Assessing the effectiveness and feasibility of implementing mitigation measures for an influenza pandemic in remote and isolated First Nations communities: a qualitative community-based participatory research approach

full article:

Introduction

It is inevitable that a novel influenza virus will cause another global influenza pandemic in the future¹. Influenza pandemics can cause high rates of morbidity and mortality in humans, along with wide-scale social and economic disruption². Marginalized populations, such as Canadian Aboriginal (First Nations, Inuit, and Métis) populations living in geographically remote areas, continue to be disproportionately impacted by influenza pandemics^3-7. Aboriginal Canadians reportedly overrepresented the number of patients admitted to an intensive care unit during the 2009 H1N1 influenza pandemic (A(H1N1)pdm09) outbreak and the severity of disease experienced was higher among Canadian First Nations^5,8. Most Canadian Aboriginal communities are faced with unique, multifaceted challenges that impact their pandemic response capacity; for instance, being geographically remote limits their access to required healthcare services and medical supplies^9-11. Access and provision of healthcare services for Canadian First Nations is further complicated since various government organizations (eg federal, provincial, and First Nations) are responsible for the health of First Nations in Canada and these organizations have yet to clearly define their roles and responsibilities during an influenza pandemic¹². Furthermore, overcrowded housing conditions and impoverished lifestyles appear to promote virus transmission during an infectious disease outbreak in these already marginalized communities¹⁰.

Given the aforementioned, it is vital for Canadian First Nations to have pandemic plans in place that include context-specific, community-informed measures in order to improve their pandemic response capacity and mitigate the injustice that may occur during the next public health emergency^11,13,14. However, in Canada, existing national and provincial pandemic plans appear to recommend universal mitigation measures that may not be effective in remote and isolated First Nations communities due to the underlying social, economic, environmental, and cultural differences that impede feasible implementation^4,9,12,15. Commonly recommended mitigation measures can be categorized as either pharmaceutical interventions (eg vaccines, antivirals) or non-pharmaceutical interventions (eg isolation, quarantine)¹. Although pharmaceutical interventions are considered to be the best mitigation measures, limitations of supply and cost restrict their usage, especially in remote and isolated First Nations communities^1,9,16. Non-pharmaceutical interventions may help reduce the number of attack and death rates, along with lessening the pressure on the healthcare infrastructure, associated with influenza pandemics and are therefore recommended to supplement the use of pharmaceutical interventions^16-18. Unfortunately, there are significant gaps in the scientific literature regarding the effectiveness and feasibility of implementing non-pharmaceutical interventions, especially for remote and isolated First Nations communities^1,12,19. It is vital to understand which mitigation measures are most effective in order to use the limited amount of resources available for maximal impact and reduce the associated unintended social and economic consequences^12,16.

Previous pandemic planning efforts worldwide have been typically guided by government agencies, public health agencies, expert scientists, and mathematical modeling studies^20-23. While these various sources provide important information during the pandemic planning process, the limited use of public consultation has been noted^20-22. In Canada, the Assembly of First Nations noted that First Nations were not appropriately included in the creation of the national and provincial influenza pandemic plans²⁴. Public participation is increasingly being encouraged in the health policy-making process^25,26 since locally impacted populations best understand the barriers faced when implementing public health recommendations and can propose innovative modifications or solutions¹³. Engaging Aboriginal populations in the pandemic planning process can provide valuable insight into how local community perspectives and cultural values impact the effectiveness and feasibility of executing recommended mitigation measures^10,22,27,28.

Thus, the purpose of the presented study was to elicit retrospective opinions regarding the effectiveness and feasibility of implementing mitigation measures during A(H1N1)pdm09 from adult key healthcare informants residing in remote and isolated First Nations communities, using a community-based participatory research (CBPR) approach. These insights will aid in creating much needed recommendations for mitigation measures in remote and isolated First Nations communities that are context-specific and include First Nations perspectives. It is important for remote and isolated First Nations communities to have specific recommendations in place to increase compliance and reduce virus transmission²⁹. In turn, as these recommendations address the unique challenges faced by Canadian First Nations, they should be incorporated into future pandemic plans to improve the response capacity and health outcomes of Canadian First Nations during the next public health emergency.

Methods

Study area and population

The present study employed a CBPR approach as participatory research methods have been shown to be successful when partnering with Aboriginal communities^30-32. CBPR approaches can encourage Aboriginal participation, and including their input may result in more appropriate outcomes from research and policy efforts^33,34. As CBPR approaches value the equitable engagement of partners, collaboration occurred between the researchers and community members throughout the research process^30-32,35. As such, a community-based advisory group was formed of three representatives (one from each study community) to aid in designing the study, informing and piloting the questions, and disseminating the results^36,37.

