NUNAVtK REGIONAL BOARD OF HEALTH AND SOCIAL.SERVICES RÉGIE RÉGIONALE DE LA SANTÉ ET DES SERVICES SOCIAUX NUNAVIK

a_CO / PUBLIC HEALTH / SANTÉ PUSLIOUr

Regional Action Plan Public Health Department 2003-2014

INSTITUT NATIONAL DE SANTE PUBLIQUE DU QUEBEC CENTRE DE DOCUMENTATION MONTRÉAL

September 2003

Phone : (819) 984-2222 P.O. Box 900 Fax: (819) 964-2814 Kuujjuaq, Québec J0M1C0 Web Site : http7/www.rrsss17.gouv.qc.ca PROJECT TEAM, CONTRIBUTORS AND INDIVIDUALS CONSULTED

Coordination • Serge Déry (Nunavik Public Health Director) • Stéfanie Houde (Community Health Resident Université de Montréal)

Development, Social Adjustment and Integration Component • Diane Pépin (Nunavik RBHSS) • Johanne Morel (Montreal Children's Hospital) • Maureen Cooney (Nunavik RBHSS) • Pierre Rioux (Nunavik RBHSS)

Lifestyles and Chronic Diseases Component • Kathy Snowball (Nunavik PHD) • Merry! Hammond (Nunavik PHD) • Roger Bélanger (Nunavik PHD) • Suzanne Paradis (Nunavik PHD)

Unintentional Injuries Component • Brian Jones (Kativik Regional Police Force) • Elena Labranche (Nunavik RBHSS) • George Okpik (Kativik Regional Police Force) • Marc Guenard (Kativik Regional Police Force)

Infectious Diseases Component • Brian Miller (Nunavik PHD) • Jean-François Proulx (Nunavik PHD)

Section on Sexually Transmitted and Bloodbome Infections • AJine Roy (Inuulitsivik Health Centre) • Annie Savard (Inuulitsivik Health Centre) • Barbara Northrup (Inuulitsivik Health Centre) • Érika Poirier (Ungava Tulattavik Health Centre) • Faye Le Gresley (Ungava Tulattavik Health Centre) • Jean-François Proulx (Nunavik PHD) • Lina Noël (Nunavik PHD, INSPQ) • Marléne Julien (Ungava Tulattavik Health Centre)

Environmental Health Component • Susie Bemier (Université Laval)

Occupational Health Component • Andrée Racine (Nunavik PHD)

Corrections and layout • Vincent Gilbert (Nunavik PHD) ACKNOWLEDGEMENTS

We would like to express our heartfelt thanks to Dr. Stéfanie Houde, resident in Community Health at the Université de Montréal. Her relentless and professionalism during her all too short internship with us made it possible to produce this preliminary version of the first Nun- avik regional action plan in public health.

We would also like to thank everyone who, as contributors or individuals consulted, have- helped to improve the content of this proposed first action plan.

Lastly, we would like to thank in advance those who will agree to review our proposal and whose comments will help to improve the contenL

Serge Déry, M.D. Public Health Director TABLE OF CONTENTS

PROJECT TEAM, CONTRIBUTORS AND INDIVIDUALS CONSULTED II ACKNOWLEDGEMENTS Ill LEGEND IX ABBREVIATIONS X INTRODUCTION 2 WHY SHOULD THERE BE A PUBLIC HEALTH ACTION PLAN FOR NUNAVIK ? 2 GENERAL HEALTH PORTRAIT OF NUNAVIK 3 FROM THE QPHP TO A REGIONAL PLAN 4 Strengthen the potential of individuals 4 Support community development 4 Improve living conditions and support vulnerable groups 4 Favour consultation and integrated approaches (participate in intersectoral action that promotes health and well-being) 5 Encourage the use of effective clinical practices in prevention 5 COMPONENT 1 - DEVELOPMENT, SOCIAL ADJUSTMENT AND INTEGRATION 6 ASSESSMENT OF SITUATION 6 Substantial natural growth, high fertility 6 High fertility among teenagers and number of single-parent families is increasing 6 Low birth weight babies, preterm births and intrauterine growth restriction 6 Health of children aged 0-5 years 6 Socio-economic status of the region 7 Substance abuse and illegal drugs 8 Alcohol ...... 8 Solvents 9 Cannabis derivatives 9 Other illegal drugs 9 Violence 9 Sexual abuse 10 Suicide and mental health 10 Seniors 10 Priorities of action by target population 10 CHALLENGES AND OPPORTUNITIES 12 Children 0-5 years old 12 6r25 years old 12 Adults : 12 OBJECTIVES 13 REGIONAL ACTION PLAN 14 Foster health and development of newborns and pre-school aged children (0-5 years) 14 Foster the development, social adjustment and integration of youth aged 6 to 25 years 16 Foster the development, social adjustment and integration of adults 18

Nunavik Public Health Department L !••»• •»•-• .-u-f »•-»»• ••...m.——- iv COMPONENT 2 - LIFESTYLES AND CHRONIC DISEASES 19 ASSESSMENT OF SITUATION 19 Diet ...19 Food insecurity 20 Dietary deficiencies 20 Sedentariness.. 21 Obesity . 21 Diabetes 21 Cardiovascular diseases 21 Cancer 22 Smoking . 22 Dental health 22 CHALLENGES AND OPPORTUNITIES 24 General issues 24 Nutrition and physical activity 24 Smoking ; 24 Cancer ...... : 25 Dental health 25 OBJECTIVES., 26 REGIONAL ACTION PLAN 28 Adoption of healthy eating habits and regular physical activity - General population 28 Adoption of healthy eating habits and regular physical activity - Young people aged 5-24 31 Smoking reduction - General population... 32 Smoking reduction - Elementary and high school students 34 Smoking reduction - Pregnant women 35 Cancer prevention.. 36 Oral-dental diseases - Preschool-aged children 37 Oral-dental diseases - School-aged children and adolescents 37 COMPONENT 3 - UNINTENTIONAL INJURIES 38 ASSESSMENT OF SITUATION 38 Motor vehicles 38 Drowning 39 Poisoning ...; 39 Fire 39 Hypothermia 39 Firearms 40 Falls .....40 Sports accidents 40 CHALLENGES AND OPPORTUNITIES : 41 OBJECTIVES 41 REGIONAL ACTION PLAN 42 Unintentional injury prevention - General population 42 Unintentional injury prevention - Young people (0-24 years old) 44

Nunavik Public Health Department atmmr 2871 COMPONENT 4 - INFECTIOUS DISEASES 45 PART I : GENERAL 45 Infectious diseases - Surveillance 45 Infectious diseases - Protection 46 PART II : DISEASES PREVENTABLE BY IMMUNIZATION 47 ASSESSMENT OF SITUATION 47 Vaccination against tuberculosis 47 Diphtheria - Tetanus - Poliomyelitis 47 Haemophilus influenzae type b 48 Whooping cough 48 Bacterial meningitis 48 Measles - Rubella - Mumps 48 Pneumococcus 49 Hepatitis A : 49 Hepatitis B ; 50 Influenza 50 CHALLENGES AND OPPORTUNITIES 51 OBJECTIVES 52 REGIONAL ACTION PLAN 53 Immunization - General aspects 53 Immunization of preschool-aged and school-aged children 55 Immunization at the old adults and people 56 PART III : SEXUALLY TRANSMITTED AND BLOODBORNE INFECTIONS (SBBI) 57 ASSESSMENT OF SITUATION 57 Sexually transmitted and blood borne infections 57 Preserving the fertility of Inuit women 58 Young people who attend school outside the communities 58 Inuit who are incarcerated outside the Nunavik territory 58 Inuit who are highly marginalized outside their communities 59 Drug and alcohol use 59 Partners in prevention 60 Reference framework 60 REGIONAL ACTION PLAN 63 HIV/AIDS and sexually transmitted infections (STIs) 63 Surveillance - Research - Evaluation 64 Prevention among adolescents and adults belonging to vulnerable groups - General population 65 Prevention among adolescents and adults belonging to vulnerable groups - Youth in school and outside the school system 67 Prevention among adolescents and adults belonging to vulnerable groups - Partners in prevention 68 Prevention among adolescents and adults belonging to vulnerable groups - Men who have sex with men 69 Prevention among adolescents and adults belonging to vulnerable groups - Incarcerated persons 69 Needle exchange to prevent hepatitis B virus, hepatitis C virus and HIV transmission - General population 70 Needle exchange to prevent hepatitis B virus, hepatitis C virus and HIV transmission - Injection drug users 70 Recovering used needles (hepatitis Bt hepatitis C and HIV) - Institutions concerned 70

Nunavik Public Health Department u.^-^. ,»,^^,,.,.....,^,,,^. .«i,,..,,.»,..-.,...^,,),,^,, ,IIU- yj Organization of integrated testing and prevention services related to STI, HCV and HIV/AIDS - General population 71 Organization of integrated testing and prevention services related to STI, HCV and HIV/AIDS - Surveillance - Research - Evaluation 72 Free-of-charge medication to treat sexually transmitted infections - General population ; 72 Post-exposure prophylaxis (HIV and HCB) - Health institutions concerned 73 Support for clinical preventive practices through systematic STI, HIV and HBV testing of pregnant women - Partners concerned 73 Promotion of preventive behaviours by raising public awareness of the consequences of HIV/AIDS, HCV and STIs - General population 73 Promotion of preventive behaviours by raising public awareness of the consequences of HIV/AIDS, HCV and STIs - Surveillance - Research - Evaluation 74 Ensure access to services adapted to the needs of HIV-positive persons in the territory 74 Ensure regional concertation regarding the implementation of the plan of action on STIs, HIV/AIDS and HCV - Partners in prevention 74 PART IV : OTHER INFECTIOUS DISEASES 75 ASSESSMENT OF SITUATION 75 Enteric and foodborne diseases 75 Bacterial and parasitic infections of fecal-oral transmission 75 Botulism 75 Diseases transmitted through direct contact or respiratory tract 76 Tuberculosis 76 Respiratory infections among children.. 76 Vectoral diseases and zoonoses 76 Rabies 76 Trichinellosis. 77 Toxoplasmosis 77 West Nile virus 78 Other zoonoses 78 Nosocomial infections 78 Travel health.... 78 Antibiotic resistance 78 CHALLENGES AND OPPORTUNITIES 79 OBJECTIVES 79 REGIONAL ACTION PLAN 80 Enteric and foodborne diseases 80 Enteric and foodborne diseases - Botulism 81 Diseases transmitted through direct contact or respiratory tract - Tuberculosis 82 Vectoral diseases and zoonoses - Rabies 83 Vectoral diseases and zoonoses - Trichinellosis 84 Vectoral diseases and zoonoses - West Nile virus 85 Vectoral diseases and zoonoses - Nosocomial infections 85 Vectoral diseases and zoonoses - Travel health 86 Vectoral diseases and zoonoses - Resistance to antibiotics 86 Vectoral diseases and zoonoses - Maternal and infant health 87 COMPONENT 5 - ENVIRONMENTAL HEALTH 88 ASSESSMENT OF SITUATION 88 Quality of outdoor air ...88 Building sanitation and quality of indoor air 88 Asbestos fireproofing 88 Exposure to ultra-violet radiation 88 Waterbome diseases 89 Environmental poisonings 89 Climate changes 89 CHALLENGES AND OPPORTUNITIES 90 OBJECTIVES 90 REGIONAL ACTION PLAN 91 Diseases due to quality of indoor air - Problems due to building sanitation 91 Waterbome diseases 92 Environmental poisonings 93 Problems due to climate changes 93 All environmental diseases 94 COMPONENT 6 - OCCUPATIONAL HEALTH 95 ASSESSMENT OF SITUATION 95 CHALLENGES AND OPPORTUNITIES 95 CHALLENGES AND OPPORTUNITIES 96 OBJECTIVES 96 REGIONAL ACTION PLAN 97 Occupational health 97 BIBLIOGRAPHICAL REFERENCES 98

FIGURES

Figure I : Example of a regional action plan ix Figure II : Links between lifestyles and chronic diseases 27 Figure III : QPHP activities to be included in the regional action plan 62

TABLES

Table I : Ratio for suicides 11 Table II : Deaths by drowning 39 Table III : Type of accident 40

Nunavik Public Health Department atmmr 2874 LEGEND

The activities of the regional action plan in public health are listed according to the following three priority levels:

Figure I : Example of a Regional Action Plan

Foster health and development of newborns

REGIONAL ACTION PLAN and preschool aged children (0-5 years)

Moil^p 044) Rfift* of PHO ê RBH8S Rate of HC/CLSC ft the hwplsmenladùw of Support (h» development of EB-GH and Meal buMdiota and groups a Integrated prog for prevention In pafnstd PSJP program* with the Integration of young parente se soon as Ilia care (EB-GH end P8JP) In region, Id nm spoctflc components such as cfiftd hnfury known thai tfiay are pregnant i mother Is unto 20 prevention. dMttl health pmnoOon find during the first years of their ct years of age. (Q ywJiuHon promotion. T Promote siIdqub nutildon Integrate nutritions) nupport adMBaa Mo > And bmiilBfldM MRMAIC I Ihe integrated programs tot prevention in perinatal cere GMtdUn /^onsttf MMton Aognrm, free (UtriiBwUon of Btoto ohsr. Promote bwutfo tdng» (d 8upport the imptemantetjpn of guidoimaa Provide Information and auppc on i

Priority level :

1. Activity to be implemented during the first cycle of the program (2004-2006) 2. Act vity to be implemented during the second cycle of the program (2007- 20(9)

3. Act rity to be implemented during the third cycle of the program (2010-2012)

Current status of activities :

[Q New activities to be Implemented [C] Existing activities to be Consolidated [M] Existing activities to be Maintained

Nunavik Public Health Departmentatmmr 2875 ABBREVIATIONS

ACADRE Aboriginal capacity and devel- MADO Maladie à déclaration obliga- opmental research environ- toire (reportable disease) ments MAPAQ Ministère de l'Agriculture, des CHUL Centre hospitalier de Pêcheries et de l'Alimentation l'Université Laval du Quebec CIHAN Canadian Inuit HIV/AIDS Net- MÉQ Ministère de l'éducation du work Quebec CPE Centre de petite enfance (child- MRSA Methicillin-resistant Staphylo- care centre) coccus aureus MSSS Ministère de la santé et des services sociaux CSST Commission de la santé et de la sécurité du travail PPD Mantoux test - Tuberculosis screening EAP Employee Assistance Program PSJP Programme de support aux EB-GH Program: Equal at Birth - jeunes parents (young parents Growing In Health support progam) First Nations of Quebec and FNQLHSSC OH Occupational health Labrador Health and Social Services Commission QPHL Quebec Public Health Labora- tory HBV Hepatitis B virus QPHP Quebec Public Health Progam Hepatitis C virus HCV 2003-2012 Hunting-Fishing-Trapping As- HFTA RAMQ Régie dé l'assurance maladie sociation du Quebec HIV Human immunodeficiency virus RAP Regional action plan HSP Hunter Support Program SAQ Société des alcools du Quebec Intoxication à déclaration obli- IADO SHPE Specific Health Program for an gatoire (reportable intoxication) Establishment Isoniazide INH SQHS Santé Quebec Health Survey INSPQ Institut national de santé publi- STIs Sexually transmitted infections que du Quebec SBBts Sexually transmitted and IWA Inuit Women's Association bloodbome infections KRG Kativik Regional Government WNV West Nile virus KRPF Kativik Regional Police Force KSB Kativik School Board INTRODUCTION

WHY SHOULD THERE BE A PUBLIC HEALTH ACTION PLAN FOR NUNAVIK ?

In 2001, the Clair Commission emphasized the need to restore a better balance between prevention, cure and care.1 Subsequently, the Government established "focus on preven- tion" as one of its priorities.2 In recent years, studies and discussions on the health and so- cial services system have served to refocus our attention on the importance of prevention in our approach to health. To significantly enhance the population's health and reduce needs for curative services, our intervention must target the factors that have a real impact on health and must also be carried out in synergy with the various disciplines and social actors.

To this end, the Quebec Public Health Program (QPHP), published in November 2002, de- fines the public heajth activities that are necessary to enhance the health and well-being of the population in the province. The public health approach is expressed through action on the factors that influence hèalth for the benefit of the entire population or specific population groups. This action is not based on a diagnosis of individuals, but rather of the population as a whole or groups with certain common characteristics. This approach is characterized by early intervention, that is, action taken mainly before problems related to health or well-being occur.

