ARCHIVED - Lessons Learned Review: Public Health Agency of Canada and Health Canada Response to the 2009 H1N1 Pandemic
3.6 Federal response in on-reserve First Nation communities
Health Canada’s First Nations and Inuit Health Branch, in collaboration with the provinces, provides health care services to on-reserve First Nation communities through direct service delivery or funding through contribution agreements to First Nation organizations for delivering health care services. The First Nations and Inuit Health Branch provides basic primary care services in nursing stations in remote and isolated on-reserve First Nation communities.
During a pandemic, the First Nations and Inuit Health Branch provides health services to on-reserve First Nation communities. This includes providing assistance in the development, testing and revision of pandemic plans. In collaboration with provinces, First Nations and Inuit Health Branch is also responsible for the distribution and administration of vaccines and antivirals, reporting of adverse effects of immunization and treatment, and providing culturally appropriate information and guidance to health care workers on reserves.
While conditions are improving, First Nations people living on a reserve may experience inadequate housing and a higher risk for chronic diseases such as diabetes and tuberculosis.Footnote 49 A September 2009 study revealed that, while a quarter of First Nations people living on a reserve knew of at least one confirmed case of H1N1, other health conditions such as diabetes, cancer, smoking, alcohol and drug use were of greater concern.Footnote 50 Some other factors affecting pandemic response efforts in remote and isolated communities include: the distance required to travel to hospitals for acute care, high rates of pregnancy and in a few communities, limited access to running water. These remote communities tend to experience more difficulty overall in gaining timely access to a full complement of health services.
The public perception of the Health Portfolio’s response in First Nation communities during the pandemic was shaped by the media coverage of three key events:
- Early in the pandemic, in the spring of 2009, there was a high incidence of infections, serious cases and deaths among Aboriginal people in Manitoba.
- In the summer of 2009, extensive national media coverage emphasized that federal government officials spent days debating whether to send alcohol-based hand sanitizers to First Nation communities over concerns about high alcohol content in the products.
- In the fall of 2009, there was a significant negative reaction to the shipment of large numbers of body bags to some reserves.
While initially there were difficulties in Health Canada’s response, many practices, changes and activities that were instituted during late spring and early summer 2009 improved the response in the fall. For example, after the shipment of large numbers of body bags to some reserves in the fall 2009, Health Canada implemented a number of changes to prevent a similar situation from recurring. Current procurement processes now have centralized control measures that set maximum quantities and flag unusual orders. In addition, regional staff review ordering patterns and supply levels when conducting regular site visits.
In general, First Nations people were able to take precautions against H1N1. By September 2009, almost seven in 10 (68 percent) of First Nations people living on a reserve stated that they had already taken steps to protect themselves against the illness, most frequently citing handwashing as the most effective way to protect against H1N1.Footnote 51
What worked well?
H1N1 was present in some First Nation communities early in the pandemic (May 2009). The experiences from the first wave helped to shape many preparedness and response decision-making processes and activities for the second wave. The nature of the pandemic in First Nation communities meant that there was no real distinction between the first and second waves but rather a continuous need for Health Canada’s response throughout. Therefore, change and adaptation were required while the response continued.
Many First Nation communities had pandemic plans in place
Pandemic planning efforts have been funded since 2006 in on-reserve First Nation communities. It was estimated that 80 percent of communities had pandemic plans in place at the beginning of the pandemic. As of fall 2009, 98 percent of communities had pandemic plans, and 87 percent had ‘tabletop-tested’ at least one component of their plans such as their mass immunization plans.
During the H1N1 pandemic, Health Canada officials continued to offer advice on the establishment of and/or details relating to pandemic plans, such as twinning with similar communities. In the future, Health Canada could consider looking at all pandemic plans to consider adaptability and scalability to different pandemic scenarios.