The three study communities (names omitted for anonymity purposes) are characterized as remote (ie nearest service center with year-round road access is located over 350 km away) and isolated (ie only accessible by plane year-round) First Nations communities and are located in northern Ontario, Canada^12,38. Adult key informants were purposively selected based on their experience as healthcare professionals (eg health directors, clinical coordinators, registered nurses) working in a healthcare facility (eg hospital, nursing clinic, health center) in a remote and isolated First Nations community. Selected participants were also directly involved in their respective communities' response to A(H1N1)pdm09; thus, they had the required experience and authority to comment. Based on the high rate of healthcare personnel turnover in the study communities and availability of participants, a total of nine participants (three from each community) met the inclusion criteria and were invited to participate in the presented study.

Data collection and analyses

Based on a literature review of current national, provincial, regional, and community level pandemic plans and relevant literature, 41 mitigation measures (two pharmaceutical and 39 non-pharmaceutical) were included in the interview questionnaire. The key informants were asked open-ended questions regarding whether each measure was used during their response to A(H1N1)pdm09 and the effectiveness of each measure in the setting of a remote and isolated First Nations community. Effectiveness was defined as 'effects under real-world constraints' that could include 'feasibility, cost, logistics, operational and infrastructure constraints, and acceptability in terms of concerns surrounding legality and ethics, equity, public confidence, and potential unintended consequences'¹⁹. Neutral probes were used to promote elaboration, and participants were encouraged to suggest and discuss alternative and/or additional mitigation measures based on their previous experiences³⁹.

The interview questionnaires were conducted by the lead author (NAC) from July 2010 to October 2011, at a place and time most convenient for each participant after verbal informed consent was obtained (being culturally appropriate for the region)^37,40. Interviews ranged from 2 hours to 4 hours in duration, were conducted in English (as requested by the participant), and audio recorded (with the participant's permission).

The qualitative data were manually transcribed into electronic format and deductively analyzed following a template organizing approach utilizing the interview questionnaire as a coding template^39,41. For subsequent analysis and interpretation, the data were further categorized according to whether or not the measure was used and considered to be effective by the participants. The aforementioned data analysis was an iterative process completed multiple times by the lead author (NAC) and confirmed by the co-author (LJST) to increase accuracy⁴².

Ethics approval

Approval to conduct this research was granted by the Office of Research Ethics at the University of Waterloo, and the involved communities (eg Band Councils, the locally elected First Nations government); ethics approval number ORE#16117.

Results

Participants reported that 30 of the 41 questioned mitigation measures were used in some form or the other during their response to A(H1N1)pdm09. All of the measures used were considered to be effective and an additional mitigation measure was suggested. Participants agreed that three measures not used during their A(H1N1)pdm09 response would be considered to be effective in mitigating an influenza pandemic in a remote and isolated First Nations community (Table 1). The most relevant findings are presented below and highlighted by participants' representative quotes⁴³.

Table 1: Effective and ineffective measures to mitigate an influenza pandemic
in remote and isolated First Nations communities suggested by study participants (n=9)

Screening the general public and travelers for influenza-like illness at public places

Participants reported that screening the general public for influenza-like illness (ILI) using health questionnaires and declarations at public places (eg airport, school, church, local stores, health facilities) was successful during A(H1N1)pdm09. Although the lack of required supplies and trained personnel were reported issues, participants stated that screening was a particularly effective measure because it provided an opportunity to diagnose and treat people with ILI early on. However, one participant raised an important ethical concern with implementing screening measures:

It's like a moral decision, do you send your workers over there, [they] have a chance of getting infected ... morally, ethically can we put our people at the front line for people to die for other people? (Participant 2)

Thus, the participants suggested some alternatives to reduce the risk associated with implementing screening measures. One alternative was to provide personal protective equipment for screeners and a 'sick bay' for them to take short-term residence in so as not to risk transmitting the virus to their family. Another suggested alternative was to only provide relevant health information instead of having personnel to screen at public places if the virus was highly pathogenic.

Participants said that screening incoming travelers at the airport was an effective measure because it was feasible to implement and would increase awareness in community members regarding the severity of the influenza pandemic situation. However, participants reported that it was difficult to have enough human resources available to screen passengers on each arriving plane. A suggested alternative was to request the airline companies to screen and provide health information to their passengers prior to boarding flights. Participants did not screen departing travelers during A(H1N1)pdm09 as the measure was perceived to be unfeasible and not a priority due to the additional human and other resources required to screen all departing passengers in addition to all arriving passengers. However, as some participants still stated that this was an ethical measure and aided in containing an outbreak, a suggested alternative was to direct efforts towards community educational health campaigns in an effort to inform community members about when it was safe to travel.