The Public Health Act was adopted in December 2001, modifying a number of practices and consolidating the role of public health protection. It should also be recalled that, under the Act respecting health services and social services, the public health director is responsible for

1. Informing the population on its general state of health and of the major health problems, the groups most at risk, the principal risk factors, the interventions he considers the most effective, monitoring the evolution thereof and conducting studies or research required for that purpose; 2. Identifying situations which could pose a threat to the population's health and seeing to it that the measures necessary for its protection are taken; 3. Ensuring expertise in preventive health and health promotion and advising the regional board on prevention services conducive to reducing mortality and avoid- able morbidity; 4. Identifying situations where intersectoral action is necessary to prevent diseases, trauma or social problems which have an impact on the health of the population, and, where the public health director considers it appropriate, taking the meas- ures considered necessary to foster such action.

It is obvious that to cover all the objectives and activities of the QPHP, new resources should be allocated at both the local and regional levels. To this end, the regional public health department has asked the Ministère to provide funding for a study of public health needs in Nunavik.

1 GOVERNMENT OF QUEBEC. - Commission d'étude sur tes services de la santé et les services sociaux, Emerging solu- tions, reports and recommendations. - 2000 ... 2 GOVERNMENT OF QUEBEC. - Health and Social Services Plan - Making the Right Choices. - 2002 ...

Nunavik Public Health Department atmmr 2 GENERAL HEALTH PORTRAIT OF NUNAV1K

Nunavik is the largest (560,000 km2) and most northern territory of Quebec. Nearly 10,000 people (2001 Census) live in 14 communities that include from 150 to 2000 inhabitants. These communities are linked up with each other and with the southern Quebec regions only by plane and boat. The great majority of the territory's population are Inuit.

The recent history of the Inuit people is marked by sedentarization and a sharp break with their traditional way of life. As a result of improved living conditions over slightly more than half a century, mortality, mainly due to infectious diseases, has drastically declined. The population is now undergoing considerable demographic growth (the Nunavik population grew from 4,815 in 1981 to 10,016 in 2002), which is reflected, among other things, by its young population. In fact, 40 % of the tenitoiYs population is under the age of 15.

Despite these health gains, mortality rates at all ages remain higher than those in the rest of Quebec. In fact, life expectancy in Nunavik is 65.3 years (imprecise value given the very small numbers of the oldest old) compared to 77.9 years in Quebec. Similarly, the infant mortality rate is 19.9 deaths per 1,000 live births compared to 5.3/1,000 in the rest of Que- bec. Not only is Nunavik facing an ever-present (and quite specific) burden of infectious dis- eases, but chronic diseases typical of our Western ways of life are also appearing.

The way of life in Nunavik is characterized by particular contraints: a harsh climate, isolated communities and high cost of food and housing. Rejative poverty is more pronounced in Nunavik than in other territories. Although the quantity and quality of dwellings have im- proved considerably as a result of the signing of the James Bay and Northern Quebec Agreement in 1976, the average number of people living in a dwelling is slightly more than 4, or nearly twice the rate observed in Quebec (Statistics Canada, 1996 Census). These particularities are linked with a range of social and health problems which pose a consider- able burden for the region: addiction, suicide, sexual abuse, child neglect and conjugal vio- lence. Culture - a key issue—should be added to these considerations. In fact, the public health approach cannot ignore the region's cultural specificities which not only influence the spo- ken language (94 % of the Inuit population speak Inuktitut at home (1992 SQHS) but also the social and political organization, social standards, eating habits and leisure activities.

Nunavik Public Health Department atmmr 3 FROM THE QPHP TO A REGIONAL PLAN The regional action plan for Nunavik puts forward public health activities based on the six areas of intervention defined by the national program : 1. Development, social adjustment and integration 2. Lifestyles and chronic diseases 3. Unintentional injuries 4. Infectious diseases 5. Environmental health 6. Occupational health

To achieve our health objectives, five strategies have been selected :

Strengthen the potential of Individuals

In this case, the role of public health is to recognize the potential of individuals to make their own decisions and to exercise a degree of control over their lives as well as to sup- port the development of this potential. The latter should be supported through actions centred not only on information, but also on the maintenance and acquisition of skills that allow individuals to make the most informed choices about their health and well- being.

Support community development

Community development is a process of voluntary cooperation, mutual help and cons- truction of social links between residents and institutions of a community, aimed at im- proving physical, social and economic living conditions.3 The role of public health is thus to encourage and support the participation of individuals who are members of these communities in a process to determine the most important health problems and the most appropriate solutions to these problems. This strategy implies the involvement of local and regional actors, use of the community approach and partnership with the other sec- tors so as to encourage the implementation of community-based projects focusing on health and well-being. Public health expertise can play a role in the consultation prior to these projects being carried out as well as in implementing, leading and evaluating the projects. In our endeavour to move towards an autonomous government for the region, the ap- proach of community empowerment is all the more relevant.

Improve living conditions and support vulnerable groups

In order to reduce the disparities in health observed in the population, it is possible to act on the risk factors themselves and on the means that individuals and communities can use to reduce the negative effects of these factors. Public health action helps to charac- terize the different forms of risk and their consequences for health as well as to deter-

3 BEAUCHEMIN, M. et al. - La santé des communautés : perspectives pour la contribution de la santé publique au dévelop- pement social et au développement des communautés. - 2002...

Nunavik Public Health Department atmmr 4 mine and implement action to attenuate these consequences. Public health action in Nunavik should also focus on the general living conditions that affect the whole popula- tion but are particularly constraining for the most vulnerable groups, that is, cost of food, access to housing and employment.

Favour consultation and integrated approaches (participate in intersectoral action that promotes health and well-being)

Most of the levers of direct action on the physical, social and economic environments be- long to sectors other than that of health and social services. It is therefore essential for public health actors to collaborate with the actors in the other sectors to establish the conditions and create the environments conducive to health, from the perspective of sus- tainable development. The actions undertaken may consist in, for example, facilitating access to resources, services or adequate equipment and influencing decisions by the population to promote health and well-being. Public health can also contribute by evalu- ating the health risks associated with measures or projects that come from the public or private sectors as well as by identifying the courses of action that are likely to attenuate their potentially negative effects on health.

Encourage the use of effective clinical practices in prevention

Clinicians provide primary care to the population. They are encouraged to promote healthy behaviours, offer counselling and detect certain risk factors and problems that are as yet asymptomatic or the first signs of health problems and psychosocial prob- lems. Public health teams can help support clinical preventive practices by determining effective preventive action as well as by disseminating guidelines or guides for maintain- ing or integrating such action into the services provided to the population. For each of the program areas or components, an assessment of the situation highlights the principal public health challenges specific to the region. We have not attempted to draw an exhaustive health portrait of the territory's population but rather to outline the health needs that can be addressed through public health action. The objectives specified for the region have been set for 2012 and will be reviewed with the cycles of the QPHP, that is, in 2006, 2009 and 2012. Activities are generally subdivided by age group (or target population).

The purpose of this document is to open the debate with partners of the health and social services network as well as with other partners involved in the issues addressed here. It is meant to be a consultation tool which will help guide the efforts of all parties towards a clear direction in the pursuit of the population's health. You are therefore invited to make com- ments on the entire document and more specifically on the sections related to your own ar- eas. *

A number of additional plans will be added to the current plan: a regional surveillance plan, a plan for mobilization and emergency measures, a RAP evaluation plan, as well as lateral plans for support for clinical preventive practices and communication campaigns.

atmmr Nunavik Public Health Department 5 COMPONENT 1 - DEVELOPMENT, SOCIAL ADJUSTMENT AND INTEGRATION

ASSESSMENT OF SITUATION

Substantial natural growth, high fertility

• 40 % of the population are aged 15 or under. • 15 % of the population belong to the 0-5 age group (proportion 2.5 times greater than in Quebec as a whole). • Fertility rate of 3.6 children per woman, compared to 1.6 in Quebec. • Total elective abortion rate is 0.65 compared to 0.58 in Quebec.

High fertility among teenagers and number of single-parent families Is increasing

• Nearly one quarter of women who give birth in Nunavik are under 19 years of age, which is nearly five times higher than the Quebec average. • Mothers1 educational level has improved since 1986. However, the gap between Nunavik and Quebec remains wide: between 1994-1998, 26.8 % of mothers in Nunavik had not reached Grade 9, compared with 4.2 % for mothers in Quebec. • In 1995-1999, nearly 30 % of mothers in Nunavik did not live as part of a couple at the time of their baby's birth, compared to 8.6 % in Quebec. • Strong increase in the number of single-parent families between 1996 and 2001. In 2001, slightly more than one in three families with a child aged 0-5 years were single-parent families. • The proportion of children aged 0-5 years living below the low income cutoff is lower than that in Quebec, but the proportion of children of the same age receiv- ing social assistance is higher (15.2 compared to 11.9 %).

Low birth weight babies, preterm births and Intrauterine growth restriction

• The proportions of low birth weight babies (6.2 %) and preterm births (11.8 %) remain comparable to those in Quebec (6.0 and 7.2 % respectively). • The proportion of live births with intrauterine growth restriction in Nunavik is sig- nificantly lower than the Quebec average (5.3 compared to 8.6 %).

Health of children aged 0-5 years

• The sepsis rate of newborns is comparable to that of Quebec (13.2/1000 in Nun- avik compared to 14.5/1000 in Quebec). • The rate of respiratory distress syndrome is markedly higher than that of Quebec (22/1000 in Nunavik compared to 11.6/1000 in Quebec). • Congenital anomalies: excess of cleft palate with cleft lip and possible excess of malformations of the abdominal wall.

atmmr Nunavik Public Health Department 6 • The hospitalization rate of children aged 0-1 in Nunavik is 3 times higher than in Quebec and has markedly increased between 1991-1996 and 1996-2002. Fifty percent (50 %) of these hospitalizations result from diseases of the respiratory tract. Considerable differences are observed between the two coasts and have become more pronounced in recent years: currently (between 1996 and 2001) the hospitalization rates for respiratory diseases are 6924/10,000 on the Hudson coast, compared to 2652/10,000 on the Ungava coast. • Infant mortality is improving but is still markedly higher than what is found in the rest of Quebec: in 1991-1998, there were 24.9 deaths/1000 live births in Nunavik, compared to 5.5/1000 in Quebec. The predominant causes are: sudden infant death syndrome and congenital anomalies. • It is more common for Inuit women to breastfeed than for women in other regions of Quebec. • The mortality rate of children aged 1-5 years is declining, but an excess of 1.6 deaths/year is observed, in comparison with Quebec. • The hospitalization rate of children aged 1-5 years is 1417/10,000 in Nunavik and is much higher than in Quebec (589/10,000). Number 1 cause in Nunavik: respi- ratory tract diseases. • Other health concerns: dental cavities, ear infections, injuries, iron deficiency anemia, fetal alcohol syndrome. • The network of childcare centres has developed considerably in recent years; currently, the rate of available childcare places is higher than that of Quebec, i.e. 55.4 % compared to 40 %.4

Socio-economic status of the region

• More welfare recipients: 14.6 % of the population received employment assis- tance in 2000, compared to 9.6 % in the rest of Quebec. • In 1996, 51 % of Inuit aged 15 or over in the region held a full-time job, compared to 55 % of the Quebec population aged 15 or over. The average employment in- come (aged 15 or over) rose to $16,122 for Inuit in Nunavik in 1995, compared to the Quebec average of $25,116. • The poverty in the region must be linked with the high cost of living in this iso- lated environment: the cost of a weekly food basket for a 4-person family is $125 in Ottawa, $180 in Kuujjuaq and $209 in Salluit. • Very few individuals in Nunavik reach college or university; in fact, the highest educational level was only Grade 9 for 33.3 % of Nunavimmiut, compared to 18.1 % of Quebec's total population. • The average number of people per dwelling is also very high in Nunavik, and even higher for the Inuit population, and a greater proportion of dwellings house more than one family (5.5 compared to 0.7 %).5,6

4 PAGEAU, M.; FERLAND. M. and DÉRY, S. - Our Children: Health Status of Children Aged 0-5 Years in Nunavik. - 2003... 5 PAGEAU, M. et al. - La portrait de santé : le Quebec et ses régions. - 2001... e SCHNARCH, B. - Living Conditions in Nunavik: cost-of-living, employment, income and housing statistics compared. - 1999....

Nunavik Public Health Department atmmr 7 Substance abuse and illegal drugs

It was during the 1960s that alcohol use became widespread and cannabis was intro- duced into Nunavik; these substances were then used mainly by young people.7 Three categories of illegal drugs predominate in the Inuit community of Nunavik: sol- vents, cannabis derivatives as well as cocaine and its derivatives. Forty-three percent (43 %) of Nunavimmiut use illicit drugs, compared to 13 % of the Quebec population. The proportion among men is nearly 5 times that of Quebec.

Alcohol

Currently, the ways in which alcohol can get into Nunavik have multiplied: orders through the Internet, orders through food markets, supply network for the two bars (Kuujjuaq and Kuufluaraapik), numerous occasions to travel south and boats during the summer. The quantity of alcohol that is smuggled into the Nunavik territory may be greater than the quantify which comes in legally.8

The Santé Quebec health surveys (Inuit population in 1992 and Quebec population in 1992-1993) reveal that 39.7 % of Inuit in Nunavik are nondrinkers or former drink- ers, a proportion that is greater than the rest of Quebec (20.8 %).

• Alcohol use in Nunavik is still an issue of great concern, with a specific con- sumption profile where "binge-drinking0 (associated with high-risk behaviours) predominates over regular daily consumption. • Thus, it is noted that 25 % of Nunavimmiut aged 15 or over consume alcohol at least monthly and then typically have 5 drinks or more. • 25 % of adults in Nunavik reported having had alcohol-related problems last year, compared to 7.6 % of Canadian adults. • In the view of many authors and the general public, the consequences asso- ciated with this alcohol use are also worrying: violence, sexual abuse, crimi- nal assaults, injuries and accidents, dysfunctional families, mental health problems (being drunk or intoxicated is recognized as a factor that precipi- tates suicide, high-risk sexual behaviours and lack of positive relationships).0 • In 2001-2002, according to the police forces, at least 70 % of all criminal of- fences in the Ungava Bay were committed under the influence of alcohol and/or drugs. • Although rare cases of alcoholic cirrhosis are reported, alcohol-related car- diomyopathies are found in the population.10

7 HODGINS Stevens. - Health and what affects it in Nunavik: how is the situation changing? - 1997... 8 MERCIER, C.; RIVARO, J. and GOYON, L. - Consommation d'alcool et de drogues dans les communautés du Nunavik : bilan des données épidémiologiques et des problèmes associés. - 2002 ... 9 MERCIER. C.; RIVARD, J. and GOYON, L - Consommation d'alcool et de drogues dans les communautés du Nunavik : bilan des données épidémiologiques et des problèmes associés. - 2002... 10 HOOGINS Stevens. - Health and what affects it in Nunavik: how is the situation changing? - 1997...

Nunavik Public Health Department atmmr 8 Solvents

• 7 % of girls and 10 % of boys aged 15 to19 sniff solvents.11 • In Nunavik, the age at which young people begin solvent sniffing was 12-13 years old in 1986. It is believed that currently they may be starting to use these substances at a younger age. In fact, in 1999, 50 % of young people in Aboriginal communities of Quebec began solvent sniffing between 4 and 11 yearsold.12 • The reality of illicit drugs seems to be trivialized in the eyes of young Inuit13

Cannabis derivatives • Cannabis is the most widespread iliicit drug in the region. • 38 % of respondents.aged 15 or over in the 1992 SQMS stated having used marijuana or hashish during the 12 months preceding the survey. Over 50 % of men aged 15 to 44 are users of cannabis derivatives. • Cannabis use thus seems to be more widespread in Nunavik than in the rest of Quebec.

Other illegal drugs

• In .the SQHS, nearly 10 % of the Inuit population reported that they were cur- rently using cocaine or crack and 6 % were using toxic substances. • Cocaine and crack are used mainly by men and individuals of either sex in the 20-24 age group. • There is little heroin in Nunavik, although there is no recent data to confirm the current situation.

Violence For two generations, there has been an increase in violent behaviours in the Nunavik population. The current situation is a serious concern for the majority of the population (1992 SQHS). The rates of crimes, abuse and negiect are markedly higher in the region than in the rest of Quebec. In 2000, the reported rate of conjugal violence was 3579/100,000, a substantial excess compared with Quebec (418 reported cases/100,000). Among children, cases of sexual abuse and neglect are mainly re- ported. Sixty percent (60 %) of assault victims taken to court are women and the majority of women hospitalized as a result of acts of violence suffered from conjugal violence.

