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Date of Latest Version: June 2009
Summary of significant changes:
The Canadian Pandemic Influenza Plan for the Health Sector (CPIP) is a guidance document developed to assist in the preparation for and response to an influenza pandemic in all jurisdictions in Canada. The purpose of Annex B is to provide guidance to pandemic planners, at all levels of government, regarding influenza pandemic considerations in on reserve First Nations communities. The targeted audiences for this Annex are on reserve First Nations community health planners and tribal councils, as well as public health departments, regional health authorities and the provinces.
Being well prepared is critical to ensuring that on reserve First Nations communities can mitigate the effects of an influenza pandemic. Incorporating the broad range of considerations outlined in this annex into influenza pandemic plans will support an effective response. It is important that influenza pandemic plans be incorporated into larger emergency response plans within the community to guarantee a coordinated community response. The annex highlights the importance for on reserve First Nations communities to work with their neighbouring communities and regional, provincial and federal governments to develop, test and implement their influenza pandemic plans.
As in the CPIP, the following components of pandemic preparedness will be addressed in Annex B: surveillance, vaccines, antivirals, health services emergency planning, public health measures and communications. Also outlined are the responsibilities of on reserve First Nations communities, provincial governments and the federal government for the delivery of health services in the event of an influenza pandemic in on reserve First Nations communities. The reader is referred to other annexes to support effective planning. It is important to consider the many variations that exist among jurisdictions in the delivery of health service for on reserve First Nations communities. This document is not meant to be a “cookie-cutter” template for all jurisdictions; it is meant to provide broad guidance to pandemic planners. Further discussions among all levels of government are required to address provincial and regional variations in planning.
This section describes the responsibilities of the various levels of government in the planning for and response to an influenza pandemic in on reserve First Nations communities.
In recognition of the unique status and needs of on reserve First Nations people in Canada, Health Canada collaborates with on reserve First Nations communities to address health barriers and disease threats, and to attain health levels comparable to other Canadians living in similar locations.
In preparing for and responding to the threat of an influenza pandemic in an on reserve First Nations community, Health Canada is responsible for the following:
PHAC works closely with the provinces and territories to improve the health of Canadians. PHAC is responsible for addressing public health emergencies and infectious disease outbreaks in Canada. It works with international and other national health authorities and stakeholders to ensure that there is clarity of roles and responsibilities and decision-making processes; enable effective, efficient and integrated federal and national health pandemic preparedness; provide linkages and coordination with provinces and territories, as well as with non-governmental and professional health organizations; and become involved with appropriate activities in the Health Portfolio and with broader Government of Canada initiatives.Footnote 13
In preparing for and responding to the threat of an influenza pandemic in an on reserve First Nations community or any other Canadian community, PHAC is responsible for the following:
INAC works collaboratively with First Nations, Inuit and Northerners, as well as with other federal departments and agencies, provinces and territories to protect the health and safety of First Nations, Inuit and Northerners.Footnote 14
In preparing for and responding to the threat of an influenza pandemic in an on reserve First Nations community, INAC is responsible for the following:
The provinces work collaboratively with on reserve First Nations communities and FNIH regional offices during the development of provincial influenza pandemic plans to define roles and responsibilities and coordinate efforts in the management of an influenza pandemic in on reserve First Nations communities.
In preparing for and responding to the threat of an influenza pandemic in an on reserve First Nations community, the provinces, including their regional health authorities, are responsible for the following:
Community leadership and health care providers in on reserve First Nations communities are on the front line in an influenza pandemic and play an essential role in the effective planning for and delivery of health care services.
In preparing for and responding to the threat of an influenza pandemic in an on reserve First Nations community, First Nations leadership and health care providers are responsible for the following:
For additional information, consult the Assembly of First Nations’ document, A First Nations Wholistic Approach to Pandemic Planning: a Lesson for Emergency Planning (PDF Document).
In developing effective plans to respond to an influenza pandemic in on reserve First Nations communities, planners are encouraged to refer to Annex A, Planning Checklists, of the CPIP for the Health Sector and other annexes referred to in this document. Annex A provides a preliminary list of planning activities developed to facilitate planning at provincial, regional and community levels.
Surveillance activities are critical for informing the public health response to a pandemic. They support the early detection and description of potential health threats present in Canada, including on reserve First Nations communities, and identify adverse drug reactions and drug resistance.
Pandemic planners should be aware of the existing provincial, regional and local surveillance systems used in their jurisdictions. Community surveillance activities, such as collection of influenza-like illness (ILI) and laboratory data, are important components of pandemic planning since the early detection of the influenza virus in Canada will have an impact on various response activities, such as the release of antiviral drugs.