Travel restrictions or advisories on arriving and departing passengers

The participants reportedly employed both travel restrictions and advisories on all arriving and departing passengers, no matter if they were visitors or community members, during their A(H1N1)pdm09 response. The travel recommendations generally began as voluntary advisories and escalated to mandatory restrictions as the outbreak progressed and more cases were confirmed in the nearby region. Anecdotal commentary indicated that these measures had low rates of compliance, as some community members doubted the worthiness of these measures, and were difficult to enforce, especially if other travel methods were available (eg winter road, boat). However, most participants reported that these travel measures helped contain the outbreak and were effective owing to the feasibility and cost-benefits associated with their implementation. In addition, participants described that these measures helped increase awareness amongst community members about the pandemic. Furthermore, other participants stated the importance of executing these measures to aid in decreasing virus transmission, especially in a remote and isolated community with a high prevalence of immunocompromised individuals:

The community did ... the [travel] restrictions and the advisories because we are [an] isolated [community], so I think it was necessary ... considering the grave consequences that H1N1 had on terms of health and ... considering all the chronic diseases prevalent in this community, I think it was very prudent and wise. (Participant 3)

Closing down all borders and quarantine of a geographic area

Closing down all borders and quarantine of a geographic area (cordon sanitaire) were not implemented during the study communities' response to A(H1N1)pdm09, although the possibility of implementing these measures was discussed during the community pandemic committee meetings. The majority of participants said that these measures were not effective; however, some participants believed that these measures could potentially protect their immunocompromised population under certain conditions. For instance, participants said that these measures could be effective if the virus was highly pathogenic, if an outbreak was not yet present in the nearby region, and if all of the coastal communities quarantined simultaneously. Participants reported that these measures would be difficult to implement, but still feasible since the communities are primarily accessed by airplanes and the Band Councils would have the political power to declare these measures.

[Be]cause we can probably quarantine the whole community ... to keep the community safe, we're [in] ... a better position to do that because we only get flights in. (Participant 2)

That's what they were discussing during our meetings, that they [First Nations governing body] could override all the other political levels out there and just say nope, nobody is coming in or out. (Participant 3)

On the other hand, some participants raised concerns about being able to maintain and enforce these measures, especially with regards to acquiring needed supplies and resources.

It would have to be [a] pretty severe virus ... it's hard to make an isolated community more isolated. It's the manner of how you get supplies, and how do you actually maintain life, especially [because it is] so remote up here. So, it would need to be done with caution and planning, careful planning. (Participant 9)

To reduce disturbances associated with implementing these measures, participants suggested that community members could practice a subsistence lifestyle to sustain themselves during this period. Also, another beneficial modification suggested was to partially close the community's borders, so that a mode of receiving needed supplies and human resources could still function.

Closing down community schools, childcare centers, and workplaces

The majority of participants said that closing down schools and childcare centers in the community were effective mitigation measures that were employed during their A(H1N1)pdm09 response. Generally, participants stated that these measures limited virus transmission in the community; they reported that it was difficult to implement other infection control measures (eg hand hygiene, respiratory etiquette) in the younger age groups. Participants noted that school closures done in tandem with restricting children's access into local community stores limited the ability of children to congregate elsewhere. Furthermore, participants stated that school and childcare center closures were feasible because there was often a guardian at home to care for the children, especially if workplaces were closed simultaneously. Although not used during their A(H1N1)pdm09 response, most participants thought closing workplaces would be an effective measure. Some participants raised concerns about the expense of employees' wages due to lost hours; thus, closing only non-essential community workplaces was suggested to minimize the associated economic losses. However, this modification was contested as some participants did not consider any workplaces in a northern remote and isolated community to be non-essential.

I can't think of any non-essential work places here ... all the ones I'm thinking of are essential, like we only have two stores, so no ... it wouldn't be practical. (Participant 3)

Isolation and quarantine

Both mandatory and voluntary isolation of ill individuals and quarantine of non-symptomatic contacts of ill individuals were used to mitigate the effects of A(H1N1)pdm09 in the study communities. These measures were perceived to be effective in minimizing virus transmission, especially if implemented at the beginning of a community outbreak. However, some participants mentioned that these measures were not feasible to implement since it was challenging to ensure that community members followed the recommendations. Also, finding locations to isolate and quarantine individuals was problematic due to the overcrowding present in most homes and the lack of space to accommodate ill people in community healthcare facilities.

Not effective, not in our community because it's like, there's overcrowding in their homes already [and] in the nursing station [local healthcare facility] there's no place to isolate them, it's just not physically possible to isolate them in our center. (Participant 8)

Thus, participants noted that some buildings in the community (eg school, church) could be potential places to isolate or quarantine people as needed. Furthermore, participants suggested that only the home contacts of an index case should be requested to quarantine, as it would be challenging to maintain daily community functions if all of the casual contacts were also required to quarantine since extensive social networking occurs in their communities.