11 HODGINS Stevens. - Health and what affects it in Nunavik how is the situation changing? - 1997... 12 DEMERS, A. et al. - Pour une approche pragmatique de prévention en toxicomanie : orientations, axes dlntervention et actions. - 2001 ... 13 Ibid.

Nunavik Public Health Department atmmr 9 Sexual abuse

In the 1992 Santé Quebec Health Survey, 41 % of women and 19 % of men stated hav- ing been forced, at least once in their lifetime, to engage in sexual activities such as kiss- ing, fondling, or intercourse.

Suicide and mental health

The region's population has been faced with a marked increase in the number of sui- cides for two decades. Between 1980 and 1984, 8 deaths by suicide were recorded, 14 were recorded between 1985-1989, and up to 38 deaths by suicide were recorded dur- ing the 1990-1994 period. In Nunavik, the rates of death by suicide are six times higher than in the rest of the Quebec population (1987-1995). This rate is 20 times higher among the 15-24 year-olds (See Table /), particularly among boys; however, the rates of death by suicide among people aged 40 and older is practically nil.

• The principal means of suicide are hanging and gunshot. • It is noted that one third of people who died by suicide had consulted health care services within 3 months before death.14 • Researchers also noted that suicide often occurs in clusters, with young people emulating their peers.15

Seniors

• The proportion of older persons is lower than in the rest of Quebec but is increas- ing: in 2000, people aged 60 or over made up 4.7 % of the population (3 % for people aged 65 or over), compared to 4 % in 1981 (census data). • The proportion of seniors living alone remains lower than in the rest of Quebec: 6.7 % of the 65-74 year-olds and 20 % of those aged 75 years or over, compared to 24.9 % and 38.7 % respectively in Quebec.16

Priorities of action by target population

• 0-5 years old: neglect, injuries, physical health (ear infections, respiratory dis- eases, iron deficiency anemia, dental health, congenital malformations, fetal al- cohol syndrome). • 6-25 years old: suicide, addiction, behavioural disorders, conjugal violence, sex- ual abuse, smoking, sexually transmitted and blobdbome infections. • Adults: mental health, violence (conjugal violence), addiction.

14 BOOTHROYD, Lucy J et al. - Completed suicides among the Inuit of northern Quebec: 1982-1996: a case-control study. - 2001... "Ibid. 16 PAGEAU. M et al. - Le portrait de santé : le Quebec et ses régions. - 2001...

Nunavik Public Health Department atmmr 10 Table I : Ratio for suicides

2002 - Indirect standardization method , • i * t * • * ' ', '• 7 n, • ' > ' ' Prop'of Quebec lesg , * /.y* <;^Njimberpf suicides 'Average number ipf.f Nuravty population, Population Quebec té» . • fiunavik sulcfdes ap- - Quebec leèsNùnavik, f >; sulcides. Nunavili, - 'jAge group Quebec population, - ; . -1999 • ' ' \ ' Nunavik, 1999 i^lied toNunavlk popula? ; 1B99 ' - 1998?2002. J! V and sex A ï«99>" CC;- ,t ' V . » .. S -. • *. ^ - . • • " '. • tion.1999 1 : " * . T . ' <•' • M • -y-f ' • Tr-'V' t *-V M . •."tî.r. 4 r •' " 35,837 37.995 114 132 35.723 37.663 0 0 0.0000 0.0000 0.000 0.000 0.0 0.0

165.310 172,542 567 573 164,743 171,969 0 0 0.0000 0.0000 0.000 0.000 0.0 0.0 234,605 244,329 652 692 233,953 243,637 0 0 0.0000 0.0000 0.000 0.000 0.0 0.0 217,267 228,271 506 558 216.761 227,713 2 6 0.0000 0.0000 0.005 0.015 0.0 0.0 ^ 15-1B "/.-- 236,686 249,932 431 453 236,255 249,479 17 77 0.0001 0.0003 0.031 0.140 2.0 6.0 243,110 255,181 369 396 242,741 254,785 12 114 0.0000 0.0004 0.018 0.177 0.0 4.5 232,615 244,367 432 450 232,183 243.917 15 114 0.0001 0.0005 0.028 0.210 0.5 1.0 267,219 279,342 388 441 266,831 278,901 29 130 0.0001 0.0005 0.042 0.206 0.0 0.6 320,270 330,365 288 326 319,982 330,039 41 167 0.0001 0.0005 0.037 0.165 0.0 0.3 40-144 ^ V 319.595 322,564 212 241 319,383 322,323 67 171 0.0002 0.0005 0.044 0.128 0.0 0.3 283.877 282,271 • *« ' 'IS.*.',. 164 183 283,713 282,088 47 146 0.0002 0.0005 0.027 0.095 0.3 0.0 £ I;" 254,727 250,252 155 144 254,572 250,108 26 97 0.0001 0.0004 0.016 0.056 0.0 0.0 201.947 195.242 85 94 201,862 195.148 20 64 0.0001 0.0003 0.008 0.031 0.0 0.0 vM ifîv?.- 162,379 151,241 80 92 162,299 151,149 17 43 0.0001 0.0003 0.008 0.026 0.0 0.3 155,663 136,432 66 70 155,597 136,362 20 45 0.0001 0.0003 0.008 0.023 0.0 0.0 139,496 107,751 40 28 139,456 107,723 5 38 **!->•' V ' \ '• ' • ,'"' 0.0000 0.0004 0.001 0.010 0.0 0.0 250,229 136,486 34 38 250,195 136,448 13 48 0.0001 0.0004 0.002 0.013 0.0 0.0

Total number of suicides that should be observed In Nunavik ff the suicide rate was the same as else- Nunavik Public Health mortality data bank, 1972-2001 where In Quebec, 1999 1.6 Richard Koury for 2002 data Average number of suicides per year that are observed In Nunavik. 1998-2002 15.8 Population projections, ISQ, July 2000 Ratio Nunavik vs elsewhere In Quebec 10.0 Total number of suitides of 15-24 years old that should be observed in Nunavik if the suidde rate was the same as elsewhere in Quebec, 1999 0.4 Average number of 15-24 years old suicides per year that are observed In Nunavik, 1998-2002 12.5 Ratio Nunavik vs. elsewhere In Quebec for 15-24 years old 34.1 Prepared by Pierre Lejeune. Public Health Department Total number of suicides of 15-19 years old that should be observed in Nunavik if the suicide rate was (NRBHSS) (819) 964-2222. ext. 228 the same as elsewhere in Quebec, 1999 : 0.2 August 21,2003 Average number of 15-19 years old suiddes per year that are observed In Nunavik, 1998-2002 : E:\Suicldes\[Suicfdes, Nunavik. 1971 to 2002.xls]Standardization 8.0 Ratio Nunavik vs. elsewhere In Quebec for 15-19 years oltJt 46.8 CHALLENGES AND OPPORTUNITIES

Children 0-5 years old

• Prevent teenage pregnancies. • Support parents, especially young parents. • Support breastfeeding. • Support the development of early educational programs for children throughout the network of childcare centres. • Implement integrated prevention programs.

6-25 years old

• Conduct concerted interventions in schools to foster the acquisition of individual and social skills. • Promote mental health. • Change social standards.

Adults

• Deal with the issues of conjugal violence on multiple levels by implementing the guidelines on conjugal violence. • Improve the population's mental health, by initially acknowledging the problem, breaking the taboos and understanding the multiple factors of the problem while taking account of the cultural realities specific to the region.

12 OBJECTIVES

• Reduce the teenage pregnancy rate. • Reduce the prematurity rate. • Reduce the number of children bom with severe congenital anomalies or other serious health problems, such as neural tube defects, fetal alcohol syndrome and congenital rubella syndrome. • Reduce morbidity due to phenylketonuria or congenital hypothyroidism. • Reduce respiratory infections, gastro-intestinal infections and iron deficiency anemia in infants. • Increase the proportion of children aged 0 to 4 whose motor, language, cognitive and social development is normal. • Reduce problems of physical and psychological abuse, sexual abuse and neglect of children and adolescents. • Reduce behavioural disorders, including violence against others and delin- quency, among children and adolescents. • Reduce problems related to drug and alcohol use. • Increase the proportion of people of all ages who have good mental health. • Reduce the number of suicide attempts and suicides. • Reduce problems of sexual abuse and conjugal violence affecting women.

13 Foster health and development of newborns and preschool aged children (0-5 years) REGIONAL ACTION PLAN

Role of other partners Priority Activities Role of PHD / RBHSS Role of HC/ CLSC (1-2-3) (Implement, Consolidate, Maintain) INSPQ Ensure and support the implementation of Support the development of EB-GH and Meet individuals and groups of integrated programs for prevention in perinatal PSJP programs with the integration of young parents as soon as it Is care (EB-GH and PSJP) in the region, to serve specific components such as child injury known that they are pregnant and as a priority families whose mother is under 20 prevention, dental health promotion and during the first years of their child's years of age. P] vaccination promotion. life. KRG - HSP Promote adequate nutrition among pregnant Integrate nutritional support activities into and breastfeeding women. [C] the integrated programs for prevention in perinatal care Canadian Prenatal Nutrition Program, free distribution of arctic char. Promote breastfeeding. [C] Support the implementation of guidelines Provide information and support to on breastfeeding. pregnant women, women who have just given birth, breastfeeding women and their partners. Implement an early educational support pro- Establish the necessary partnerships with CPEs gram in childcare centres (CPEs). [j] childcare centres (CPEs). Support the design and implementation of educational activities by the Inuit while respecting the region's cultural specifici- ties. Generalize services related to consultation on Support the implementation of the action Provide services of elective abor- KSB - Schools sexual matters - youth clinic type - and emer- plan to prevent teenage pregnancy. tion, individual consultations on gency oral contraception as well as free-of- contraception and promote acces- charge elective abortion services throughout sibility to emergency oral contra- the Nunavik territory. [C] ception.

Direction de santé publique du Nunavik 14 Foster health and development of newborns and pre-school aged children (0-5 years) (cont)

Priority Activities Role of PHD / RBHSS Role of HC / CLSC rRole ofpther partners (1-2-3) (Implement, Consolidate, Maintain) 1 Promote clinical preventive practices to Support clinicians in the following Refer disadvantaged children to CPEs ensure the health and healthy develop- clinical preventive practices: childcare centres for early edu- ment of newborns and children. [C] * Women of childbearing age taking cational interventions. a sufficient dose of folic acid; ^ Case-finding and counselling preg- nant women on alcohol use; * Counselling pregnant women on smoking; s Counselling on breastfeeding; S Systematic screening of newborns for phenylketonuria and congenital hypothyroidism; s Physicians, nurses and midwives recommending that disadvantaged families participate in integrated programs for prevention in perina- tal care (EB-GH, PSJP);

Direction de santé publique du Nunavik 15 Foster the development, social adjustment and integration of youth aged 6 to 25 years

^Priortty? m 1 Implement activities to develop personal and Meet the School Board in order to estab- School nurse KSB - Schools social skills through a concerted and integrated lish an agreement between the health intervention in schools, p] and education networks, regarding the activities and means to be implemented to create healthy environments, as speci- fied under the MÉQ - MSSS framework agreement 2 Implement a Fluppy-type program for the de- Meet the School Board. School nurse KSB - Schools velopment of personal and social skills of kin- dergarten and Grade 1 children, p] Support the implementation of Fluppy- type programs. 2 Communication campaigns to foster the acqui- Assess the possibility of adapting the Media sition of personal and social skills. [I] provincial communication campaign to Nunavik's reality. KSB - Schools 1 Consult organizations to develop intersectoral Set up a regional committee to develop . KSB - Schools actions on suicide prevention, p] an action plan on suicide prevention. Youth centres KRPF Makivik 1 Deploy a network of sentinels who can identify Ensure and support the establishment of KSB - Schools and lead a suicidal person to the appropriate a sentinel network with the partners. resources, p] Youth centres

Direction de santé publique du Nunavik 16 Foster the development, social adjustment and integration of youth aged 6 to2 5 years (cont)

-jRrlorMyS W àMËËËÊÈÊÈÊMÊ 2 Reduce access to firearms. [C] Meet the partners to promote awareness KRPF of the importance of safe storage of fire- H FT A arms. HSP Promote public awareness of the impor- tance of safe storage of firearms, through advertising messages and specific activi- ties with the partners. 2 Reduce access to alcohol for young peo- Meet the SAQ to discontinue the cur- SAQ ple under 18. [C] rent subsidy for the transportation of KRPF alcoholic beverages. Bars Make representations to regional government and police authorities N.I. regarding the sale of alcoholic bever- ages to minors. 2 Participate in works related to the imple- Disseminate in the region ministerial N.I. mentation of ministerial policies on drug policies on drug addiction prevention, addiction prevention. [C] while taking account of the region's KRPF particularities. KSB - Schools Youth centres 1 Promote clinical preventive practices that Support the following clinical preven- are relevant to youth development and tive practices: adjustment. [C] Suicide prevention Detection of alcohol-related problems Detection of the slightest sign of con- jugal violence or sexual abuse

Direction de santé publique du Nunavik 17 Foster the development, social adjustment and Integration of adults

Priority Activities (1-2-3) (implement, Consolidate, Maintain) Role of PHD / RBHSS Role of HC / CLSC Role of other partners 1 Integrate activities to detect and prevent con- Promote awareness among workers and Case finding and management. Battered women's homes jugal violence into programs intended for train them. young parents (EB-GH - PSJP). [1] KRPF Incorporate these activities into the inte- grated programs for prevention in perina- tal care. 2 Support communities in their projects to reduce Support the community which is inter- N.I. drug addiction, p] ested in developing projects to reduce drug addiction within a pilot approach of community development 2 Meet public organizations in order to reduce Meet the SAQ to discontinue the eurent SAQ access to alcohol, p] subsidy on transportation of alcoholic beverages. 2 Promote public awareness of mental health Develop a public education program Inuit Women's Association problems, p] aimed at demystifying mental illnesses. Regional television network N.I. 1 Promote the relevant dinical preventive prac- Support the following clinical preventive tices. [C] practices: • Detect the slightest sign of sexual abuse or conjugal violence • Detect alcohol-related problems

Direction de santé publique du Nunavik 18 COMPONENT 2 - LIFESTYLES AND CHRONIC DISEASES

ASSESSMENT OF SITUATION

As a result of the drastic change in their way of life, which has taken place within only two generations, Nunavimmiut are currently undergoing a profound demographic and epidemi- ological transition. In fact the extension of life expectancy (a result of improved living conditions, access to safer food sources and reduced infectious disease mortality) is accompanied by the usual appearance of chronic diseases typical of Western societies: lack of physical activity, obe- sity, diabetes, cardiovascular diseases and cancers.

However, many characteristics of Nunavik and its inhabitants have been changed by these transitions. Diet

Traditionally, the Inuit's diet is made up of food produced through hunting, fishing and picking. For a long time, caribou has been one of the main dietary intakes for these communities which at the time depended on the herd. Other animals such as the beluga whale, arctic char, bear, walrus and seal are also of prime importance in terms of their contribution to the traditional diet. In general, hunting and fishing products are consumed raw or dried. However, the contribution of traditional food in the Inuit diet has been de- clining for several years.

According to the popular view of the Inuit, 75 % of the diet of the elders is made up of traditional foods, a proportion which has fallen to around 50 % for adults and 25 % for children. The 1992 SQHS revealed that traditional foods provide around 30 % of calories for people aged 45 or over and 18 % for the under 45s. Several phenomena may con- tribute to this change. The break in traditional eating habits (which occurred mainly dur- ing the 1950s to 1970s) stems from a number of factors:17

• Increased demographic pressures on natural resources; • The introduction of paid employment has reduced both the time available for hunting and fishing and these workers' dependency on traditional foods; • Growing availability and popularity of commercialized foodstuffs; • The population's concern over contaminants in traditional foods (cadmium, mer- cury, organochlorine compounds).

Although research on this issue is continuing, the nutritional advantages of traditional foods seem to outweigh the risks associated with the contaminants that they contain. It is noted that the omega-3 fatty acid intake of the Inuit remains generally high. In fact, ac- cording to a study, the consumption of traditional foods has changed little since 1992 and the sources of foods rich in polyunsaturated fatty adds are still popular among the

17 KUHNLEIN, HV. - Culture and ecology in dietetics and nutrition. -1989...

Direction de santé publique du Nunavik 19 Inuit population.18 The presence of contaminants in foods is still being studied, but cur- rently researchers all agree that, on the basis of the evidence collected, the advantages of eating traditional foods outweigh the risks associated with them.