FluWatch, Canada’s national influenza surveillance system, is coordinated by PHAC. FluWatch objectives are the early detection of influenza activity in Canada; the provision of timely and up-to-date information on influenza activity in Canada and abroad to professionals and the public; the monitoring of circulating strains of influenza virus, including new subtypes and antiviral resistance; and the contribution of virological surveillance information to the World Health Organization to assist with decision making for the following season’s vaccine components.
Surveillance is a key activity of monitoring and responding to the occurrence of known and unexpected serious adverse reactions to antiviral drugs and to antiviral drug resistance and effectiveness. Canada is enhancing its existing adverse reaction surveillance system, known as the Canada Vigilance Program, and will be relying on the National Microbiology Laboratory to monitor drug resistance.
Pandemic planners are referred to the CPIP, Annex N, Pandemic Influenza Surveillance Guidelines, for guidance on the standard development or enhancement of surveillance activities.
In the event of an influenza pandemic, laboratories will be instrumental in facilitating the delivery of rapid and appropriate public health responses for Canadians, including on reserve First Nations.Footnote 15 Communities will not know that they have pandemic influenza until they receive a laboratory confirmation. It is critical, therefore, for pandemic planners in on reserve First Nations communities to be familiar with established provincial testing guidelines and processes to ensure that laboratory specimens are dealt with appropriately. Planners must consider geographical location and weather conditions when transporting laboratory specimens, which are time and temperature sensitive. Once the pandemic is established in a community, it is likely that viral tests will be restricted to specific indications (e.g. to rule out the emergence of a resistant strain). It will be important to look for specific testing guidelines once the pandemic virus and its epidemiology have been identified.
Pandemic planners are referred to the CPIP, Annex C, Pandemic Influenza Laboratory Guidelines, which provides guidance on laboratory testing, surveillance and data collection.
Vaccination is an essential public health intervention during a pandemic; it is the most effective intervention that can prevent influenza. All band registered members and non status community members of on reserve First Nations communities will have timely and equitable access to the pandemic influenza vaccine, as will other Canadians. However, there will be cases of pandemic influenza in Canada before the availability of the vaccine, which will likely not be until after the first wave of illness in the country.
All levels of government (local, regional, provincial and federal) play a role in providing the pandemic influenza vaccine to on reserve First Nations people. At the May 2006 Conference of F/P/T Ministers of Health, all Ministers reaffirmed that vaccines will be available to on reserve First Nations communities on the same basis as they are provided to other Canadians. Current immunization practices in Canada and in on reserve First Nations communities will continue unless superseded by federal/provincial agreement. Given that regional differences exist, pandemic planners for on reserve First Nations communities also need to consider how they will receive, store and administer vaccines. Because of the geographically remote or isolated location of some on reserve First Nations communities and Canada’s diverse climate, planners need to consider the challenges of maintaining the cold chain during transport when distributing pandemic influenza vaccine.
Pandemic planners are referred to the CPIP, Annex D, Preparing for the Pandemic Vaccine Response, which describes the preparations for the pandemic vaccine program that are under way at the federal and pan-Canadian levels, as well as the key planning issues.
Until the pandemic vaccine becomes available, antivirals (anti-influenza drugs such as oseltamivir, zanamivir and amantadine) may be the only specific pharmacological intervention available. Antiviral drugs can be used to prevent influenza under specific circumstances, such as outbreak control, and can also be used for early treatment of cases (within 48 hours of the onset of symptoms).Footnote 16
At the May 2006 Conference of F/P/T Ministers of Health, it was reaffirmed that antiviral drugs from the joint National Antiviral Stockpile will be available to on reserve First Nations communities on the same basis as they are provided to other Canadians. The provinces, together with their regional and local partners, are responsible for implementing the antiviral program in their own jurisdictions, including on reserve First Nations communities. Since the current antiviral supplies have been allocated on a per capita basis, antivirals will be provided to all residents who meet the criteria for early treatment, including on reserve First Nations. While some differences in the implementation plans are expected, provinces will remain consistent in their uses of antivirals as indicated in Annex E; consistencies will include, but are not limited to, overall approach, eligibility for drugs, off-label use and shelf-life extensions, and communications messages. Given the criteria for early treatment of known and/or suspected influenza cases, all levels of government should discuss the feasibility of pre-positioning antivirals in remote and remote-isolated communities to assure that all on reserve First Nations people who meet the criteria for early treatment have rapid access to antivirals on the same basis as other Canadians.