Vaccination clinics on reserves were generally successful
The vaccination clinics that took place in fall 2009 in on-reserve First Nation communities were generally successful. Overall uptake was 64 percent, some 20 percent higher than in the rest of the Canadian population.
Given the ongoing shortages of health care professionals and the increased demands on the health care system, community health resources were sometimes overwhelmed. This resulted in a limited capacity to implement community mass immunization plans. In three regions, additional nurses, physicians and pharmacists were provided by Health Canada. Other communities received surge capacity resources through their provincial health system. Again, lessons about processes and activities learned during this time should be incorporated into future pandemic planning.
Antivirals were pre-positioned in remote and isolated communities for the second wave and personal protection equipment was purchased
Health Canada’s Non-Insured Health Benefits program incorporated antiviral drugs into their standard formulary. Concurrently, Health Canada and the provinces worked together during the spring and summer of 2009 to ensure that antivirals were stockpiled in, or near, isolated or remote communities. This activity was crucial, especially for those First Nations people living on reserves. Ready access to antivirals can reduce the likelihood of serious illness. During the H1N1 pandemic, this strategy may have reduced the need for some First Nations people to be transported to tertiary care facilities for acute primary care services. This practice should be taken into account in future pandemic planning efforts.
In May 2009, in response to the H1N1 virus, Health Canada supplemented the routine personal protective equipment supplies already available by pre-positioning its modest stockpile of personal protective equipment supplies, housed at the Drug Distribution Centre in Edmonton, in many on-reserve First Nation community nursing stations and other health facilities.
First Nations and Inuit Health Branch purchased additional personal protective supplies to meet the immediate and longer-term needs of health care workers in on-reserve First Nation communities. These supplies were stored in two separate distribution centres to ensure rapid distribution of supplies to communities. Communities could order supplies monthly based on the instructions highlighted in the H1N1 personal protective equipment procedure.
There was good cooperation among Health Canada, the Public Health Agency of Canada, Indian and Northern Affairs Canada, the provinces and First Nations leadership
A number of activities took place in the summer and fall of 2009 that demonstrated cooperation between all parties. The Remote and Isolated Communities Task Group of the Pandemic Coordination Committee was established to build on and adapt existing national guidelines to “better ensure an effective and coordinated federal/provincial/territorial influenza pandemic response in remote and isolated communities, in the context of the H1N1 outbreak.” Membership included a total of 25 representatives from the Assembly of First Nations, provincial/territorial governments, the Council of Emergency Social Services Directors, the Council of Health Emergency Management Directors and the federal government.Footnote 52 This provided a framework for concentrated and coordinated response to H1N1 and established relationships for future consultations of this nature.
In addition, other activities such as the signing of a Communications Protocol in September 2009 between Health Canada, Indian and Northern Affairs Canada, and the Assembly of First Nations aimed to improve coordination of communication activities (including communications regarding access to water and transportation for public health purposes). As part of this activity, a virtual summit on H1N1 in First Nation communities was held, which helped further outline infection control practices for First Nations.Footnote 53 Footnote 54
Moreover, communication activities used established contacts to distribute information to First Nation communities. Notices and posters were sent to co-ops, Band Council offices, Northern stores, and friendship centres. Once posted and distributed, important health information was provided to leaders at 1,400 Aboriginal health organizations such as community health groups, healing lodges, health access centres, addiction centres and nursing stations.Footnote 55
Provincial public health counterparts provided continuing support to Health Canada’s First Nation and Inuit Health regions, as well as First Nation communities, whether it was the completion and testing of First Nation pandemic plans, the timely pre-positioning of antivirals or the efficient distribution of the vaccines for the mass immunization clinics.
Finally, national Aboriginal organizations representing the interests of First Nations, Inuit and Métis people across Canada were a key component of the Public Health Agency of Canada’s strategic relations plans, to which the First Nations and Inuit Health Branch contributed. Even though roles and responsibilities for regular communication with these groups needed to be clarified, collaborating with national Aboriginal organizations played an integral role in the stakeholder engagement strategy throughout the H1N1 pandemic.