Restricting public gatherings, modifying cultural practices, and traditional medicine

Participants stated that all non-essential community events (eg dances, pow wows), whether indoors or outdoors, were either canceled or postponed during A(H1N1)pdm09. Participants generally reported that canceling or postponing events was more effective than simply restricting attendance since no human or other resources were required to screen people attending the event. Furthermore, as people generally travel often between the coastal communities, participants reported that cancelling or postponing events limited virus transmission as people would not have the opportunity to congregate. Participants stated that most community members seemed disappointed by the enforcement of these measures but generally complied.

Church services and funerals were still held during A(H1N1)pdm09 as these events were considered to be essential and culturally important. Thus, participants stated that cultural practices (eg kissing, handshaking) were modified and various infection control measures (eg limiting attendance, health teachings, using hand sanitizers and masks) were employed to decrease virus transmission. The vast majority of participants believed these measures to be effective, feasible to implement, and accepted by community members especially if advocated by the Band Council and the Elders in the community.

They teach people right at the entrance door of the church and they provided gloves and masks if they ... [had] mild signs and symptoms, they had the cleaning soap ... they were told not to do it, not even the communion, and also you know limit church gathering as much as you can. (Participant 1)

Moreover, traditional medicine was suggested as an additional effective measure to mitigate an influenza pandemic in a remote and isolated First Nations community as some community members reportedly sought treatment from traditionalists during A(H1N1)pdm09. Thus, participants reported that traditional medicine should be included as a helpful mitigation measure for the next influenza pandemic.

Rapid influenza diagnostic tests in healthcare facilities

Although commercially available influenza diagnostic tests were not available for use during their A(H1N1)pdm09 response, the majority of participants said that these diagnostic tests would be effective to determine if influenza was the causative agent of a community outbreak. Participants stated that these point-of-care diagnostic tests would be helpful to reinforce a diagnosis and ensure proper treatments are prescribed. Although some participants raised concerns about the accuracy and cost-effectiveness of these diagnostic tests, others said it would be especially valuable in a remote and isolated setting because of the long time period typically required to receive laboratory results.

Point-of-care is critical up here because it can be days before we get specimens out and then days before we get results back. So any kind of point-of-care, anything is most effective here, more so than it would be in a hospital where there's a lab that can do it. (Participant 9)

Vaccines and antivirals

All of the participants reported that pandemic vaccines and antivirals were used during their A(H1N1)pdm09 response and were effective since community infection rates appeared to reduce after commencing these measures. It was also noted that antivirals were not given prophylactically to healthcare providers or contacts of an index case during A(H1N1)pdm09. Although some participants reported that prophylactic antiviral treatment would be ideal, others said it would not be the best use of resources and may contribute to the creation of antiviral-resistant virus strains.

Although the communities received enough vaccines and antivirals, some difficulties related to distribution to and within the communities were reported. For instance, it was noted that one community was only distributed half of their allotted vaccines in a timely manner. Also, shortages of qualified personnel to immunize and lack of adequate education hindered the distribution of vaccines in the communities. Confusion regarding what symptoms were required to receive antivirals led to inadequate patient treatment in some cases, and some participants reported that antivirals with short expiration dates were delivered to their community. Thus, participants suggested that providing more education regarding these measures would increase community vaccine uptake rates and help ensure that individuals seek and receive antiviral treatment when appropriate.

Discussion

In general, participants reported that most of the questioned measures could potentially be effective in mitigating an influenza pandemic in a remote and isolated First Nations community. Participants reported that mitigation measures were considered to be effective particularly if the measures aided in decreasing virus transmission, protecting their high-risk population, and increasing community awareness about influenza pandemics. However, participants reported that some of the measures that they considered to be effective were not necessarily feasible to implement given the unique conditions experienced in their communities. A number of barriers limited the feasibility of implementing community mitigation strategies, such as lack of supplies, monies, trained personnel, and community awareness, along with overcrowding in homes and insufficient healthcare facilities. Furthermore, participants noted that compliance with some recommendations was low and therefore the measures were hard to enforce. As previously alluded to, many characteristics of remote and isolated First Nations communities (eg geographic isolation, inadequate access to health care, culture)³⁸ affect their pandemic response capacity¹¹. Thus, in order to address their unique conditions and reduce the unintended consequences associated with implementing mitigation measures, the study participants suggested numerous alternatives and modifications to most of the proposed measures.