Nowadays, products from southern Quebec are imported either by boat for non- perishable foodstuffs or by plane for perishable foodstuffs, resulting in high prices, par- ticularly for perishable foodstuffs. Moreover, the availability and quality of perishable foods can be compromised. As noted in the 1992 SQHS, certain eating patterns of the Inuit of Nunavik are less conducive to good health compared with those of the Cree or Quebecers, in particular

• they have less knowledge of the relationship between food and health; • they use more fat and salt; • they eat vegetables less often but consume prepared dishes more frequently; • they make fewer attempts to change eating habits.

Although young people appear to eat more vegetables and to be more inclined to change their eating habits, they are less aware than their elders of the relationship be- tween food and health. They consume more non-traditional fat and prepared dishes and perceive traditional foods in a less favourable light

Food insecurity

In this context, the high cost of store-bought foods, combined with the lack of financial resources and the difficulties in hunting and fishing, result today in food insecurity in around 30 to 40 % of households (1992 SQHS). The use of community freezers (where hunting and fishing products are stored and are thus available to the community free of charge) can compensate for part of these needs, but it is limited by both individ- ual tastes and supply constraints.20

Dietary deficiencies These dietary realities in Nunavik also leave the population at risk of developing various dietary deficiencies. For example, iron deficiency anemia was observed among 22 % of women during their first trimester of pregnancy. Some intake evaluations suggest that the population is susceptible to several deficiencies in vitamins and trace minerals (1992 SQHS 1992), in particular :

> Calcium > Vitamins A, B6, C and D > Zinc > Folic acid

18 KUHNLEIN. HV. - Culture andecotogyln dietetics andnutrfton. -1989... 19 Demand* fa réfêraira'^ 20 ^^ël^^lÎÉrl ^cerTcejT^Stll^ Mâij

Direction de santé publique du Nunavik •«rrymffCT 20 Sedentariness

The population is becoming more sedentary. The reduction of traditional activities ap- pears to be a key factor in growing sedentariness, since the data show that there is greater sedentariness inside than outside the villages This also suggests that the com- munity environment is not highly conducive to physical activity (moving around in motor vehicles and the lack of sports infrastructures in some communities). Sedentariness is particularly widespread among women and people aged 45 or over, where they lag be- hind considerably compared to the rest of the Quebec population (1992 SQHS 1992).

Obesity

The increase in the prevalence of obesity observed since the early 1980s can be ex- plained by the phenomena of diet and sedentariness. Obesity is a risk factor for cardio- vascular diseases. Moreover, it is also known that individuals with a body mass index (BMI) that is equal to or greater than 27 have health problems more frequently. How- ever, these criteria were defined for non-Aboriginal population groups and there is little research data, which would allow us to transpose the models of morbidity associated with BMIs for Caucasian population groups onto the Inuit population.

Although this comparison may not be conclusive, it should nevertheless be noted that in 1992,19 % of adult Inuit in Nunavik had a BMI equal to or greater than 30. This propor- tion was 12.8 % for adult Quebeckers in the same period. This problem is particularly prevalent among women and seems to occur quite early in the lives of Inuit people. Also according to 1992 data, only 55 % of Inuit believed that obese people have a greater risk of health problems (compared to 94 % of Quebeckers).

Diabetes

The appearance of cases of diabetes for the last ten years also reflects the change in lifestyles. Researchers have found that the longer the contact of the Aboriginal popula- tions with the non-Aboriginal populations, the higher the prevalence of diabetes in these populations.21 Currently, approximately 1.5 % of the Inuit population has been diagnosed with diabetes (type 2). The data suggest that there will be a substantial increase in dia- betes in the future. Cardiovascular diseases

Cardiovascular diseases account for around 12 % of all deaths (Nunavik Mortality Data, 1992-2001), a proportion that is lower than in the rest of Canada, where 36 % of deaths are attributable to cardiovascular diseases. In particular, ischemic heart disease and strokes represent 2.4 % of deaths in the region (Nunavik Mortality Data, 1987-2001). However, when interpreting these data, the age structure of the population should be taken into account. It is interesting to note that the lipid profile of the Inuit remains fa- vourable in terms of HDL and the proportion of people suffering from systemic hyperten- sion was 6 % compared to 14 % in the rest of Quebec (1992 SQHS).

21SCHRAER, C.D. et al. - Prevalence of diabetes mellitus in Alaskan Eskimos, Indians, and Aleuts. -1988...

Direction de santé publique du Nunavik •«rrymffCT 21 Cancer

Cancer mortality is also increasing. Increased life expectancy and accessibility to diag- nostic services are related to this phenomenon. Lung cancer is responsible for the great- est number of deaths among both men and women, a reflection of the very high smoking rate. Between 1995 and 1999, lung cancer mortality in Nunavik was 2.3 times greater than in the rest of Quebec. Cancer of the upper respiratory tract is also one of the main cancers responsible for deaths in the region.

Breast cancer remains rare and was responsible for 6 deaths between 1987 and 2001 However, its incidence is likely to increase and should be monitored closely. The inci- dence of invasive cervical cancer (responsible for 6 deaths between 1987 and 2001) is twice higher in Nunavik than in Quebec as a whole and is linked with the prevalence of sexually transmitted infections.

Smoking

The prevalence of smoking remains markedly higher in the region than in the rest of Canada (or Quebec). Indeed, the proportion of smokers in Nunavik is the highest in Canada: 16 % of 6-7 year-olds are already smokers, a proportion that rises to 68 % among 12-13 year-olds (recently, 80 % of high school young people stated that they smoke) and is maintained throughout adulthood. In fact, 65 % of men and 71 % of women are smokers.22

The high rates of smoking constitute catalysts for vascular diseases and lung cancers and are also associated with a multitude of health problems, including chronic obstruc- tive pulmonary diseases (COPD), chronic respiratory infections, intrauterine growth re- striction, sudden infant death syndrome and chronic infections in children. Respiratory tract diseases result in 3.5 times more hospitalizations in Nunavik than in Quebec ® COPD is responsible for 10 % of deaths (Nunavik Mortality Data, 1987-2001).

Ecological approaches to smoking reduction are effective. Caution should be exercised when intervening with young people so as to avoid generating perverse effects.

Dental health

The incidence of tooth decay among Inuit children of Nunavik remains high. Only 2 6 % of 6-year-old Inuit children are cavity-free. The percentage of 15 and 16 year-old adoles- cents who are cavity-free is nearly nil-or 0.7 % (one in 147 adolescents). Seven-year-old Inuit children have on average 8.07 primary teeth that are decayed, missing or filled and 12-year-old adolescents have 5.63 permanent teeth with cavities. Although the health of Nunavik children's primary dentition has not improved for the last 15 years it must be emphasized that between 1983 and 1998, the cavity rate of these children's" permanent dentition dropped by 20 to 25 %.

Examination of the questionnaires distributed to children aged 6 to 12 years shows that nearly two-thirds (65.5 %) said that they had brushed their teeth the day before the

* HODGINS Stevens; - Health and what affects it in Nunavik: how is the situation changing? - 1997... Ibid.

Direction de santé publique du Nunavik •«rrymffCT 22 check-up, but only one-third said they had brushed their teeth more than once. The ma- jority of children, or 70.9 %, have an average or fair oral hygiene. Nearly 50 % of adoles- cents, mainly giils, brush their teeth twice or more times per day and 80 % chew sugar- less gum. Teeth brushing habits have improved since 1983-8454 and even since 1998- 1999.25 As a comparison with a population that has a lower cavity rate, in 1996-1997, nearly 70 % of 14-year-old Quebec adolescents brush their teeth twice ôr more times per day.?8

As of 1985, Inuit children started taking fluoride supplements systematically during the first three years of elementary school. The widespread drinking of tea by children and the use of toothpaste are additional fluoride sources. These fluoride intakes have helped to reduce tooth decay but also resulted in dental fluoroses. However, the great majority of adolescents in the region, or 92.5 %, do not have this problem. It is difficult to consider fluoridation of the water in the region, given the mode of distribution of drinking water.

The intake of sugary foods, one of the leading causes of tooth decay, is high. Although Inuit adolescents are aware of the harmful effect on their teeth of consuming refined sugar, they chew 0;5 sugared gum, drink 2.79 cans of soft drinks and eat 3.27 candies per day. In fact, 94 % of adolescents consume at least one of these sweet snacks eve- ryday.

! ( " 24 VÉRONNEAU, J. and LAMARCHE, G. - Enquête en santé dentaire chez les Inuits. -1985... * BÉLANGER, R. - La santé dentaire des enfants du Nunavik, en 1996-1999. - 2000... ' 20 BRODEUR J.-M. et al. - Étude 1996-1997 sur la santé buccodentaire des élèves québécois de 11-12 et 13-14 ans. - 1999...

Direction de santé publique du Nunavik BB28II •«rrymffCT 23 CHALLENGES AND OPPORTUNITIES

As shown in Figure II, lifestyles and diseases are linked in several respects. For example, the promotion of healthy eating habits will have an impact not only on obesity, osteoporosis! diabetes and cardiovascular diseases, but also on dental health and cancer prevention.

The assessment of the situation in Nunavik brings out a number of issues, which differ from the reaiity of other Quebec regions.

General Issues

• Foster the establishment of social standards conducive to the adoption of healthy lifestyles. • Increase the preventive practices of counselling on smoking, eating habits, physical activity and the use of fluoride. • Support clinicians in early detection of the following chronic diseases: breast cancer, cervical cancer, hypertension and diabetes. • Support community actions and community projects.

Nutrition and physical activity

• Increase public awareness of the links between physical activity and health. • Increase public awareness of the links between food and health. Promote the use of traditional foods. • Enhance women's knowledge about how to combine store-bought foods with tra- ditional foods. • Create safe environments that are conducive to physical activity. • Increase the availability of healthy foods at reasonable prices.

Smoking

• Increase public awareness of the harmful effects of cigarette and second-hand smoke on health. • Increase public awareness of the harmful effects on fetal health of smoking dur- ing pregnancy. • Increase the number of smoke-free establishments. • Restrict the sale of tobacco products to minors. • Facilitate smoking cessation. • Inform the public about the practices of tobacco companies.

Direction de santé publique du Nunavik 24 Cancer In addition to support for clinical preventive practices, change in eating habits, smoking reduction and promotion of safe sexual practices:

• Specific cancer screening activities are to be reinforced or developed.

Dental health

• Promote increased teeth brushing, particularly among children and adolescents. • Reduce intake of sweet snacks among adolescents. • Distribution of fluoride supplements in schools.

Direction de santé publique du Nunavik 20 25 OBJECTIVES

• Decrease by 3 % per year the rates of mortality and morbidity due to cardiovas- cular diseases (including ischemic heart diseases and strokes). • Reduce by 30 % the rates of mortality and morbidity due to chronic obstructive pulmonary disease. • Slow down the increase in the incidence of diabetes. • Maintain breast cancer mortality to under one case per year among women aged 50 - 69 years. • Reduce the prevalence of overweight among adults in addition to preventing overweight and obesity in both children and adolèscents. • Increase physical activity among children and adolescents. • Increase physical activity among adults. • Foster the adoption of healthy eating habits (daily intake of 5 servings of fruits and vegetables, consumption of dietary fibres and traditional foods). • Reduce smoking among high school students from 80 to 50 %. • Reduce from 70 to 60 % the proportion of people aged 15 or over who smoke. • Reduce exposure to environmental tobacco smoke. • Reduce by 25 % the average number of decayed, missing or filled tooth surfaces among young people under 18. • Increase the proportion of individuals who have good oral and dental hygiene habits, in particular among children and adolescents. • Reduce the prevalence of food insecurity.

Direction de santé publique du Nunavik 26 Figure II : Links between lifestyles and chronic diseases

Aggravating Other Direct link Synergy link factor

Source: DÉRY, Véronique and LACHANCE, B. - Habitudes de vie et maladies chroniques : une amorce de vision commune. - 2001 ...

Direction de santé publique du Nunavik 27 Adoption of healthy eating habite and regular REGIONAL ACTION PLAN physical activity - General population

Create a regional intersectoral table on physi- Introduce and coordinate discussions on KRG : Regionel and local recrea- cal activity whose mission is to coordinate ac- the various projects. tional activity coordinator tivities to promote physical activity and facili- tate the creation of environments conducive to Provide scientific support School Board and schools physical activity. [I] Support the implementation of activities. Representatives of the population Municipalities Design an intensive and concerted communi- Find physically active people in.the com- KRG (Recreational Activity Coordina- cation campaign on the promotion of healthy munity who can be promoted as role tor) lifestyles, including promotion of the traditional models. diet. [C] Northern-QOOP-FCNQ Create promotional material in Inuktitut HSP Provide scientific and technical support to the Recreational Activity Coordinator as Nunavik Research Center part of promoting activities. HFTA Promote the Nunavik Food Guide. Reach agreements with food markets so as to organize food demonstration stands there.. Disseminate among the population accu- rate Information on the benefits and risks associated with eating traditional foods. Create an environment conducive to physical Meet the School Board to increase the KSB-Schools activity by establishing or increasing accessibil- general population's access to existing ity to safe and adapted sports facilities. [C] sports facilities. HSP Define with the partners strategies for KRG (Recreational Activity Coordina- encouraging the practice of traditional tor) physical activities. Adoption of healthy eating habits and regular physical activity — General population (cont.)

Priority Activities Role of PHD / RBHSS Role of HC/CLSC Role of qther partners (1-2-3) (Implement, Consolidate, Maintain) Support the development of community KRG (regional and local Recreational projects to promote physical activity Activity Coordinator) (e.g., hiking trails, walking club, etc.). Municipalities Explore jointly with representatives of the KRG population and municipalities the possi- Municipalities bilities of developing sports infrastruc- tures that meet the population's needs Nunavik Youth Association and are feasible in terms of implementa- tion, operation and maintenance costs. Explore the possibility of getting the Foundation "Quebec en forme' program under way in Nunavik. Conclude a specific agreement with Kino- Kino-Quebec Quebec concerning access to fitness counsellors. 1 Ensure availability of healthy foods in the Meet representatives of food markets COOP -FCNQ community. [C] and COOPs to raise their awareness of health problems related to diet and pro- Northern mote the marketing of healthy foods. With community groups, label foods or COOP-FCNQ display containers in stores according to the Food Guide. Provide labels based on Northern the Food Guide to be affixed in grocery stores. Collaborate with our partners in support- ing the Food Mail pilot project that is go- ing on in Kangiqsujuaq village to maintain the study's training component. Meet the government organizations re- Canada Post sponsible for managing food transporta- tion to maintain the program and its im- First Air & Air Inuit pact on the real price of foods. Health Canada

Direction de santé publique du Nunavik 29 Adoption of healthy eating habits and regular physical activity — General population (cont.)

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD / RBHSS Role of HC/CLSC Role of other partners 2 Support clinical preventive practices in physical Train physicians, nurses, community Kino-Quebec activity. [C] health workers (CHWs) on fitness coun- selling, mainly Inuit workers. 1 Foster the acquisition of know-how to exploit Experiment with the concept of collective HSP the potential of traditional foods by supporting kitchen within a pilot community. the establishment of collective kitchens, pam- COOP-FCNQ phlets, posters, in-store demonstrations. [I] Conclude agreements with partners of food stores and the Hunter Support Pro- Northern gram so as to support the collective kitch- ens by providing foods.

Direction de santé publique du Nunavik 30 Adoption of healthy eating habits and regular physical activity - Young people aged 5-24

Priority Activities (1*2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC/CLSC Role of pther partners 1 Develop communication campaigns in collabo- Coordinate discussions. KSB-Schools ration with local representatives to promote physical activity among young people, p] Produce communication material. KRG (Recreational Activity Coordina- tor) Youth centres 1 Explore jointly with representatives of the Coordinate the development of safe KSB-Schools population and municipalities the possibilities sports infrastructures projects intended of developing sports infrastructures that meet for young people (e.g., skate board ramp, Youth centres the needs of young people and are feasible in half pipe for snowboarding) in a commu- KRG (Recreational Activity Coordina- terms of implementation, operation and main- nity. tenance costs. [C] tor) Broaden the process to include other communities. 1 Develop schools by promoting physical activity Meet the School Board so as to establish KSB-Schools through a concerted and integrated interven- an agreement between the health and tion in schools, p] education networks, regarding the activi- ties and means to be implemented for the creation of healthy environments, as specified in the MÉQ-MSSS framework agreement Conclude a partnership with the School Board and schools in implementing the "Ça bouge après l'école' program.