Pandemic planners are referred to the CPIP, Annex E, Planning Recommendations for the Use of Anti-Influenza (Antiviral) Drugs in Canada During a Pandemic. This annex provides information to assist pandemic planners with the development and refinement of their antiviral strategies. Recommendations are intended to facilitate consistent use of antivirals across Canada at the time of an influenza pandemic and to form the basis for an effective, equitable, flexible and informed national antiviral strategy.Footnote 14
Pandemic planners should be aware that diversities exist in health care service delivery within and among regions. These diversities must be considered when developing influenza pandemic strategies and plans. For the purposes of planning, pandemic planners are encouraged to become familiar with the health care services for their region by contacting their FNIH regional representative. See Appendix 1: FNIH Regional Contacts.
The federal government, provinces, territories and communities all have key roles to play in the health care system in Canada. According to the constitutional division of powers, provincial governments have primary responsibility for organizing and delivering health and social services to their residents. Each province and territory is bound by the public health legislation in that province or territory. To receive a full cash contribution as part of the Canada Health Transfer, provinces are required to comply with the criteria in the Canada Health Act. Provinces and territories also provide specific groups with supplementary health benefits not included under the Act, such as prescription drug coverage. The level and scope of coverage for supplementary benefits varies among jurisdictions.Footnote 17 More information on provincial/territorial public health legislation can be found on the Canadian Legal Information Institute Website
At the federal level, FNIHB of HC provides or funds certain health programs and services to on reserve First Nations communities, outside the northern territories. This can include the provision of public health services, primary care services and health expertise.Footnote 18Planners are referred to the Health Canada Website for more information.
HC provides basic primary care services in nursing stations in approximately 200 remote on reserve First Nations communities.Footnote 19 It also provides public health activities such as health promotion, chronic disease prevention and infectious disease control in approximately 225 health centres.Footnote 19 For region-specific information, contact the FNIH regional representative. See Appendix 1: FNIH Regional Contacts.
Not all health services in on reserve First Nations communities are provided directly by HC. Communities governed by Band Councils have the responsibility for the provision of health care services in their communities as per level-of-funding agreements.Footnote 20
Several types of professional and non-professional health care workers provide health care services in on reserve First Nations communities. They all assume different and complementary roles and responsibilities in the delivery of health care.
Other community members may be called upon to help in the event of an influenza pandemic in a First Nations community. For example, elders and/or traditional healers can be used to help educate the community about at-home self-assessment, to provide information on self-care and to support worried healthy persons who may be presenting with ILI symptoms.
In the event of an influenza pandemic, the professional and non-professional health care workers and volunteers are likely going to assume multiple roles during all the phases, and this may include the need for additional preparation, education and/or training. Non-professionals and volunteers will stay within the scope of practice for which they have received training before an influenza pandemic.
Planners at all levels of government should address the considerations discussed below to promote the effectiveness of the influenza pandemic plan and response, while acknowledging that regional and provincial variations exist.
A multitude of factors can influence the health status of an individual or a population. For many on reserve First Nations communities, culture and tradition are integral components of a holistic approach to health and well-being. The health of on reserve First Nations people is also the result of a complex interaction of many determinants, such as education, employment and income, housing and community infrastructure, and geographical location.Footnote 22These, and non-medical factors, are key components in on reserve First Nations communities and must be respected and considered in the design and the delivery of health care services, including influenza pandemic planning and response, to promote effectiveness and efficiency.
This section refers pandemic planners to other annexes of the CPIP to support the assessment of patients with ILI in on reserve First Nations communities, as described below. While these annexes are important resources to guide clinicians in their assessment of ILI patients, the delivery of health care services in on reserve First Nations communities often differs from that in the rest of Canada and must be planned for accordingly.
Annex G, Clinical Care Guidelines and Tools, provides guidance to pandemic planners and clinicians in preparing for and responding to a pandemic. It describes the complementary roles of clinical care providers, the laboratories and public health in responding to a widespread infectious disease outbreak such as an influenza pandemic. With the information, advice and practical tools provided in Annex G, pandemic planners will be able to enhance clinical preparedness in their jurisdiction, and clinicians will increase their knowledge of the clinical aspects of an influenza pandemic response.Footnote 23
Annex G, Appendix 1, Pandemic Primer for Front Line Healthcare Professionals, explains the two interim clinical care guidelines, i.e. primary assessment and secondary assessment protocols, for patients presenting with ILI. These protocols offer a systematic approach to the triage of a large number of patients presenting with ILI symptoms; they are based on the best knowledge currently available and on clinical experience with seasonal influenza.