The retrospective insights collected from this study reveal some important issues that are necessary to address when planning for a future influenza pandemic in a remote and isolated First Nations community. Considering the challenges of timely distributing pharmaceutical interventions to remote locations, these findings suggest that the implementation of non-pharmaceutical interventions is especially vital to mitigate the effects of an influenza pandemic in these communities. Accordingly, the participants desired that many options for mitigation measures be recommended and that the measures be modified to address their specific community needs. It is also important that mitigation measures incorporate traditional medicine and practices as this aligns with the First Nations holistic approach to health and the importance First Nations place on these practices to aid in health emergencies⁴⁴.

Moreover, these findings suggest that community acceptance of mitigation measures is conducive to people actually adhering to the measure. In many cases, participants mentioned the need for educational health campaigns to increase community awareness and in turn adherence to public health recommendations. These findings highlight the importance of providing community- and culturally appropriate education to these communities to raise awareness so members understand the situation and how to appropriately respond^29,36,45. Also, these results revealed that participants often stated that the decision to implement mitigation measures would be dependent on the virulence of the virus. This notion of considering different community mitigation strategies depending on the severity and magnitude of the influenza pandemic situation aligns with the direction given from reputable authorities^46,47.

Furthermore, previous research has noted that living in a remote and isolated community may initially provide a barrier to the introduction of an infectious disease¹⁰. However, due to the living conditions (eg impoverished overcrowded housing), small population sizes, a high proportion of immunocompromised individuals, and tight social networking apparent in most remote and isolated communities, disease transmission is typically intensified and difficult to contain once community exposure has occurred^{4,10,29,48,49}. Thus, participants emphasized the value of rapidly commencing measures that helped to delay or contain a community disease outbreak. For instance, rapid diagnostic interventions ideally implemented at the initial stages of a community outbreak are particularly important in enclosed settings^49,50.

Likewise, border control measures (eg travel restrictions and advisories, screening measures) were generally considered to be effective by the participants and may be more feasible in isolated communities because identifying exposure sites and monitoring the movement of individuals may be more easily achieved¹². Also, participants highlighted the importance of limiting or preventing the ability of community members to congregate (eg closing down schools, canceling public gatherings) in order to reduce virus transmission. Although church services and funerals were still held for cultural reasons, these findings support the results of previous studies in that participants were open to modifying cultural practices to decrease virus transmission, especially if advocated by community Elders²⁹.

Given the aforementioned, these findings have some implications for pandemic planners. Previous studies have highlighted the importance of addressing local characteristics in pandemic plans so that recommended measures will be feasible, culturally appropriate, and accepted by the community^27,28,48,51. These findings reinforce the importance of engaging and partnering with community members in the pandemic planning process as they possess a vast amount of knowledge regarding community mitigation measures and the potential unintended consequences of implementing such interventions^27,48. Thus, CBPR approaches are recommended to update current pandemic plans with more recommendations specific for remote and isolated First Nations communities as these plans are important guides for communities. These participatory approaches foster engagement as partners are equitably engaged, knowledge generation is combined with action-oriented outcomes, and various methods can be employed^35,52-55. Also, it is imperative that action is directed at addressing the barriers these communities faced when implementing recommended mitigation measures. For instance, supply and resource distribution plans and the strategies that guide these plans should be revamped to better address the needs of remote and isolated First Nations communities during a public health emergency⁴⁵.

The presented research has various strengths: it provided policy-makers and health professionals with insight from local key informants regarding the effectiveness and feasibility of implementing mitigation measures in remote and isolated First Nations communities in hopes of designing more appropriate mitigation strategies for the future. However, some limitations were noted. In this study, it was assumed that the key informants would share reliable and trustworthy information regarding their experiences and the topic at hand²⁸. Also, the results may not be widely generalizable due to the unique characteristics of the study communities and the non-random sample of participants; however, the presented suggestions and insights may be of use to other similar enclosed settings.

Future studies evaluating the use of community mitigation measures in geographically remote Aboriginal communities during various influenza pandemic scenarios are required as great variation exists within and between each Aboriginal group in Canada^3,56,57. Furthermore, research suggests that community-level epidemiological and modeling studies are required to quantitatively confirm the effectiveness and potential cost-benefits of recommended mitigation measures^58,59. Given this, future research should be directed towards conducting community mitigation models to quantitatively evaluate which of the suggested community-specific mitigation measures would be most optimal in geographically remote Aboriginal communities.

Conclusion

As another global influenza pandemic is inevitable, it is important that pandemic plans contain effective community mitigation measures. Geographically remote Aboriginal communities are predicted to be disproportionately impacted by a future influenza pandemic; thus, it is vital that recommended mitigation strategies are feasible, accepted, and culturally appropriate. However, current Canadian pandemic plans appear to have been developed without adequate First Nations consultation and universally recommended mitigation measures may not be effective in remote and isolated First Nations communities.