Health Canada appointed a Senior Medical Advisor to oversee the H1N1 on-reserve response
A number of operational changes were made during the summer of 2009 to streamline the H1N1 response. A specific H1N1 operational team was created, and roles and responsibilities were clarified. This allowed for an improved response during the second wave. In addition, a Senior Medical Advisor was appointed to lead the response with on-reserve First Nation communities (with reporting authority) while the Assistant Deputy Minister of the First Nations and Inuit Health Branch continued as the financial authority. This appointment provided a credible medical authority for discussions both within the federal government as well as with First Nation communities. The Senior Medical Advisor also enhanced media relations and communication to Canadians regarding the federal government’s response to First Nations on-reserve.
Areas for action
As a result of H1N1, the level of preparedness on-reserve has significantly increased. However, important work remains to help prepare First Nation communities for any future pandemics or other public health emergencies.
Develop guidance on the logistical aspects of implementing pandemic plans
Health Canada officials noted that, while pandemic plans were put in place, there appeared to be confusion about some logistical aspects of the plans during the response that may need further consideration. Guidance is needed about timing to activate plans, such as when and under what circumstances a community should begin certain activities. As First Nation communities are diverse and spread across the country, this guidance should be specific enough to allow communities to activate their plan at the time most appropriate for them.
Ensure timely availability of public health guidance for First Nation communities
According to a survey of First Nation communities in September 2009, there was confusion about certain infection control practices. A majority of those living on a reserve believed that hand sanitizers were more effective in protecting against H1N1 than handwashing with regular soap and water. In addition, there appeared to be confusion about the seasonal vaccine as protection against H1N1.Footnote 56
Clear guidance on the use of alcohol-based hand sanitizers as an effective means of infection control was not available until after a very public incident about the delay in the supply of requested hand sanitizers in Manitoba in the summer of 2009. In addition, stakeholders requested guidance regarding the use of masks, gowns and pain medication, as well as on the risks and benefits of vaccines to help people make informed decisions. Finally, a coordinated approach across all jurisdictions for guidance regarding antivirals was required very early on in the pandemic. To minimize confusion and ensure that proper public health measures are instituted, quick production and dissemination of clinical care and infection prevention and control guidelines for health care workers and community members is essential, so that they can be disseminated to staff.
Respond to local issues by using regional spokespeople
To provide consistent federal messages to the media, the Minister of Health, the Chief Public Health Officer and the Health Canada Senior Medical Advisor were primary spokespeople. However, Health Canada officials mentioned the difficulties associated with the lack of regional Health Canada spokespeople to respond to local issues during the pandemic. Further consideration should be given to the use of regional Health Canada spokespeople during a pandemic to allow qualified and trained regional staff, with specific knowledge regarding local conditions, as well as established relationships, to publicly address issues arising from their jurisdiction.
Address barriers for the movement of health professionals during a public health event
To assist regions and First Nation communities in the delivery of mass vaccination clinics, First Nations and Inuit Health Branch provided surge capacity staff to communities in Saskatchewan, Manitoba and Ontario. However, almost all of the vaccination volunteers were licensed in Ontario and thus needed interjurisdictional licenses. To address this issue during the H1N1 pandemic, agreements were made with the provincial governments of Saskatchewan and Manitoba whereby they would recognize Ontario licenses for vaccination only and for a limited period. A special service in Human Resources expedited these agreements and special arrangements to assist in travel were established. Recognizing that surge capacity for mass vaccination clinics will be needed in future pandemic situations, barriers to the movement of health professionals across jurisdictions should be minimized to enable a quick and effective response to a public health event.
Challenges relating to surveillance are addressed in section 3.1, Science, surveillance and research. In addition, Health Canada officials working in this area raised a number of operational management issues, such as roles and responsibilities and surge capacity that are covered in section 3.9, Operational management.
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