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 needed and/or a lack of appropriate local medical equipment and services (e.g. ventilators, oxygen therapy). If transfer is necessary, health care workers should follow the guidelines already in place at their health care facility. It is important to consider infection control practices during the transportation of patients to other health care facilities, e.g. the cleaning/disinfecting of transport vehicles in between patients to minimize the transmission of the pandemic virus.
Certain circumstances, including lack of transportation capacity, unpredictable weather conditions and overwhelmed acute care facilities, may prevent the transfer of patients. For that reason planners at all levels of government need to develop mitigation strategies to deal with severely ill patients who are unable to leave the community.
Depending on the severity of the influenza pandemic, some on reserve First Nations communities will establish alternative sites to care for patients during an influenza pandemic. An alternative site is a location 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. These sites can be used for a variety of reasons, such as to provide health care services, to prepare food, etc. Most provinces, regions and communities will rely heavily on the help of trained volunteers, alternative workers and health care workers in the management of influenza patients in local health care establishments and alternative facilities.
During an influenza pandemic, there will also be increased demand for health human resources to care for patients and to do the work necessary to mount an effective response. Alternative workers and trained volunteers will be needed to support health care workers. For example, as previously stated, elders and/or traditional healers can help with educating the community about at-home self-assessment and supporting worried healthy persons who may be presenting with possible psychosomatic ILI symptoms.
For more in-depth information on alternative sites and alternative workers, pandemic planners are referred to the CPIP, Annex J, Guidelines for Non-Traditional Sites and Workers. This annex offers guidance on the use and administration of alternative sites, and the preparedness and operational activities that should take place during the interpandemic, pandemic and post-pandemic periods of an outbreak. It also focuses on the need for and identification of additional human resources as part of pandemic planning, and identifies activities by each pandemic period.Footnote 2
Within an on reserve First Nations community, as in all other communities, infection control is essential to prevent the transmission of communicable diseases, including pandemic influenza virus. Infection control is essential in health care facilities, community facilities and at home. Routine practices are to be used in the routine care of all patients at all times in all health care settings, including alternative sites. These practices include handwashing before and after caring for patients; use of PPE when splashes or sprays of blood, body fluids, secretions or excretions are possible; the cleaning of equipment, the patient’s physical environment and soiled linen; and use of every precaution to reduce the possibility of health care worker exposure.Footnote 24
As per article 125, part II, of the Canada Labour Code, employers are responsible for the health and safety of their employees. As HC is a federal employer that uses front-line HCWs in many First Nations communities, the Canada Labour Code is applicable. Part II of the Code, section 124, states that “every employer shall ensure that the health and safety at work of every person employed by the employer is protected.”Footnote 25
In community and home settings, family members should recognize that proper handwashing is the cornerstone of infection prevention and may be the only preventive measure available during a pandemic. Hands should be washed after direct contact with sick family members or their belongings. If running water is not available, an alcohol-based gel should be used. Family members should also practise good hygienic measures, i.e. dispose of tissues after use; cover nose and mouth when sneezing and coughing; wash hands after coughing, sneezing or using tissues; keep hands away from the eyes and nose; and clean shared surfaces.
Annex F, Infection Control and Occupational Health Guidelines During Pandemic Influenza in Traditional and Non-Traditional Health Care Settings, provides a detailed overview of infection prevention and control policies and procedures that will be critical for minimizing the spread of pandemic influenza and preventing other infectious diseases. This annex guides pandemic planners in the management of pandemic influenza in both traditional and alternative health care settings.
A pandemic can occur at any time with the potential to cause extensive social and economic disruption, serious illness and death throughout the world. Annex I, Guidelines for the Management of Mass Fatalities During an Influenza Pandemic, provides some information on the special religious and ethnic considerations related to the management of bodies after death. Pandemic planners should work with communities to plan for mass fatalities to assure that cultural considerations are observed. Annex I also provides information on particular issues that northern and isolated communities could encounter in dealing with large numbers of fatalities. The psychosocial impacts of mass fatalities should be considered in planning as referred to in section 3.7.
During a pandemic, community-based public health measures will be used; such as public advice on voluntary self-isolation for ill persons, travel advisories and, if necessary, school closures and cancellation of public gatherings. Public health measures are critical components of any public health intervention to manage and control an outbreak, including the response to an influenza pandemic. For example, during the SARS outbreak, public health measures were very effective strategies in managing and controlling the transmission of the disease. For that reason, it is important for regional and provincials planners to discuss with local health authorities the need for public health measures and their implementation at the community level during an influenza pandemic.