The results of this study indicated that most mitigation measures would only be effective and feasibly implemented in a remote and isolated First Nations community if modifications were made to account for the unique characteristics of these communities. Local key informants should be engaged using participatory approaches in the pandemic planning process as they possess a wealth of knowledge concerning the effectiveness of mitigation strategies and the direction of mitigation efforts in health policies. These findings should be used by pandemic planners to update current pandemic plans and include more recommendations specific for remote and isolated First Nations communities as it is ethically important to address the concerns of marginalized populations to improve their pandemic response capacity and health outcomes during the next public health emergency.

Acknowledgments

The authors would like to thank the participants who were involved in this study for their invaluable contributions. This study was funded by the Canadian Institutes of Health Research (Institute of Aboriginal Peoples' Health), Aboriginal Affairs and Northern Development Canada (Northern Scientific Training Program), the Government of Ontario, and the Vanier Canada Graduate Scholarship program.

References

1. Oshitani H. Potential benefits and limitations of various strategies to mitigate the impact of an influenza pandemic. Journal of Infection and Chemotherapy 2006; 12: 167-171.

2. World Health Organization. Pandemic influenza preparedness and response: WHO guidance document, April 2009. (Online). Available: http://www.who.int/influenza/resources/documents/pandemic_guidance_04_2009/en (Accessed 23 December 2010).

3. O'Neil JD. Issues in health policy for Indigenous peoples in Canada. Australian Journal of Public Health 1995; 19(6): 559-566.

4. Kermode-Scott B. Canada has world's highest rate of confirmed cases of A/H1N1, with Aboriginal people hardest hit. British Medical Journal 339: b2746. (Online) 2009. Available: http://www.bmj.com/content/339/bmj.b2746 (Accessed 10 November 2009).

5. Kumar A, Zarychanski R, Pinto R, Cook DJ, Marshall J, Lacroix J, et al. Critically ill patients with 2009 influenza A(H1N1) infection in Canada. Journal of the American Medical Association 2009; 302(17): 1872-1879.

6. Barker K. Canadian First Nations experience with H1N1: new lessons or perennial issues? International Journal of Tuberculosis and Lung Disease 2010; 14(2): 130.

7. Spence N, White JP. Scientific certainty in a time of uncertainty: predicting vulnerability of Canada's First Nations to pandemic H1N1/09. International Indigenous Policy Journal 2010; 1(1): 1-36.

8. Zarychanski R, Stuart TL, Kumar A, Doucette S, Elliott L, Kettner J, et al. Correlates of severe disease in patients with 2009 pandemic influenza (H1N1) virus infection. Canadian Medical Association Journal 2010; 182(3): 257-264.

9. Ministry of Health and Long-Term Care. Ontario health plan for an influenza pandemic 2008. (Online). Available: http://www.health.gov.on.ca/english/providers/program/emu/pan_flu/pan_flu_plan.html (Accessed 17 December 2009).

10. Groom AV, Jim C, LaRoque M, Mason C, McLaughlin J, Neel L, et al. Pandemic influenza preparedness and vulnerable populations in tribal communities. American Journal of Public Health 2009; 99(S2): S271-S277.

11. Richardson KL, Driedger MS, Pizzi NJ, Wu J, Moghadas SM. Indigenous populations health protection: a Canadian perspective. BioMed Central Public Health 12: 1098. (Online) 2012. Available: http://www.biomedcentral.com/1471-2458/12/1098 (Accessed 8 February 2013).

12. Public Health Agency of Canada. The Canadian pandemic influenza plan for the health sector 2006. (Online). Available: http://www.phac-aspc.gc.ca/cpip-pclcpi (Accessed 17 December 2009).

13. Uscher-Pines L, Duggan PS, Garoon JP, Karron RA, Faden RR. Planning for an influenza pandemic: social justice and disadvantaged groups. Hastings Center Report 2007; 37(4): 32-39.

14. Lee C, Rogers WA, Braunack-Mayer A. Social justice and pandemic influenza planning: the role of communication strategies. Public Health Ethics 2008; 1(3): 223-234.

15. Webster P. Federal policies fuel spread of swine flu, experts say. Canadian Medical Association Journal 2009; 181(5): E90-91.

16. Low DE. Pandemic planning: non-pharmaceutical interventions. Respirology 2008; 13(S1): S44-S48.

17. Bell D, Nicoll A, Fukuda K, Horby P, Monto A; World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, international measures. Emerging Infectious Diseases 2006; 12(1): 81-87.