Direction de santé publique du Nunavik 31 Smoking reduction - General population

^Priority*

1 Consultation among organizations working on Initiate discussions and bring together the Participate In discussions N.I. the promotion of healthy lifestyles and on de- partners. Provide scientific expertise. pendencies. . [1] Inuit Women's Association 1 Promotion of non smoking and "Safer smok- Create and produce posters and pam- Distribution ing • [CJ phlets on "Safer smoking." Create and produce a pamphlet on The Distribution Money you save from not smoking." 1 "J'arrête, j'y gagne" Quit and win challenge. Launch the challenge every year. Distribution of material [M] Sponsors Conduct biological tests 1 National Non-Smoking Week. [M] Contact and support partners In their Na- KSB tional Non-Smoking Week activities. Schools Distribute the (trilingual) material to part- ners. Radios 1 Promote and apply the provincial law on non Establish liaison with the MSSS inspec- MSSS' smoking in public places and workplaces. [C] tion services. Create the material to promote smoke- free environments. Meet public and private organizations regarding the creation of smoke-free envi- ronments.

Direction de santé publique du Nunavik 32 Smoking reduction - General population (cont) Priority: HiWfà 1 Set up a network of smoking cessation coun- Recruit and train. sellors (2 counsellors per community) in the entire Nunavik territory. [C] Create and provide training tools. Create and provide tools to support con- sultation of the population. Use telephone service to support coun- sellors' actions. Follow up actions undertaken by counsel- lors. Assess impact of the program. 3 Promote an English-language telephone ser- Promote the telephone service provided vice to support smoking cessation, p] by smoking cessation counsellors. 1 Support the clinical preventive practices of Provide training on the specificities of Have clinicians participate in train- clinicians in the region for detecting and coun- Nunavik (distribution of booklet called ing activities. selling on smoking. [C] 'Helping your patients healing from smok- ing"). Provide tools to patients Ç Healing Provide case-finding and counsel- from smoking0 booklet intended for pa- ling services. tients). Inform clinicians about smoking among the population and smoking reduction activities and services in the region through letter and newsletter.

Direction de santô publique du Nunavik 33 Smoking reduction- Elementary and high school students

Priority Activities (1-2-3) Role of PHD/RBHSS Role Qf HC / CLSC Rote of other partners (Implement, Consolidate, Maintain) . - V 1 Develop smoke-free environments and smok- Meet the School Board so as to establish KSB ing prevention activities through a concerted an agreement between the health and and integrated intervention in schools. [1] education networks, regarding the activi- ties and means to be implemented for the creation of healthy environments, as spedfied in the MÉQ-MSSS framework agreement. 2 Create a network based on "Gang allumée Recruit one mandatary per school and School nurses and community KSB - Schools pour une vie sans fumée. "( Light the Gang support their activities to promote non- health workers educational site). [1] smoking. 3 Creation of theatre activities by and for Inuit, Assess feasibility of this project with our KSB - Schools inspired from the *IN Vivo" tour, p] partners. Youth centres Provide logistic and scientific support for the development of this activity. 1 Raise public awareness of the effects of youth Create advertising messages to raise Media smoking through advertising messages. [1] adults' awareness of the importance of not giving or buying dgarettes for chil- dren.

Integrate activities of creating "Anth Media Smokintf advertising messages by and for young people. Ensure distribution. 1 Promote and apply the law on the sale of to- Create and distribute the material in COOP - FCNQ bacco products to minors. [I] cigarette outlets to raise public and retail- sale workers' awareness of the law. Northern Convenience stores Meet store managers to raise their COOP -FCNQ awareness of the content of the law and foster its application. Northern Convenience stores Establish link with the Health Canada Health Canada inspection service for the application of the law in Nunavik.

Direction de santé publique du Nunavik 34 Smoking reduction - Pregnant women :Prtbrity£ (1-2-3) -^(Implemen^ Consolidate,' Rtajntain)^^; SÊÊSËÊÊÊSÊS mmm^^^mmpm^mmm 1 Conduct a communication campaign on the Create and distribute posters and pam- effects of smoking on the fétus. [1] phlets on the effects of smoking during pregnancy. 1 Integrate smoking detecting and counselling Provide training on the specificities of activities into the clinical practices in perinatal Nunavik (distribution of booklet called care (physicians, nurses and midwives). p] 'Helping your patients healing from smok- ing").

Provide tools to patients ('Healing from • smoking' booklet intended for patients). Inform clinicians about smoking among the population and smoking reduction activities and services in the region through letter and newsletter. 1 Integrate a smoking reduction component into Coordinate smoking reduction activities the integrated programs aimed at pregnant during implementation of the EB-GH pro- women (EB-GH). p] gram. Provide tools to workers.

Direction de santé publique du Nunavik 35 Cancer prevention

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC / CL3C Role of other partners 1 Adequately screen for cervical cancer in the Assess coverage in each community of Provide data from laboratories population of each community. [C] screening activities using the Papanicalou test. Support preventive activities. Participate in training activities Conduct screening tests based on regional protocols 1 Maintain implementation of the Quebec breast Coordinate activities inviting women to Facilitate implementation of the cancer screening program for women aged 50- undergo mammograms. 69. [1] program in Nunavik Establish procedures for mammograms Inform the target population and their follow up. 2 Coordinate colon cancer screening activities Transmit the information on colon cancer Participate in training activities based on the latest recommendations. [1] screening to clinicians. Provide screening tests and their Support clinicians in the application of this follow up. measure. Establish a regional colon cancer screen- ing program, if applicable.

Direction de santé publique du Nunavik ——————— _ —.. Oral-dental diseases - Preschool-aged children

Priority Activities (1-2-3) (Implement Consolidate, Maintain) Role of PHD/ RBHSS Role of HC/CISC Role of other partners 1 Educate parents so that children aged 12,18 Assess parents' comprehension of the Provide educational activities. and 24 months can benefit from Individualized information received. follow up. p] 1 Apply fluoride varnishing on the teeth of chil- Assess children's eligibility for this meas- Apply fluoride varnishing. dren aged 12,18 and 24 months, p] ure. 1 Visit childcare centres every year and train Support application of this activity. Conduct visits. Childcare centres (CPEs): Daily teeth educators on dental health. [I] brushing in daycares

Oral-dental diseases - School-aged children and adolescents Priority Activities (1-2*3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC / CLSC Role of other partners 1 Distribute fluoride tablets to all children in kin- Check prescribed dosages. dergarten and grades 1,2 and 3 of elementary Provide fluoride tablets and follow Schools: distribute fluoride tablets to school. [M] up in schools students everyday 1 Distribute fluoride mouthwash to all elementary Check eligibility for this measure at all schoolchildren. [M] Provide fluoride mouthwash and Schools: distribute fluoride mouth- school levels. follow up in schools. wash to students everyday 1 Apply sealants on the surfaces of permanent Check pertinence of this measure for the Apply sealants Schools: monitor children treated by molars that have fossa and sulci to all children Inuit population. aged 5 to 15 years. [C] dentists

Direction de santé publique du Nunavik 37 COMPONENT 3 - UNINTENTIONAL INJURIES

ASSESSMENT OF SITUATION

In the field of public health, what the media call accidents are referred to as "unintentional injuries." The term is intended to connote the fact that these injuries do not happen by chance, resulting from a series of random events, but rather the great majority of these events can be prevented. This program area includes all injuries and poisonings which oc- cur involuntarily and are mostly preventable.

In Quebec, unintentional injuries are the third leading cause of potential years of life lost. In Nunavik, unintentional injuries are the leading mortality cause among all age groups from 0 to 50, except among the 15-24 year-olds, where suicide causes the most deaths. In total, in the region, one in five deaths is attributable to an unintentional injury. In comparison with the rest of Quebec, taking account of the age structure and size of the population, in Nunavik there are 12.6 times more deaths attributable to unintentional injuries.

Motor vehicles

Injuries caused by the use of motor vehicles have been increasing in the region since 1970 (Nunavik Mortality Dataf 1987-1999), even without considering the appreciable de- cline in the rest of Quebec. The mortality rate by accidents involving motor vehicles is nearly 4 times higher in Nunavik than in the rest of Quebec (Nunavik MortalityData, 1995-1999). Between 1987 and 1999, all-terrain vehicles (ATVs) were responsible for nearly half of thesé deaths, while snowmobiles and automobiles or trucks each repre- sented slightly more than one quarter of these deaths. These data reflect both the grow- ing number of motor vehicles in the region and their use on roads and in the back coun- try.

Since the few roads in Nunavik are not linked with the Quebec road network, provincial regulations are scarcely enforced. In fact, there is little police control of safety measures and they are applied very freely:

• Minimum driving age; • Impaired driving (efforts have recently been made to control drivers' level of in- toxication) ; • Driving without a licence; • Driving at high speeds or dangerous driving; • Number of passengers; • Use of protective equipment such as a seat belt or helmet: in 1992, only 11.5 % of the Inuit interviewed in the SQHS stated that they wore a seat belt always or most of the time, a proportion which dropped to 4.6 % for wearing an ATV safety helmet. Incentive measures have been introduced in Kuujjuaq since winter 2002 to encourage the wearing of snowmobile safety helmets. The municipal administration reimburses 50 % of the helmet's cost.

Direction de santé publique du Nunavik 38 Drowning

Drowning is another major cause of death by unintentional injuries (represents more than one quarter of these deaths). Nunavik is a vast territory which does not have roads to link up communities. During the summer, its impressive water network serves as a highway. Lakes and rivers are also extensively used for fishing. Drowning causes more deaths in Nunavik than in other Aboriginal populations.27

Table II : Deaths by drowning

Deaths by drowning (/100,000/year) Nunavik (1987-1994) 46 Nunavut (1989-1993) 16 Amerindians of Canada (MSB - 10

People rarely wear a personal flotation device. The Hunter Support Program is currently promoting the wearing of life jackets by its members, by subsidizing vests that are ac- ceptable to fishermen. Alcohol is probably responsible for a number of drownings.

Poisoning

The other prevalent causes of deaths by unintentional injuries are poisoning and fire which are each responsible for around 10 % of these deaths. These are followed closely by exposure and firearms. Very few poisoning cases among children aged 0 to 5 years in Nunavik are reported to the Poison Control Centre, markedly less than in the rest of Quebec.29

Fire In the last 10 years, 14 fire-related deaths were reported. The factors explaining the inju- ries and deaths related to fire are, among others, individual behaviours such as smoking, drinking and unsupervised use of matches by children. Other environmental factors also contribute to this problem: substandard electric circuits in old dwellings, little mainte- nance of fire extinguishers and fire alarms (although many dwellings are equipped with them).30

Hypothermia

Accidents and mechanical breaks that occur during a trip into the tundra are responsible for deaths due to hypothermia. Some safety measures are known and applied (for ex- ample, going on trips into the tundra with at least two snowmobiles). Rangers of each community are trained in survival techniques and transmit their knowledge on wilderness survival to members of their communities.

27 HODGINS, Stevens.-A portrait of injury in Nunavik. - April 1997 ... 28 HODGINS Stevens. - Health and what affects it in Nunavik: how is the situation changing? - 1997... 29 PAGEAU, M.; FERLAND, M.and DÉRY, S. - Our Children: Health Status of Children Aged 0-5 Years in Nunavik. -2003 (forthcoming) 30 See note at the end of page n° 27

Direction desantô publique du ^«pf*^— •••••• , |UllLt,u,i..iiiUi,lu.i,.^.1 , , llu 1JUIU.M 3g Firearms

Firearms are more commonplace in Nunavik than in the rest of Quebec (1992 SQHS) since the Inuit use them more often for hunting: 82 % of Nunavimmiut state that they have a firearm in the home compared with 23 % in Quebec. Among individuals who pos- sess firearms, 54 % say that they keep them under lock and key either all time or most of the time. Unintentional injuries can result from the imprudent handling of a firearm, but widespread access to firearms can also help turn suicidal or homicidal intentions or im- pulses into real acts.

Falls

Falls cause the majority of hospitalizations for injuries. They represent slightly less than 2 % of all hospitalizations in Nunavik.

Sports accidents

There are many reported sports accidents. (See Table V: Type of accident). Currently, every summer, some communities organize a bicycle rally in which young people learn safety measures in cycling. The SQHS (1992) reported the following causes of injuries resulting from an accident for the 12 months prior to the survey:

Table III : Type of accident

Type % Pe Sports accident 19.4 48 Snowmobile accident 18.1 45 Fall 17.3 43 Accident involving an ATV 13.2 33 Other 9.5 24 Brawl 6.6 17 Boat accident 4.5 11 Accident involving a 2-wheel vehicle 3.7 9 Work accident 3.6 9 Hunting accident 2.3 6 Car accident 1.7 4 TOTAL 100 250 (Santé Quebec: Health Profile of the Inuit) CHALLENGES AND OPPORTUNITIES

• Take advantagè of the studies and collaboration of the National First Nations and Inuit Injury Prevention Working Group as well as the Quebec public health net- work. • Make the problem more visible. • Promote unintentional injury prevention among decision-makers. • Inform the population about their power to reduce injuries and deaths due to un- intentional injuries by using protective means. • Train workers in the health and social services network in offering prevention ad- vice. • Stimulate and support community actions. • Underline, develop, promote awareness among the population and decision- makers of the predominant role played by alcohol consumption in injuries and re- lated deaths. • Deepen our knowledge about adapted and effective interventions regarding the use of ATVs and snowmobiles. • Document the contexts in which falls occur and their consequences.

OBJECTIVES

• Reduce the number of deaths observed among road users and off-road vehicle drivers, mainly injuries related to alcohol intoxication. • Reduce the number of deaths by drowning. • Reduce injuries due to handling of firearms. • Reduce morbidity due to falls. • Reduce fire-related lesions and deaths. • Reduce sports-related injuries.

Direction de santé publique du Nunavik ••'»» ^•.«.••^••wii». Mt.wuH.»,.i».wijii.iwpplui-ii.mHMHJtM«iw.....! ... JQ Unintentional injury prevention REGIONAL ACTION PLAN General population priority SW^mpL® 1 Establish research plans on injuries and Conduct studies to characterize victims of Participate in data collection. KRPF deaths related to the use of ATVs and snow- these injuries, the related causes and mobiles in the territory; morbidity related to factors that can be changed. falls; injuries and deaths resulting from lire. [1]

1 Collaborate In the definition and implementa- Promote awareness among decision- Municipalities tion of measures aimed at traffic control and makers of the issue of road planning. road planning. [C] KRPF Provide decision-makers with tools to evaluate road planning. INSPQ Support organizations in research and KRG interventions. t Design and promote an intersectoral strategy Plan and conduct a societal communica- Stimulate and support community KRPF: Strengthen enforcement to reduce impaired driving. [1] tion campaign on drinking and driving, actions of awareness and interven- measures on the application of the adapted to Nunavik. tion in reducing impaired driving. law governing impaired driving. Coordinate this campaign with enforce- KRPF: Participate in communication ment mesures aimed at controlling im- campaigns, if applicable. paired driving. 2 Preventive intervention aimed at reducing risks Coordinate with communication cam- KRG (Training component) associated with drug and alcohol use, includ- paigns and apply enforcement measures, ing training waiters, using ride services and support the training of waiters in estab- Bars designated drivers. [1] lishments and develop the habit of using KRPF a designated driver.

Nunavik Public Health Department Unintentional Injury prevention — General population (cont.)

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC / CLSC Role of other partners 1 Ensure the safety of facilities for physical rec- In our actions to develop infrastructures Municipalities reational activities. p] and an environment conducive to physi- cal activity, apply existing safety stan- KRG (Recreational Activity Coordina- dards and encourage safe behaviours tor) (such as wearing protective equipment). KSB-Schools

1 Collaborate with local and regional partners in Bring local and regional partners together KRPF order to develop a strategy to promote public in order to develop such a strategy. (See awareness of the means to reduce risks asso- also Component 1 - Development, Social Hunter Support Program ciated with firearms. 0] Adjustment and Integration). Hunting-Fishing-Trapping Associa- tion 1 Conduct a campaign to promote the use of With the partners, plan and conduct a Fire departments smoke detectors. [C] communication campaign on measures to strengthen enforcement of use and ade- Municipalities quate maintenance of smoke detectors. KRG 1 Promote the wearing of a floater vest by fish- Bring local and regional partners together KRPF ermen. [C] in order to develop such a strategy. Hunter Support Program Hunting Fishing Trapping Association 2 Support for clinical preventive practices to re- Counselling by clinidans on the use of Participate in training activities. KRPF duce injuries and deaths due to unintentional safety devices: injuries. [C] Provide counselling to the popula- HFTA • helmet: ATVs, snowmobiles, motorcy- tion. des, bicycles; HSP • floater vest; • seat belt; • firearms; Provide (trilingual) tools to clinicians.

