in advance, taking transportation and weather delays into account.
• Health care providers establish Mutual Aid Agreements with neighbouring health care authorities for stockpile supplies.

RI Challenges: Limited controlled and secure storage capacity
Due to the potential for limited controlled and secure storage space in a RI community, challenges may arise with the appropriate care and control of stockpiled emergency supplies.

Strategies to consider:

• Public health planners should consider all sites in the community, and ensure the storage area is protected from damage by the elements, and is free from hazards (e.g. fire, water, rodents) and that supplies are stored safely and securely and the site inspected regularly.
• Public health planners provide easy access to storage facilities by health care providers.

RI Challenge: Delayed delivery of vaccine
Delivery and transportation of vaccine in RI communities can be challenging due to inclement weather. This can also impact cold chain.

Strategies to consider:

• Public health planners liaise with FNIH or their province/territory for information on mass vaccination strategies and advice on implementation strategies for the community.
• Public health planners encourage rapid and secure transfer of vaccines, with temperature monitors in place to ensure the cold chain is not breached, as per usual protocols for shipping vaccine to a RI community.
• Public health planners plan to ship all vaccines together (100% of their allocation) in one shipment as soon as possible while taking into consideration weather conditions in November and beyond.
• Health service providers plan alternate clinic dates in the event vaccine delivery is delayed.

RI Challenge: Managing adverse reactions to the vaccine
Those with potential for adverse reactions (e.g. egg allergies, previous reaction to a vaccine) in a RI community may not wish to be (nor would it be recommended that they be) vaccinated in that setting due to the challenges associated with managing an anaphylactic reaction in a RI setting.

Strategies to consider:

• Public health planners develop policies for patients with severe egg allergies. The concept of herd immunity should be discussed^xxiii with the patient and if they wish to still be immunized, if feasible, they should be referred to a setting that can provide the appropriate supervision and support, such as an acute care facility.

RI Challenge: Lack of human resource capacity to vaccinate
Mass vaccination of RI communities may be operationally difficult due to lack of capacity for vaccination clinics while maintaining normal services, additional immunization campaigns and surge needs in the fall.

Strategies to consider:

• Rather than identify individuals in the community for ‘prioritization’, it is recommended that an entire community be vaccinated at one time. Since this population is relatively small, outbreaks are particularly challenging, and there is ample vaccine for all Canadians, it would be time-effective and logistically more plausible than vaccinating segments of the community in phases.
• Public health planners consider a RI vaccination campaign whereby teams of nurses are flown in to vaccinate the community at a time while the existing staff are able to carry on with regular duties.
• Involvement and promotion of the campaign by community health care providers will help promote uptake of the program, in addition to early vaccination for elders in an Aboriginal community.
• Health service providers immunize with additional vaccines (e.g. pneumococcal) during pH1N1 vaccination, if feasible, to reduce/eliminate the need for multiple campaigns.
• Communities preparing for mass vaccination clinics can refer to the document, Mass Immunization Clinics in Remote and Isolated Communities. An online H1N1 vaccination course for health professionals is also available on www.mdbriefcase.com. For more information, see the Training section of this document.

RI Challenge: Lack of availability of non-medical supplies
Delivery and transportation of non-medical supplies (e.g. soap, food, household items, etc.) in RI communities can be challenging due to limited transportation, possible illness in the household, and other factors such as inclement weather.

Strategies to consider:

• Communities and families should be prepared. Encourage and increase awareness of individuals, families and communities to have a surge of supplies (soap, household cleaning products, non-perishable food and fluids, tissues, etc.) to maintain their needs. Refer to Appendix A of this document for a suggested list of at-home supplies

RI Challenge: Limited access to running water
Unlike most urban communities in Canada, some RI communities have limited access to clean running water for hand hygiene. Existing hand washing guidelines assume that there is access to clean running water.

Strategies to consider:

• Public health planners and health service providers increase awareness of individuals and families in RI communities on alternative means for effective hand washing if they are without clean running water. Guidelines are available in the document entitled Hand Hygiene Recommendations for the Remote and Isolated Community Settings.

RI Challenge: Public gatherings
The potential for spread of infection during public gatherings may put undue strain on already limited resources in RI communities.

Strategies to consider:

• Public health planners consider the presence of ILI activity as well as the availability of health care providers, basic medical supplies, medications, isolation beds/rooms, etc when considering the postponement of public gatherings. Advice on public health measures related to mass gatherings is located in the guidance document entitled Public Health Guidance for the Prevention and Management of ILI, including Pandemic (H1N1) 2009 Virus, related to mass gatherings.

RI Challenge: Impact of school closures
School closures in RI areas may have a significant impact on a community. Given limited qualified substitute staff in the community, the school may not be able to implement a business continuity cycle if there is a high attack rate. Hence, the school closure may be longer than in urban communities.

Strategies to consider:

• Communities considering school closures should consult with local public health authorities consistent with various school guidelines.
• Public health planners actively involve schools in surveillance to identify cases before an outbreak occurs.^xxiv
• Communities develop a business continuity plan for each school which would include a list of human resources.

RI Challenge: Potential lack of tailored public health awareness campaigns
RI communities may not be exposed to the same degree as urban communities to public health awareness campaigns. In addition, the messaging that RI communities receive is often not suited or tailored to the circumstances (e.g. limited water, limited accessibility to supplies) in these communities or considerations given to health literacy, language barriers and limited access to telecommunications including basic phone and internet.

Strategies to consider:

• Public health planners identify communities where tailored communication strategies are required given the local circumstances. Tailored strategies could include: mail outs, community radio, working with neighbouring communities to obtain necessary information, posters, door-to-door messaging, and community meetings. Tailoring may also include messaging from people who are familiar or trusted (e.g. Inuit elders or Indigenous physicians).
• Public health planners develop and communicate campaigns that are specifically tailored to the circumstances of RI communities. Posters promoting respiratory etiquette and hand hygiene are available in various languages in the Tools and Resources section of the PHAC website.