18. Markel H, Lipman HB, Navarro JA, Sloan A, Michalsen JR, Stern AM, et al. Nonpharmaceutical interventions implemented by US cities during the 1918-1919 influenza pandemic. Journal of the American Medical Association 2007; 298(6): 644-654.

19. Aledort JE, Lurie N, Wasserman J, Bozzette SA. Non-pharmaceutical public health interventions for pandemic influenza: an evaluation of the evidence base. BioMed Central Public Health 7: 208. (Online) 2007. Available: http://www.biomedcentral.com/1471-2458/7/208 (Accessed 10 June 2010).

20. Kotalik J. Preparing for an influenza pandemic: ethical issues. Bioethics 2005; 19(4): 422-431.

21. Marshall H, Ryan P, Roberton D, Street J, Watson M. Pandemic influenza and community preparedness. American Journal of Public Health 2009; 99(S2): S365-S371.

22. Hampton T. Pandemic flu planning falls short: many vulnerabilities in health care system. Journal of the American Medical Association 2007; 297(11): 1177-1178.

23. Patriarca PA, Cox NJ. Influenza pandemic preparedness plans for the United States. Journal of Infectious Disease 1995; 176(S1): S4-S7.

24. Assembly of First Nations. Resolution no. 66. (Online) 2005. Available: http://64.26.129.156/article.asp?id=2086. (Accessed 20 November 2010).

25. Maxwell J, Rosell S, Forest PG. Giving citizens a voice in healthcare policy in Canada. British Medical Journal 2003; 326: 1031-1033.

26. Thurston WE, MacKean G, Vollman A, Casebeer A, Weber M, Maloff B, et al. Public participation in regional health policy: a theoretical framework. Health Policy 2005; 73: 237-252.

27. Blendon RJ, Koonin LM, Benson JM, Cetron MS, Pollard WE, Mitchell EW, et al. Public response to community mitigation measures for pandemic influenza. Emerging Infectious Diseases 2008; 14(5): 778-786.

28. Braunack-Mayer AJ, Street JM, Rogers WA, Givney R, Moss JR, Hiller JE. Including the public in pandemic planning: a deliberative approach. BioMed Central Public Health 10: 501. (Online) 2010. Available: http://www.biomedcentral.com/1471-2458/10/501 (Accessed 31 May 2011).

29. Massey PD, Pearce G, Taylor KA, Orcher L, Saggers S, Durrheim DN. Reducing the risk of pandemic influenza in Aboriginal communities. Rural and Remote Health 9: 1290. (Online) 2009. Available: http://www.rrh.org.au/journal/ (Accessed 26 June 2010).

30. St Denis V. Community-based participatory research: aspects of the concept relevant for practice. In: WK Carroll (Ed). Critical strategies for social research. Toronto, ON: Canadian Scholars' Press, 2004; 292-302.

31. Macaulay AC, Delormier T, McComber AM, Cross EJ, Potvin LP, Paradis G, et al. Participatory research with native community of Kahnawake creates innovative code of research ethics. Canadian Journal of Public Health 1998; 89(2): 105-108.

32. Davis SM, Reid R. Practicing participatory research in American Indian communities. American Journal of Clinical Nutrition 1999; 69(S): 755S-759S.

33. Ten Fingers K. Rejecting, revitalizing, and reclaiming: First Nations work to set the direction of research and policy development. Canadian Journal of Public Health 2005; 96(S1): S60-S63.

34. Noe TD, Manson SP, Croy C, McGough H, Henderson JA, Buchwald DS. The influence of community-based participatory research principles on the likelihood of participation in health research in American Indian communities. Ethnicity & Disease 2007; 17(S1): 6-14.

35. Israel BA, Eng E, Schulz AJ, Parker EA. Introduction to methods in community-based participatory research for health. In: BA Israel, E Eng, AJ Schulz, EA Parker (Eds). Methods in community-based participatory research for health. San Francisco, CA: John Wiley & Sons, 2005; 3-26.

36. Charania NA, Tsuji LJS. Government bodies and their influence on the 2009 H1N1 health sector pandemic response in remote and isolated First Nation communities of sub-arctic Ontario, Canada. Rural and Remote Health 11: 1781. (Online) 2011. Available: http://www.rrh.org.au/journal/ (Accessed 24 October 2011).

37. Kirby AM, Lévesque L, Wabano V, Robertson-Wilson J. Perceived community environment and physical activity involvement in a northern-rural Aboriginal community. International Journal of Behavioral Nutrition and Physical Activity 4: 63. (Online) 2007. Available: http://www.ijbnpa.org (Accessed 10 December 2009).

38. Tsuji LJS. A decade of change in the Mushkegowuk Territory (1987-1997): moving towards a self-governing health-care system. Canadian Journal of Native Studies 1998; 18(2): 233-254.