Nunavik Public Health Department 43 Unintentional Injury prevention — Young people (0-24 years old)

Priority Activities fiole of other partners d-2-3) (Implement, Consolidate, Maintain) . Role of PHD/RBHSS Role of HC / CLSC 1 Integrate injury prevention activities into pro- Support the implementation of these ac- Conduct activities related to pre- CPEs grams intended for the very young (PSJP, EB- tivities. vention. GH) and childcare centre activities. [1] Provide tools. 1 Ensure safety of play spaces. [C] Check that play modules of childcare CPEs centres meet safety standards. 1 Conduct activities to promote awareness of Meet the School Board so as to establish School nurses and community KSB-Schools unintentional injury prevention as part of a an agreement between the health and health workers concerted and integrated intervention in education networks, regarding the activi- schools, p] ties and means to be implemented for the creation of healthy environments, as specified in the MÉQ-MSSS framework agreement

Nunavik Public Health Department BB 44 COMPONENT 4 - INFECTIOUS DISEASES PART I : GENERAL Infectious diseases - Surveillance

Maintenance of health surveillance: surveillance .of reportable diseases and emerging diseases ^Priority! ^(Implémen^ Mw^m^mm 1 Reach an agreement with the network to Coordinate discussions on protocol for Participate in intersectoral meet- establish procedures and responsibilities in surveillance of reportable diseases. ings. the monitoring of reportable diseases (MÀDOs) in accordance with the surveillance Coordinate MADO system for the region. plan. [C] Provide scientific and technical support. 1 Update MADO system. 0] Update health professionals (physicians Make health professionals and and nurses) and laboratories on report- laboratories accountable for report- able diseases. ing all MADOs. Participate in training.

Nunavik Public Health Department 45 Infectious diseases - Protection

Implementation of guidelines for case investigation, prevention of secondary cases and co nirol of outbreaks, as provided fo r under chapter XI of the Public Health Act. vPriorlt^ wwmmm®**^^ (1-2-3) SSMM lIlSiiHiW 1 Maintain an efficient system for detecting and Inform partners of their responsibilities As provided by the Act, profes- reporting real or apprehended threats (by bio- to report any real or apprehended sionals report any real or appre- logical agents). [C] threat to the population's health. hended threat to health.

• Provide 24 hours, .7 days a week ser- vice for infectious diseases. Support studies on conditions that are Maklvik conducive to the emergence of threats to the population. 1 Implement a strategy for epidemiological inves- Coordinate epidemiological investiga- Collect data In collaboration with Different partners: collaboration in tigations. [C] tion and analyze data. the PHD. investigation based on needs. Support network personnel in data col- lection processes. 1 Implement interventions to control infèctions Establish guidelines to prevent secon- Implement guidelines. when outbreaks occur. [C] dary cases and control outbreaks: Ensure and support the implementation of guidelines in network institutions and with partners outside the network. 1 Establish an emergency measures plan In the Consult with network partners and Participate in discussions. Public security event of pandemic influenza or any other bio- other partners In the community. logical threat (SARS, smallpox, etc.). [1] KRG KRPF Municipalities

Nunavik Public Health Department BB 46 PART II : DISEASES PREVENTABLE BY IMMUNIZATION

ASSESSMENT OF SITUATION

The relatively recent epidemics caused by several infectious diseases are still vividly re- membered in Nunavik. The youth of the Nunavik population (40.5 % of the Inuit in Nunavik are aged 15 or under, compared to 20 % in Quebec; 1992 SQHS) must be taken into ac- count in outlining the risk profile for the development of certain infectious diseases. Recent outbreaks of shigellosis, severe pneumonias and measles clearly exemplify this considera- tion.

Immunization programs are currently provided by the CLSCs, in the service points of each community. In 1996-1997, a survey revealed that vaccination coverage for children under 2 was similar to MSSS standards. In fact, 91.6 % of 2-year-old children had been completely immunized against diphtheria, whooping cough, tetanus, poliomyelitis, measles, rubella mumps and tuberculosis; a reflection of both the collective consciousness in which the memory of these diseases is still alive and the enormous efforts made by Nunavik's health workers to follow the immunization schedule.

Vaccination against tuberculosis

The Inuit population of Nunavik has been hard hit by tuberculosis. In 1957, it was re- ported that one in seven Canadian Inuit was resident in a tuberculosis treatment cen- tre. Today approximately six tuberculosis cases are still reported annually to the regis- try of reportable diseases (MADO) (incidence of 67/100,000 between 1990 and 2002) The BCG (Bacillus of Calmette-Guérin) vaccine is included in the immunization schedule for infants and children. It is administered soon after birth so as to reduce the risks of in- vasive tuberculosis disease in childhood.

Diphtheria - Tetanus - Poliomyelitis

There have been no cases - either recorded in the registry of reportable diseases or in the recent memory of public health - of diphtheria, tetanus or poliomyelitis since 1990 and this reflects the excellent vaccination coverage for 2-year-old children which reached 97.3 % at 24 months of age for children bom in 1996 and 1997.32 The CLSCs vaccinate Secondary 3 students against tetanus and diphtheria. However there are no recent data on rates of vaccination coverage for this booster.

* HODGINS Stevens. - Health and what affects it in Nunavik: how is the situation changing? - 1997 PROULX, Jean-François. - Rapport sur la couverture vaccinale des enfants de 2 ans du Nunavik. - 2001

Direction de santé publique du Nunavik eebq Jwiwnmin 47 Haemophilus influenzae type b

Cases of meningitis caused by the Haemophilus influenzae type b bacterium were an important cause of death and severe morbidity in Nunavik until the early 1990s. At the time, this disease was much more prevalent in Nunavik than in Quebec as a whole. On the Hudson coast, 3.3 % of children bom between 1980 and 1990 developed bacterial meningitis before age 1 and most cases were attributable to Haemophilus influenzae type b. The introduction of the conjugate vaccine in late 1991 helped to reduce the num- ber of cases.33 Between 1992 and 2002, 3 cases of Haemophilus influenzae type b in- fection were reported for the region and they all involved individuals who had not been adequately immunized (MADO). Vaccination coverage was sufficient for children bom in 1996 and 1997, reaching 96 % among 2-year-olds.34

Whooping cough Six cases of whooping cough (MADO) were reported in the region in the last 10 years (average annual incidence of 1.4/100,000). Vaccination coverage is 97.3 % at 2 years old for children bom in 1996 and 1997.35 Unlike the usual comparisons, between 1990 and 1999, the average annual incidence of whooping cough was 36/100,000 in Quebec.

Bacterial meningitis

• 6 cases of meningococcus infections reported in last 10 years, all serogroups combined. • 96.4 % vaccination coverage in 2000-2001 immunization campaign against sero- group C meningococcus. • Since 2002, vaccination at age 1 included in routine immunization schedule.

Measles - Rubella - Mumps Nunavik was hit by several relatively recent outbreaks of measles. In .1952, an epidemic on the coast of Ungava Bay claimed the lives of 131 of its 700 inhabitants.36 Immuniza- tion of children was introduced in the late 1960s. However, in 1975 the Ungava coast was once again hit and then successively in 1989 and 1991, with 29 and 71 cases re- ported on both coasts.

In spring 1996, a massive immunization campaign was implemented to administer a booster dose against measles (MMR) to young people aged 18 months to 18 years. At the same time, a second dose was added to the regular immunization schedule.37 For children bom in 1996 and 1997, vaccination coverage against measles (including the booster dose) was 95.8 % at the age of 24 months.38

33 HODGINS Stevens. - Health and what affects it in Nunavik: how is the situation changing? - 1997... 34 PROULX, Jean-François. - Rapport sur ia couverture vaccinale des enfants de 2 ans du Nunavik. - 2001 35 Ibld. 39 Ibid. 37 Ibid.

Direction de santé publique du Nunavik ••'»» ^•.«.••^••wii». Mt.wuH.»,.i».wijii.iwpplui-ii.mHMHJtM«iw.....! ... JQ Pneumococcus

Every year in Nunavik, respiratory infections represent the most common reason for hospitalization with an adjusted rate (1995-1999) of 505/10,000, that is, five times the rate of the Quebec population as a whole.39 Like elsewhere, hospitalization for pneumo- nia particularly affects children under 2 and persons aged 65 or over.40,41 A recent study of three Hudson Bay communities found that 26 % of children are hospitalized for pneu- monia before age 1. More recently, Nunavik has seen an outbreak of serious type 1 pneumococcus pneumo- nias, a strain that is rare in Quebec and Canada and documented for the first time in Nunavik in November 2000.

A polysaccharide vaccine against pneumococcus (Pneumovax-23) was first introduced in the early 1990s. Following the outbreaks in 2000-01, an immunization campaign tar- geting the general population was carried out in spring 2002. At the end of this cam- paign, coverage with polysaccharide 23-valent vaccine reached 84 % of persons aged 5 and over. Catch-up immunization of children aged 2 months to 4 years with the 7-valent conjugate vaccine resulted in a vaccination coverage (dose #1) of 80 % as of July 1, 2002.

Finally, from April 2002 onwards, the 7-valent conjugate vaccine (Prevnar) was added to the regular immunization schedule for children. It should also be noted that in Nunavik, the prevalence of chronic otitis media (perforated eardrum) is 11 % among children aged 4 to 6 and that the resulting hearing problems af- fect 20 % of secondary school students.

Hepatitis A

An outbreak of hepatitis A in 1991-1992 in Nunavut (Baffin Island) resulted in a signifi- cant number of cases of fulminant hepatitis, underscoring the Inuit population's suscep- tibility in reaction to this infection. In addition, access to drinking water and regional eat- ing habits could facilitate the propagation of the hepatitis A virus (See Component 4, Part IVEnteric and foodborne diseases). The most recent outbreaks of hepatitis A in Nunavik date back to the 1970s.

Given this vulnerability and the fact that most young people have never been exposed to the virus, a massive immunization campaign targeted at people aged 2 to 20 was intro- duced in autumn 2001 (the data for the Ungava coast indicate that all children received a first dose and approximately 97.3 % of the target population received two doses). Since then, the vaccine-has also been added to the regular immunization schedule: two doses are administered between the ages of 3 and 6.

39 PAGEAU, M et al. - Le portrait de santé : le Quebec et ses régions. - 2001... 40 ROBINSON, Katherine A. et al. - For the active bacterial core surveillance / emerging infections program network : epidemi- ology of invasive streptococcus pneumoniae infections in the United States, 1995-1998: opportunities for prevention in the conjugate vaccine era. - 2001... " BANERJI, Anna et al. - Lower respiratory tract infections in Inuit infants on Baffin Island. - 2001...

Direction de santé publique du Nunavik sa 49 Hepatitis B The rate of reported cases of hepatitis B for the 1991-1993 period was 50/100,000/year, that is, five times higher than the rate in the rest of Canada for the same period.42 Since 1993, 3 cases of acute hepatitis B and 21 cases of chronic or unspecified hepatitis B have been reported in the region.

As in the rest of Quebec, universal immunization of Grade 4 students against hepatitis B is carried out by the CLSCs. In 2000-2001, the communities1 nurses succeeded in achieving a 97 % vaccination coverage for the 3 doses in the entire region (98.4 % for the Ungava coast and 95.7 % for the Hudson coast).

Influenza

Respiratory infections constitute the main reasons for hospitalizations for the territory and more than a third of these hospitalizations are a direct result of pneumonias or influ- enzas. The data for 2002-2003 on the Hudson coast indicate a vaccination coverage against influenza of 68 % for people aged 60 or over, 55 % for the target groups of peo- ple aged 6 months to 59 years, 27 % for health centre employees and 67 % for essential services workers.

42 HODGINS Stevens. - Health and what affects it in Nunavik: how is the situation changing?Kuujjuaq - : Nunavik Regional Board of Health andSocial Services, Department of Public Health. -1997. - 321 p. CHALLENGES AND OPPORTUNITIES

• Monitor vaccine safety so as to identify individuals inoculated with a product or lot identified as problematic or ineffective. • Monitor Immunization status of the population to highlight, in real time, situations in which incomplete immunization may endanger the population. • Determine individual immunization status so as to be able to provide non- immunized persons with the appropriate immunizing agents in the event of an outbreak. . • Maintain vaccination coverage as part of the effort to reduce infectious diseases that are preventable by immunization. • Introduce, vaccine against pneumococcus which could help to change stereo- types prevalent in the population as well as modify the epidemiological profiles of more benign infections such as otitis media. • Assess the relevance of BCG vaccination, considering its possible serious side effects as part of the effort to reduce the number of cases of contagious tubercu- losis. • Increase vaccination coverage of annual campaigns against influenza, mainly among health-care workers.

Direction de santé publique du Nunavik sa 51 OBJECTIVES

• Maintain at zero the annual incidence of indigenous cases of diphtheria, polio- myelitis and tetanus. • Maintain the average annual incidence of measles, rubella and mumps under the elimination threshold. • Maintain at under 1 case/5 years the average number of cases of invasive Hae- mophilus influenza type b infection among children under 5. • Maintain at 1 case/5 years the maximum threshold of the average incidence of invasive serogroup C meningococcus infections in the population aged 20 or un- der. • Reduce by 60 % the average annual incidence of invasive pneumococcal infec- tions in children aged 6 months to 2 years as compared to the 1996-2000 period. • Maintain at under 3 cases/5 years the average incidence of whooping cough in the region. • Maintain at under 1 case/5 years the average incidence of reported cases of in- digenous hepatitis A. • Maintain at under 2 cases/5 years the average incidence of reported cases of acute hepatitis B. • Begin reducing the incidence of chickenpox. • Maintain at zero the number of cases of invasive tuberculosis among children. • Reduce the annual incidence of invasive pneumococcal infections in the adult population groups eligible for vaccination. • Maintain the decline in the annual hospitalization rates for influenza and pneu- monia and in people aged 65 or over.

Direction de santô publique du Nunavik 52 RÉGIONAL ACTION PLAN Immunization - General aspects

Activities Role of PHD / RBH$S Role of HC / CL$Ç . Role of other partners I (Implement, Consolidate, Maintain) 1 Determine and update the content and pa- Conduct required studies. Deliver immunization program to rameters of the region's immunization pro- the population. gram. [M] Coordinate implementation in institu- tions. Provide scientific and technical support. Promote immunization activities. 1 Establish a vaccination information system so Support the development of required Implement vaccination information that people can be registered in a vaccination computer resources. system in service points. registry. [1] Provide timely training to vaccinators. Provide in timely fashion informational material for patients in Inuktitut, English and/or French. 1 Maintain a system for reporting unusual clini- Inform vaccinators and clinicians about Make vaccinators or clinicians cal manifestations associated with vaccina- their responsibility for reportingan d accountable, under the Act, for tion. [M] about regional specificities. reporting any unusual clinical manifestation that they suspect is Receive reports. linked to vaccination. Investigate as needed. 1 Reach an agreement with the health and Coordinate discussions. social services network so as to design reli- Appoint local respondents. able mechanisms for managing immunizing Appoint a regional respondent. products and specify the role of each party. [C] 1 Monitor the quality of immunizing products [C] Ensure quality of immunizing products Participate in quality management and support interventions. system for immunizing products. 1 Efficiently manage immunizing products. [C] Ensure that immunizing products are Participate in quality management available and properly managed. system for immunizing products.

Direction de santé publique du Nunavik 53 Immunization - General aspects (cont)

•Priority^ ^Lr^ImplementiiConaolidate^Maintaln)®^: 3 Define and implement a research program on Identify the partners to get involved in this Participate In research. what motivates people to get vaccinated and process. on the means to encourage the use of vacci- nation, in the specific context of Nunavik. [1] Role of coordination and/or consultation during research process. 2 Collaborate with network partners and child- Design a strategy to promote vaccination Childcare centres (CPEs) care centres, conduct vaccination awareness targeted at childcare workers and mothers campaigns targeted at mothers and childcare through the childcare centres. workers, [i] 1 Combine objectives of vaccination promotion Include concepts about vaccination in in- with perinatal care (EB-GH) and support for tegrated programs in perinatal care. young parents (PSJP). p] 1 Support clinical preventive practices in immu- Update concepts for vaccinators: Check immunization status and nization. [C] complete as needed. • Check immunization status including at-risk populations targeted by certain specific programs and complete as needed.