Pandemic planners are referred to the CPIP, Annex M, Public Health Measures, for more information on public health measures recommended to minimize serious illness and overall deaths, and to minimize disruption among Canadians, including on reserve First Nations communities, as a result of an influenza pandemic.Footnote 26
On reserve First Nations communities will need accurate, timely and consistent information so that they can take appropriate action to help minimize death, illness and social disruption in the event of an influenza pandemic.Footnote 27As stated previously, this communication is the responsibility of all levels of government (local, regional, provincial and federal). FNIH regions will work closely with their respective provinces to ensure that communities receive timely, accurate and consistent messages during an influenza pandemic.
Annex K, Communications Annex, of the CPIP presents a cascading approach to pandemic communications that is closely aligned with the World Health Organization’s pandemic phases. Roles, responsibilities and strategies are outlined by jurisdiction and by World Health Organization pandemic phase so that communications are appropriate to the threat level.Footnote 27
In addition to the physical health threat of an influenza pandemic, the secondary consequences will be substantial. Illness, death, caregiving responsibilities and fear of infection will place extreme demands on the health care system and contribute to sudden and significant shortages of personnel and resources in all sectors. High rates of absenteeism, public health measures and fears of infection may result in the disruption of many normal business activities, contributing significant economic downturns particularly in tourism and other service-related industries. There may be extended and multiple periods of time when community members will not be able to engage in the routines of school, work and many leisure activities while simultaneously coping with the ongoing uncertainty of the threat and the grief of losing friends, family and colleagues.
The multiple secondary consequences of the pandemic, along with the primary (medical) consequences, have significant implications for the psychological, emotional, behavioural or psychosocial well-being of individuals and communities.
The new Annex P, Pandemic Influenza Psychosocial Annex, outlines a suggested planning framework for addressing the psychosocial implications of a pandemic influenza or any large-scale public health emergency. The annex is not prescriptive in structure; rather, it is based on the assumption that activities will be undertaken in accordance with local organizational structures and arrangements.
There are a variety of ethical principles that guide decision making during any emergency, including an influenza pandemic. Pandemic planners should apply ethical principles to guide their planning and decision making at the local, regional and provincial levels.
According to the World Health Organization, the main reasons to invest in pandemic preparedness are to improve public health infrastructure through pandemic planning, as it has immediate and lasting benefits that increase overall response capacity for all threats to public health, and to strengthen coordination among all levels of government in their response activities.Footnote 28
Being well prepared is a critical aspect in assuring that on reserve First Nations communities can mitigate the effects of an influenza pandemic. Incorporating the broad range of considerations outlined in this annex into influenza pandemic plans will support an effective response in the event of an influenza pandemic. It is also vital for on reserve First Nations communities to work with their neighbouring communities and regional, provincial and federal governments to develop, test and implement their pandemic plans. Communities with tested pandemic plans will be better prepared to respond to the threats of an influenza pandemic, thus minimizing illness, death and community disruption.
Annex B was prepared by the Communicable Disease Control Division of HC’s FNIHB and is a direct result of engagement with key internal and external stakeholders.
The Assembly of First Nations and their First Nations partners
Pandemic planners are referred to their FNIH regional offices for information on regional diversities and for guidance on influenza pandemic planning. Please direct your questions to the offices listed below.
|British Columbia Region||604-666-9106||First Nations and Inuit Health Branch
540-757 West Hastings Street
Vancouver, British Columbia V6C 3E6
|Alberta Region||780-495-5439||First Nations and Inuit Health Branch
9700 Jasper Avenue, Suite 730
Edmonton, Alberta T5J 4C3
|Saskatchewan Region||306-780-3427||First Nations and Inuit Health Branch
4th Floor, 2045 Broad Street
Regina, Saskatchewan S4P 3T7
|Manitoba Region||204-983-4199||First Nations and Inuit Health Branch
391 York Avenue, Suite 300
Winnipeg, Manitoba R3C 4W1
|Ontario Region||807-737-5865||First Nations and Inuit Health Branch
64 King St., P.O. Box 1500
Sioux Lookout, Ontario P8T 1C2
|Quebec Region||514-283-6338||First Nations and Inuit Health Branch
Guy-Favreau Complex, East Tower, Suite 216
200 René-Lévesque Boulevard West
Montreal, Quebec H2Z 1X4
|Atlantic Region||902-426-8568||First Nations and Inuit Health Branch
Suite 1525, 15th Floor, Maritime Centre
1505 Barrington Street
Halifax, Nova Scotia B3J 3Y6