39. Bryman A. Social Research Methods. New York, NY: Oxford University Press, 2001.

40. Skinner K, Hanning RM, Tsuji LJS. Barriers and supports for healthy eating and physical activity for First Nation youths in northern Canada. International Journal of Circumpolar Health 2006; 65(2): 148-161.

41. Crabtree BF, Miller WL. Using codes and code manuals: a template organizing style of interpretation. In: BF Crabtree, WL Miller (Eds). Doing qualitative research, 2nd ed. Newbury Park, CA: Sage Publications, 1999; 163-177.

42. Westhues A, Lafrance J, Schmidt G. A SWOT analysis of social work education in Canada. Social Work Education 2001; 20(1): 35-56.

43. Knafl KA, Howard MJ. Interpreting and reporting qualitative research. Research in Nursing and Health 1984; 7: 17-24.

44. Assembly of First Nations. A First Nations wholistic approach to pandemic planning: a lesson for emergency planning. (Online). 2007. Available: http://www.afn.ca/cmslib/general/pan-planning20078310219.pdf (Accessed 20 November 2010).

45. Charania NA, Tsuji LJS. The 2009 H1N1 pandemic response in remote First Nation communities of subarctic Ontario: barriers and improvements from a health care services perspective. International Journal of Circumpolar Health 2011; 70(5): 564-575.

46. Bell D, Nicoll A, Fukuda K, Horby P, Monto A; World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, national and community measures. Emerging Infectious Diseases 2006; 12(1): 88-94.

47. Nuzzo JB, Toner E. CDC issues interim guidance for nonpharmaceutical interventions in a pandemic. Biosecurity and Bioterrorism 2007; 5(2): 88-89.

48. Massey PD, Miller A, Saggers S, Durrheim DN, Speare R, Taylor K, et al. Australian Aboriginal and Torres Strait Islander communities and the development of pandemic influenza containment strategies: community voices and community control. Health Policy 2011; 103: 184-190.

49. Finnie TJR, Hall IM, Leach S. Behaviour and control of influenza in institutions and small societies. Journal of the Royal Society of Medicine 2012; 105: 66-73.

50. Balicer RD, Huerta M, Levy Y, Davidovitch N, Grotto I. Influenza outbreak control in confined settings. Emerging Infectious Diseases 2005; 11(4): 579-583.

51. Charania NA, Tsuji LJS. A community-based participatory approach and engagement process creates culturally appropriate and community informed pandemic plans after the 2009 H1N1 influenza pandemic: remote and isolated First Nations communities of sub-arctic Ontario, Canada. BioMed Central Public Health 12: 268. (Online) 2012. Available: http://www.biomedcentral.com/1471-2458/12/268 (Accessed 18 September 2012).

52. Macaulay AC, Commanda LE, Freeman WL, Gibson N, McCabe ML, Robbins CM, et al. Participatory research maximises community and lay involvement. British Medical Journal 1999; 319: 774-777.

53. Israel BA, Schulz AJ, Parker EA, Becker AB, Allen III AJ, Guzman JR. Critical issues in developing and following CBPR principles. In: M Minkler, N Wallerstein (Eds). Community-based participatory research for health: from process to outcomes, 2nd ed. San Francisco, CA: John Wiley & Sons, 2008; 47-66.

54. Israel BA, Coombe CM, Cheezum RR, Schulz AJ, McGranaghan RJ, Lichetenstein R, et al. Community-based participatory research: a capacity-building approach for policy advocacy aimed at eliminating health disparities. American Journal of Public Health 2010; 100(11): 2094-2102.

55. O'Brien MJ, Whitaker RC. The role of community-based participatory research to inform local health policy: a case study. Journal of General Internal Medicine 2011; 26(12): 1498-1501.

56. Waldram JB, Herring DA, Young TK. Aboriginal health in Canada: historical, cultural, and epidemiological perspectives, 2nd ed. Toronto, ON: University of Toronto Press, 2006.

57. Robbins JA, Dewar J. Traditional Indigenous approaches to healing and the modern welfare of traditional knowledge, spirituality and lands: a critical reflection on practices and policies taken from the Canadian Indigenous example. International Indigenous Policy Journal 2011; 2(4): 1-17.

58. Ferguson NM, Cummings DAT, Fraser C, Cajka JC, Cooley PC, Burke DS. Strategies for mitigating an influenza pandemic. Nature 2006; 442(27): 448-452.

59. Lee VJ, Lye DC, Wilder-Smith A. Combination strategies for pandemic influenza response - a systematic review of mathematical modeling studies. BioMed Central Medicine 7: 76. (Online) 2009. Available: http://www.biomedcentral.com/1741-7015/7/76 (Accessed 19 July 2012).