Direction de santé publique du Nunavik 54 Immunization of preschool-aged and school-aged children Priority Activities d-2-3) (implement, Consolidate, Maintain) Role of PHD / RBHSS Role of HC / CLSC jpole of other partners 1 Collaborate with health centres to ensure that Provide scientific and technical support Carry out vaccination. School board and schools: immunization activities for infants and children (updating indications, adverse clinical • tetanus and diphtheria booster are maintained and updated according to the manifestations, etc.) in routine immuniza- regional schedule. [M] tion activities. vaccination in Grade 3 • hepatitis B booster vaccination in Coordinate immunization activities in the Grade 4. territory. 1 Update the plan for vaccination against sero- Monitor development of invasive sero- Vaccinate according to the regional group C meningococcus based on national group C meningococcus infections. schedule. recommendations and the regional reality. [1] Follow national recommendations and Report cases. adapt them to regional constraints. 1 Monitor resurgence of pneumococcal infec- Monitor serotypes based on MADO data. Report cases. tions of serotypes that are not covered by vac- cination. [1]

1 Define immunization strategies that take into Coordinate planning and implementation Conduct immunization campaign School board account the specificities of the territory in the of a whooping cough immunization strat- against whooping cough, as case of implementation of a Quebec whooping egy as needed. needed. Schools cough vaccination catch-up program for ado- lescents. p] Support immunization activities as Youth centres needed. Other 1 Terminate BCG vaccination program for new- Implement a communication strategy to boms. p] transmit information to clinicians and the general public justifying the termination of the BCG vaccination program. Assess the relevance of establishing mechanisms for monitoring tuberculosis infection among young children. 1 Define and implement a strategy that takes Verify vaccine compatibility and its inclu- Vaccinate as needed. into account the specificities of the territory in sion in Nunavik's complete immunization the case of inclusion of chickenpox vaccination schedule for children, as needed. in the Quebec immunization schedule for chil- dren. p] Train vaccinators and provide (trilingual) informational material for vaccinators and the general population as needed.

Direction de santô publique du Nunavik 55 Immunization at the old adults and people Priority Activities Role of PHD/RBHSS Role of HC/CLSC Role of other.partnere (1-2-3) (Implement, Consolidate, Maintain) 1 Support influenza and pneumococcus Train and support, upon request, in- Maintain annual influenza and immunization for targeted groups of adults fluenza and pneumococcus Immuniza- pneumococcus immunization and older persons. [C] tion campaigns. campaigns for people aged 65 or over as well as chronic dis- ease carriers. Carry out an annual promotion cam- Promote campaign in local me- Media paign for influenza and pneumococ- dia (radio) every autumn. cus immunization. Monitor resurgence of invasive pneu- Report cases. mococcal infections of serotypes not covered by vaccination. 1 Vaccinate health care workers against Support implementation of annual Vaccinate and be vaccinated. influenza. [C] immunization campaigns in collabora- tion with health centre respondents. Recruit coordinators in each institution to work together to Promote influenza immunization of increase vaccination coverage. health care workers.

Direction de santé publique du Nunavik 56 PART III : SEXUALLY TRANSMITTED AND BLOODBORNE INFECTIONS (SBBI) ASSESSMENT OF SITUATION

Sexually transmitted and bloodborne infections

Inuit are among the populations most affected by sexually transmitted infections (STIs). The in- cidence rates of Chlamydia Trachomatis and Neisseria Gonorrhea infections can be up to 10 times higher than those for Quebec as a whole.43 Nunavik has recorded the highest rates of sexually transmitted infections in Quebec since the early 1990s when the systematic collection of data was first introduced.44 In 2001, the chlamydia infection rate was 2900 per 100.000 popu- lation (4329 for women and 1600 for men) compared to 133 per 100,000 population for Quebec as a whole.45 The 15-19 and 20-24 age groups are most affected by chlamydia infection. Al- though the numbers of gonococcal infection are not as high (24 cases in 2000,18 cases in 2001 and 47 cases in 20024®), they are nevertheless worrying. Incidence rates are generally higher (168 per 100,000 population) than those for all of Quebec (10.8/100,000) and more women (183.5/100,000) are affected than men (152.4/100,000), unlike most Quebec regions. Finally, it should be noted that the monthly census of gonococcal infections (MADO data bank) shows that there has been an outbreak in the region since February 2002 characterized by an increase of cases in several communities.

Just as in Quebec as a whole, these rates decreased during the latter half of the 1990s. A num- ber of factors may have contributed to the decrease in the number of Chlamydia Trachomatis in- fections, such as greater vigilance in clinical practices, availability of more user-friendly labora- tory tests and increase in preventive practices. It should be noted that this decrease was only transitory since, in 2002, there was an increase in Chlamydia Trachomatis and Neisseria Gonor- rhea infections.

Although the number of acute hepatitis B cases is low (1 case in 2000), 10 cases of chronic hepatitis B have been reported since 1998.47 As in the rest of Quebec, there has been a focus on vaccination against hepatitis B for all at-risk groups. Until very recently, hepatitis C cases were largely attributable to blood transfusions. However, of the 12 hepatitis C cases that oc- curred during the last five years, eight are attributable to the use of needles for injection drugs.

HIV is not an alarming problem (in terms of the number of cases) within the Nunavik population but it is generally agreed that it is important to implement prevention measures so as to keep the infection rates very iow for as long as possible. Canadian data show that, regarding AIDS cases and HIV-positive rates, Aboriginal populations are among the groups that are most ex- posed, if the proportion of Aboriginal people (3.3 %) in the Canadian population is taken into ac- count.46 AIDS cases among Aboriginal people represented 8.5 % of total AIDS cases in Canada in 2000.49 In addition, unlike other population.groups in Canada, Aboriginal people are infected at a younger age and the main risk factor is injection (35.9 % of cases). The data on HIV are

43 GOVERNMENT OF QUEBEC. - Stratégie québécoise de lutte contre les MTS : orientations 2000-2002. - 2000... 44 PARENT, R. et al. - Analyse des cas dlnfection génitale à chlamydia trachomatis, de gonorrhée, d'hépatites b et de syphilis déclarés au Quebec par années civiles 1996-2000. - 2002 ... 45 Ibid. 48 Ibid. 47 Ibid. 46 GOVERNMENT OF CANADA. -The Daily. Aboriginal peoples of Canada: a demographic profile. - 2003 ... 49 HEALTH CANADA (2003) HIV/AIDS Epi Updates. Division of HIV/AIDS Epidemiology and Surveillance of the Centre for Infectious Disease Prevention and Control, Population and Public Health Branch, April 2003,82 p.

Direction de santé publique du Nunavik sa 57 just as worrying since it is estimated that 8.8 % of all new cases for which ethnicity is known are Aboriginal people and that 64 % of new infections in 1999 were attributable to injection.50

Even though these data relate largely to Aboriginal populations in Western Canada, it is becom- ing increasingly urgent to mobilize the First Nations and Inuit of Quebec and Labrador around the issue of HIV and hepatitis within communities. This concern was raised on the one hand, by the appearance of hepatitis C cases among Quebec Aboriginal people and, on the other, by the alarming rates of STIs among Aboriginal populations. Studies have shown that the risks of HIV transmission are higher when an STI is involved.51,52

Preserving the fertility of Inuit women

As mentioned above, the rates of chlamydia infection are higher among women than men. Many studies have shown the degree to which chlamydia infections are responsible for a large num- ber of infertility cases among women. Thus, the measure most often used to estimate the harm- ful effects of STIs on women's fertility is the rate of ectopic pregnancies among cohorts of women who were previously exposed to chlamydia infections and gonococcal infections. In Nunavik, the rates of ectopic pregnancies recorded between 1994 and 1997 were two times higher (between 19.2 and 29.1 per 100,000 population) than those for Quebec as a whole (be- tween 11.1 and 12.3 per 100.000).53

Young people who attend school outside the communities

In Nunavik, all young people who wish to further their education and pursue their studies at the college and university levels must leave their communities and live in urban centres.54 A large proportion of these young people are accepted at educational institutions in urban centres such as Montreal. This situation of being far from home combined with the culture shock experienced by these young people requires greater vigilance in terms of prevention and the promotion of safe behaviours among this client group.

Inuit who are incarcerated outside the Nunavik territory

As long as there is no correctional institution in the Nunavik territory, all Inuit who must serve a sentence will be incarcerated in correctional institutions in southern Quebec. Studies of persons incarcerated in Quebec55,56 correctional institutions show high rates of HIV and hepatitis among prison populations as well as risks of transmission through the sharing of injection equipment. Thus, the risks for Inuit incarcerated in correctional institutions in southern Quebec are a public health concern since these persons may be exposed to HIV and HCV transmission through the 1 • sharing of contaminated needles. Prevention among Inuit incarcerated outside the territory should therefore be a focus of concern.

50 HEALTH CANADA (2003) HIV/AIDS Epi Updates. Division of.HIV/AIDS Epidemiology and Surveillance of the Centre for Infectious Disease Prevention and Control, Population and Public Health Branch, April 2003,82 p. 5t FLEMING, D.T. and WASSERTHEIT Jr. - From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexually transmission of HIV infection. - 1999... 52 COHEN M.S. - Sexually transmitted diseases enhance HIV transmission: no longer an hypothesis. —1998... 53 PARENT R. and ALARY M. - Analyse des cas d'infection génitale à chlamydia trachomatis, de gonorrhée, d'hépatites b et de syphilis déclarés au Quebec par années civiles 1995-1999. - 2001 54 HODGINS Steven - Health and what affects H in Nunavik: how is the situation changing? - 1997 55 HANKINS C. et a\.HIV infection among women in prison. An assessment of risk factors using a nonnominal methodology. -1994... 59 DUFOUR A. et al. - Prevalence and risk behaviours for HIV infection among inmates of a provincial prison in Quebec City. -1996...

Direction de santé publique du Nunavik sa 58 Inuit who are highly marginalized outside their communities

Information from intervention groups in urban centres indicate that there is cause to be con- cerned about Inuit who live outside the Nunavik territory. Certain members of the community who are exiled temporarily or for longer periods may be in situations of severe marginalization and social exclusion, putting them at risk of contracting HIV and hepatitis. Drug use, drug injec- tion, mobility and prostitution are high-risk situations to which these Inuit are exposed.7 Self- help group workers, despite doing remarkable work with these Inuit, often lack the resources needed to intervene in the area of STI, HIV/AIDS and HCV prevention. In addition, closer links with the home communities of these Inuit would allow the social workers to provide assistance and support to those who wish to leave a difficult situation in an urban centre and return to their home community.

Drug and alcohol use

Alcohol and drug use is increasingly recognized as a risk co-factor in the transmission of STIs, HIV and HCV. The use of alcohol and psychotropic substances alters judgment and may cause a person to take risks during sexual relations. Protection behaviours, i.e. the use of a condom or abstinence from relations in situations considered to be risky, are not always maintained when alcohol and drugs are being used.

Over the last decade, it has been demonstrated that injection is a risk factor in HIV transmission and, more recently, that the sharing of equipment in the preparation of drugs such as cocaine, crack and heroin is a risk factor in hepatitis C transmission, making it necessary to rethink drug abuse prevention measures. Special efforts have been made to reduce the harmful effects of the inappropriate use58, 59 of substances and products. The harm reduction approach focuses on reducing the damaging effects of drug use rather than on abstinence from drugs.60

The first principle involved is pragmatism, which is based on universal access to health care and services, the protection of health and public security as well as the promotion of individual and collective health.

The second principle is humanism, which is based on the values of social equity, human rights advocacy and participation in society. In the specific context of Nunavik where problems of al- cohol and drug use may have harmful consequences for individuals and society, the reduction of the risks associated with the inappropriate use of drugs is a first foothold in the prevention of STIs, HIV/AIDS and HCV. Moreover, the Canadian Aboriginal AIDS Network has produced a guide aimed at developing a harm reduction approach adapted to Aboriginal communities.61

57 Pitsulala Lyta, Native Friendship Centre of Montreal (personal communication) 58 THIBOUTOT P et al. - Pour une approche pragmatique de prévention en toxicomanie : orientations et stratégies. -1998... 59 GOVERNMENT OF QUEBEC. - Agir ensemble : cadre de référence pour l'élaboration d'un plan national de lutte contre la toxicoma- nie. - 2002... BRISSON P. -La réduction des méfaits : sources, situation, pratiques: Comité permanent de la lutte à la toxicomanie. -1997... 1 Canadian Aboriginal AIDS Network (undetermined) Joining the Circle: an Aboriginal Harm Reduction Model. CAAN, 57 p.

Direction de santé publique du Nunavik sa 59 Partners in prevention

Let us first underline the major role that CLSCs are required to play under the Quebec Public Health Program.62 Since 1998, a number of activities have been implemented under the Inuit Plan of Action on HIV/AIDS and the Circle of Hope Strategy. The interventions developed are aimed more specifically at HIV/AIDS, but include prevention components that are highly relevant to STI prevention. The actors involved in the application of these strategies in the Nunavik terri- tory are key partners in the implementation of the Nunavik Plan of Action on STIs, HIV and HCV. They will be called upon to participate actively in prevention and provided with support for the projects that they will be mandated to implement in the territory as well as in the steps that they take to increase their capacity for intervention in the area of prevention.

Other actors who can contribute to prevention are: midwives, who play a predominant role among Inuit women; schools and youth centres, which can promote activities among young people; and community health workers in the territory's CLSCs. The identification of partners in the communities who can play a key role in the implementation of the Nunavik Plan of Action on STIs, HIV and HCV will be an additional asset in optimizing prevention interventions. Finally, the organizations that are actively involved in supporting Inuit who live outside the territory and that could play a strategic role in the prevention of STIs, HIV/AIDS and HCV and in maintaining links with community members required to live in urban centres in the South will be contacted.

Reference framework

The Nunavik Plan of Action on STIs, HIV/AIDS and HCV was developed in 2003 within the spe- cific context of the implementation of the Quebec Public Health Program 2003-2012.63 In addi- tion, the Working Group's members benefited from the development of various provincial64,65166 and federal67 strategies on STIs, HIV/AIDS and HCV, the Circle of Hope Strategy, 66,69 and the Inuit Plan of Action of the Pauktuutit network70 and the Quebec strategy to fight STIs. The Nun- avik Plan of Action on STIs, HIV/AIDS and HCV is based on all these documents developed over the last 10 years with the aim of fighting STIs, HIV/AIDS and HCV. Given our public health mandate, our efforts will be guided primarily by the framework of the Quebec Public Health Pro- gram (QPHP) tabled in 2003. In this regard, the activities of the QPHP, which are based on the public health functions, are considered to be priority activities (Figure III: QPHP activities to be included in the regional action plan (STIs)). However, the Nunavik Public Health Department strongly encourages collaboration between the Circle of Hope (FNQLHSSC) and the Canadian Aboriginal AIDS Network and intends to support cooperation between the actors in these differ- ent organizations in its territory.

62 GOVERNMENT OF QUEBEC. - Quebec Public Health Program 2003-2012. - 2003 ... 63 Ibid. " GOVERNMENT OF QUEBEC. - Stratégie québécoise de lutte contre le sida : phase 4 : orientations 1997-2002. - 1997 ... 65 GOVERNMENT OF QUEBEC. - Le dépistage anonyme du VIH : vers des services intégrés de dépistage du VIH, des MTS et des hépatites virales, orientations. - 2001... 60 GOUVERNMENT OF QUEBEC. - Notification aux partenaires des personnes atteintes d'une MTS. - 2001 ... 67 Canadian Aboriginal AIDS Network (undetermined) Joining the Circle: an Aboriginal Harm Reduction Model. CAAN, 57 p. 68 First Nations of Quebec and Labrador Health and Social Services Commission - The Circle of Hope: effort, solidarity, prevention, organizsation, intervention and research. First Nations and Inuit of Quebec HIV/Aids Strategy. 2000... 89 First Nations of Quebec and Labrador Health and Social Services Commission - The Circle of Hope, First Nations and Inuit of Quebec HIV/Aids Strategy, Action Plan 2002-2005. - The Circle of Hope. - 2002. -18 p. 70 Author unknown, The Inuit Plan of Action on HIV/AIDS Executive Summary.

Direction de santé publique du Nunavik sa 60 Lastly, in accordance with the orientations in the "Health and Social Services Plan: Making the Right Choices" presented in 2002,71 our choice of priorities for the regional action plan have been guided by the national targets for 2003-2006 activities, which relate to the national priori- ties in public health. Previous strategies on STIs, HIV/AIDS and HCV have also been consid- ered in the development of prevention strategies.

For more details on these different plans of action or strategies, please consult the regional Nunavik Plan of Action on STIs, HIV/AIDS and HCV (2003).

Thus, the foregoing provides an outline of the foundations of the STI strategy which serve as a guide to the development of the Nunavik Plan of Action on STIs, HIV/AIDS and HCV.

Considering all of the partners involved in this file, it appears that the preferred course of action would be to harmonize the regional plans with the QPHP while emphasizing the adaptation of regional strategies to the reality of the territory. The Nunavik Action Plan takes all of these pa- rameters into account.

71 GOVERNMENT OF QUEBEC. - Health and Social Services Plan: Making the Right Choices. - 2001., Figure III : QPHP activities to be included in the regional action plan (STIs)

Surveillance • Surveillance of STIs, HIV/AIDS and HCV as well as their risk and/or protection factors within the territory's population. Protection • Application of guidelines for case investigation, prevention of secondary cases and control of outbreaks, as provided for in Chapter XI of the Public Health Act. Prevention • Prevention among adolescents and adults belonging to groups who are vulnerable to being infected by HIV/AIDS, HCV and STIs. • Intervention involving needle exchange to prevent the transmission of hepatitis B virus, hepatitis C virus and HIV. • Intervention to retrieve used needles or syringes (hepatitis B, hepatitis C, HIV). • Organization of integrated screening services for HIV/AIDS, hepatitis C and STIs. • Free drugs to treat sexually transmitted infections. • Preventive intervention with partners of a person who has contracted a sexually transmitted infection and, at the request of the attending physician, with a person who has contracted HIV. • Post-exposure prophylaxis (HIV and HBV). Support for clinical preventive practices

• Support for clinical preventive practices through systematic STIf HIV and HBV testing of pregnant women. Promotion of preventive behaviours • Promotion of preventive behaviours by raising public awareness of the consequences of HIV/AIDS, HCV and STIs. REGIONAL ACTION PLAN

Priority Activities (1-2-3) (Implement Consolidate, Maintain) Role of PHD /RBHSS Role of HC / CLSC Role of other partners

1 Identify a working group which will be man- Appoint members of the working group, Participate in working group dated to adapt the guidelines to the regional after consultation with the partners con- reality. [1] cerned.

1 Identify a PHD resource person dedicated to Entrust the mandate to a resource person Collaborate with the resource per- STI, HIV/AIDS and HCV issues who will also within its organization. son for the transmission of informa- act as a respondent regarding the application tion useful for his or her mandate. of guidelines, training of partners and dis- semination of information useful for case in- vestigation, prevention of secondary cases and control of outbreaks. [1]

1 Communicate the guidelines on STIs to all Transmit the appropriate documents to Disseminate information to the partners by disseminating the documents. [M] the institutions concerned. workers concerned. 1 Support training on the application of guide- Ensure that partners have up-to-date in- Provide training to workers who lines in all appropriate cases. [M] formation. need it in the exercise of their func- tion. 1 Ensure that workers in STI, HIV/AIDS and Provide training on the new provisions of Ensure that workers in STI, HCV prevention receive the training on the the Public Health Act and ensure that staff HIV/AIDS and HCV prevention re- new provisions of the Public Health Act. [1] are put on oath when required by law. ceive the training and are put on oath.

Direction de santé publique du Nunavik 63 Surveillance - Research - Evaluation

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD / RBHSS Role of HC / CLSC . Role of other partners

1 Maintain surveillance mechanisms for STIs, Play this role as part of its surveillance Collect and transmit data according HIV/AIDS and HCV as well as their risk and/or functions. to established agreements. protection factors as part of activities to pro- tect and control infectious diseases. [M]

1 Conduct sporadic analysis of epidemiological Play this role as part of its surveillance Compile data and disseminate them data and provide feedback to partners. [M] functions. to staff within their organizations. 2 Conduct an assessment of vaccination cover- Supervise the project age against hepatitis A and B as part of a re- search project and/or through the vaccination registry. [1]

Direction de santô publique du Nunavik 64 Prevention among adolescents and adults belonging to vulnerable groups - Youth in schoola ndoutsi deth e school system

Priority Activities Role of PHD/RBHSS Role of HC / CLSC Rote of other partners (1-2-3) (Implement, Consolidate, Maintain) Support the implementation of prevention and Evaluate requests and offer appropriate Disseminate material and/or partici- health promotion activities within the commu- pate in activities whenever appro- 1 support. nities developed under the Circle of Hope priate, at the PHD's request. Strategy, whenever appropriate. [M]

1 Support the implementation of prevention and Evaluate requests and offer appropriate Disseminate material and/or partici- health promotion activities developed under support. pate in activities whenever appro- the strategy of the Inuit Plan of Action on priate, at the PHD's request. HIV/AIDS and CI HAN (Canadian Inuit HIV/AIDS Network), whenever appropriate. [M]

1 Support cultural appropriation as well as the Evaluate requests and offer appropriate Disseminate material and/or partici- translation into Inuktitut of certain documents support. pate in activities whenever appro- or intervention tools considered as a priority in priate, at the PHD's request. STI, HIV/AIDS and HCV prevention. [M]

Introduce an STI, HIV/AIDS and HCV preven- 1 Assign the mandate to prepare a plan of Participate in the development of tion week which would preferably be held in action to support the activities under the activities and implementation of the spring (March) and whose objectives would be STI, HIV/AIDS and HCV prevention week. plan of action. centred on prevention and appropriation by the communities - If necessary, involve the CIHAN and the Circle of Hope. P]

1 Conclude an agreement with "Approvisionne- Conclude the agreement with "Approvi- ment Montréal" in order to purchase condoms sionnement Montréal." for prevention activities at competitive prices. [C]

Direction de santé publique du Nunavik 65 Prevention among adolescents and adults belonging to vulnerable groups - General population (cont)

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC /CLSC ( Role of other partners 1 Ensure accessibility to condoms in a user- Inform the partners about the access to Ensure availability of condoms in friendly and confidential manner in recrea- condoms program. institutions, and make the program tional venues such as arenas and community known to their partners. halls. [1]

1 Inform and make known the risks of STI and Find the appropriate material and make it Disseminate the material provided HIV/AIDS transmission in sexual relations available to partners. by the PHD and make partners between male partners, p] aware of it.

Direction de santé publique du Nunavik 66 Prevention among adolescents and adults belonging to vulnerable groups - Youth in school and outside the school system Priority Activities Role of PHD/RBHSS (1-2-3) (Implement, Consolidate, Maintain) Role of HC / CLSC Role of other partners

1 Maintain a high level of protection of young Assess the situation sporadically and, Vaccinate client groups and partici- Youth centre people against hepatitis B through vaccina- together with the partners, develop strate- pate in the development of strate- tion. [M] gies to maintain a high level of protection. gies.

1 Offer a sex education and STI prevention pro- Find the most appropriate material to re- As needed, support implementation gram to high school students with the agree- spond to the needs of schools, together of the program and ensure the ment of the school authorities and parent with the partners. transfer of expertise by school committees. [I] nurses who will participate in the process.

1 Disseminate information material on STI pre- Find appropriate material and make it Support schools and other institu- vention to young people in schools and out- available to partners. tions in making the information ma- side the school system. [1] terial available through school nurses.

1 Make condoms accessible in schools in a Prepare a plan of action to promote ac- Participate in the development of user-friendly and confidential manner, with the cess to condoms in schools. the plan of action. agreement of the school authorities. [1]

1 Make condoms accessible in youth centres in Prepare a plan of action to promote ac- Participate in the development of a user-friendly and confidential manner, with cess to condoms in these institutions. the plan of action. the agreement of youth centres and youth residential centres. [1]

1 Ensure that young people have access to STI Find appropriate material and make it Make the material available to their prevention material which also deals with fer- available to partners. client groups. tility and reproduction issues. [1]

Direction de santé publique du Nunavik 67 Prevention among adolescents and adults belonging to vulnerable groups - Partners in prevention

Priority Activities (1-2-3) (Implement Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC . Role of other partners

1 Identify a person in each of the CLSCs and Mobilize the partners. Appoint a person responsible for CLSC service points who will be responsible the promotion/prevention compo- for the promotion/prevention component of the nent of the STI, HIV/AIDS and HCV STI, HIV/AIDS and HCV file, and who will be file. mandated to support the development of pre- vention activities among all the client groups targeted by the plan of action, in accordance with Priority 1.1.2 of the QPHP. [I

1 Prepare a training plan for partners who will Prepare the training plan together with Collaborate in the training plan. be involved in STI, HIV/AIDS and HCV pre- HC/CLSC partners. vention (CHWs, midwives, rehabilitation cen- tre youth workers, workers with people in resi- dential centres, etc...). [1]

1 Provide training on STIs, HIV/AIDS and HCV Prepare the training plan together with Collaborate in the training plan. to workers in women's shelters. [1] HC/CLSC partners. 1 Provide training on STIs, HIV/AIDS and HCV, Prepare the training plan together with Collaborate in the training plan. including harm reduction approaches, to HC/CLSC partners. workers in residential centres and drug reha- bilitation centres. 0]

1 Establish and maintain contact with resources Establish contact and encourage discus- outside the territory which receive the Nunavik sions. student client-group so as to ensure that the latter have access to prevention material and receive the support needed to maintain safe behaviours to prevent STIs, HIV/AIDS and hepatitis. [1

1 Establish and maintain contact with resources Establish contact and encourage discus- Make the targeted client groups outside the region which receive the Nunavik sions. mobile client-group so as to ensure that the aware of the availability of the re- latter receive the necessary care and support source (to be discussed). [1]

Direction de santé publique du Nunavik 68 Prevention among adolescents and adults belonging to vulnerable groups - Youth in schoola nd outsideth e school system

Priority Activities (1-2-3) (Implement Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners 1 Support activities to demystify homosexuality Evaluate requests and offer appropriate in the communities. [I] support.

1 Ensure that all men who have sex with men Assess the situation sporadically and, Vaccinate client groups and partici- are vaccinated against hepatitis A and B. [1] together with the partners, develop strate- pate in the development of strate- gies to maintain a high level of protection. gies. Ensure access, as needed, to prevention sup- Evaluate requests and offer appro- port adapted to the needs of men who have priate support. sex with men.

Prevention among adolescents and adults belongingto vulnerabl e groups - Incarcerated persons

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC/CLSC Role of other partners Establish contacts with correctional institutions Establish contact and encourage discus- in which Inuit from northern communities are sions. 1 incarcerated so that the latter can have ac- cess to appropriate means of prevention. [I] Maintain links with the Centre Sida Amitié des Establish contact and encourage discus- Laurentides so that prevention tools can be sions. 1 made available to incarcerated persons. [I] Ensure that all incarcerated persons are vac- cinated against hepatitis A and B. [1] Assess the situation sporadically and, 1 together with the partners, develop strate- gies to ensure that these persons have access to vaccination.

Direction de santé publique du Nunavik 69 Needle exchange to prevent hepatitis B virus, hepatitis C virus and HIV transmission — General population Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD / RBHSS Role of HC / CLSC Role of other partners

2 Prepare a guide for travellers informing them Prepare a guide for travellers together Collaborate in the development and of the risks of HIV and HCV transmission as- with the HC/CLSC partners. dissemination of the guide. sociated with the use of injection drugs, p] Needle exchange to prevent hepatitis B virus, hepatitis C virus and HIV transmission - Injection drug users Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners 1 Offer assistance and advice on prevention to Disseminate information on the harm re- any injection drug user who requests needles duction approach and its application in the for injecting drugs. [1] specific context of injection drug use and public health risks.

2 Establish links with organizations charged with Establish contact and encourage discus- preventing HIV and hepatitis infections among sions. injection drug users in urban centres where Inuit from the Nunavik communities live so as to support their prevention activities in urban environments as well as when the injection drug users return to their communities, p]

Recovering used needles (hepatitis B, hepatitis C and HIV) - Institutions concerned Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC/CLSC . Role of other partners

2 Review protocols for the recovery of used initiate the process. Collaborate in the process. injection equipment and provide for the possi- bility of safe recovery of needles used for drug injection. [M]

Direction de santé publique du Nunavik 70 Organization of integrated testing and prevention services related to STI, HCV and HIV/AIDS - General population

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners Ensure that all clinics in the territory offer an 1 Assess the situation sporadically and, Make these services available to integrated and comprehensive range of testing together with the HC/CLSCs, develop the client groups and participate in services for STIs, HIV/AIDS and hepatitis A, B strategies to ensure access to these ser- the development of strategies. [M] andC. vices.

Maintain activities aimed at contact tracing and Evaluate the situation sporadically and, Participate in the development of prevention with partners of individuals who strategies and provide contact trac- 1 together with the HC/CLSCs, develop have contracted an STI. [M] strategies to support activities aimed at ing and prevention services to the contact tracing and prevention. latter.

Document the status of vaccination against Assess the situation sporadically and, Disseminate directives on vaccina- hepatitis A and B for all persons who test posi- 1 together with the HC/CLSCs, develop tion coverage of persons who have tive for an STI and complete the vaccination strategies to evaluate vaccination cover- tested positive for an STI and en- as needed. [C] age. sure that they receive follow up.

Provide training on HIV/AIDS testing to all Prepare the training plan together with Collaborate in the training plan. workers who will provide the integrated testing the HC/CLSC partners. 1 sen/ices. [1] Carry out epidemiological investigation of all Supervise epidemiological investigations cases of gonorrhea and hepatitis and transmit Carry out epidemiological investiga- and analyze data. 1 findings within the deadlines established by tions and collect and compare data. the Public Health Department. [M]

Maintain and increase, in the case of gonor- 2 Facilitate the links between professionals rhea, the reliability and rapidity of access to a Collaborate in the process. and institutions in the diagnosis and diagnosis and to STI laboratory results. [1] transmission of results.

Direction de santé publique du Nunavik 71 Organization of integrated testing and prevention services related to SU, HCV and HIV/AIDS - Surveillance - Research - Evaluation

Priority Activities Role of PHD /RBHSS Role of HC/CLSC Role of other partners (1-2-3) (Implement, Consolidate, Maintain) 1 Define and implement interventions relevant Join with the INSPQ to analyze the differ- Participate in the evaluation proc- to STI testing so as to significantly reduce the ent scenarios for appropriate testing. ess. pool of STI transmitters. [I]

2 Implement a project to study HIV/AIDS test- Supervise the study project. ing among pregnant women according to services used - Project for a social medicine student. [I]

Free-of-charge medication to treat sexually transmitted Infections - General population

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners 1 Continue to offer free-of-charge medication for Ensure that ail patients who test positive all STI cases and their contacts. [M] for an STI have access to free medication. 1 Continue to offer free treatment required for all Ensure that ail pregnant women who are pregnant women who are HIV-positive. [M] HIV-positive have access to free-of- charge medication.

1 Disseminate the procedure to apply for free- Assess the situation sporadically and of-charge STI medication as well as the pro- make recommendations to the workers cedures for coverage by RAMQ [C] concerned.

Direction de santé publique du Nunavik 72 Post-exposure prophylaxis (HIV and HVB) - Health institutions concerned Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners

1 Ensure that all health centres have medication Ensure that the HC/CLSCs have access Manage medications and adminis- for post-exposure prophylaxis and adequate to medication. ter medication when appropriate. information. [M] Provide training on the potential exposure to 1 Prepare the training plan, together with Collaborate in the training plan. [M] HIV and HBV to all workers concerned. the HC/CLSC partners.

Support for clinical preventive practices through systematic STI, HIV and HBV testing of pregnant women - Partners concerned Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC / CLSC Role of other partners Update the HIV testing protocol and include a 1 Together with the institutions concerned, Collaborate in the process and ap- section on testing of pregnant women. [C] define a testing protocol. ply the protocol.

Promotion of preventive behaviours by raising public awareness of the consequences of HIV/AIDS, HCV and STIs - General population

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners

1 Support activities to promote preventive be- Ensure that all partners have access to Participate in promotion activities. haviours developed under various Quebec information. and Canadian strategies. [M]

Direction de santé publique du Nunavik 73 Promotion of preventive behaviours by raising public awareness of the consequences of HIV/AIDS, HCV and STIs - Surveillance - Research - Evaluation

Priority Activities Role of PHD /RBHSS (1-2-3) (Implement, Consolidate, Maintain) Role of HC/CLSC Role of other partners 1 Take advantage of the 2004 Inuit Health Sur- Appoint a regional respondent who will Contribute to the process of build- vey in order to better understand high-risk consult the partners about the choice of ing knowledge based on the survey. sexual behaviours for STIs, HIV/AIDS and questions and analysis of regional data. HCV and their determinants. [C]

Ensure access to services adapted to the needs of HIV- positive persons In the territory — Persons living with HIV Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners

2 Ensure that HIV-positive persons in Nunavik Evaluate the situation and make recom- Participate in assessing the situa- have access to appropriate clinical services as mendations to the workers concerned tion and provide services when well as to the anti-retroviral drugs needed. [C] appropriate.

1 Provide training upon request on services for Prepare training plan together with the Collaborate in the training plan and HIV-positive persons and anti-retroviral treat- HC/CLSC partners. provide training. ments. [C] Ensureregional concertatio nregarding th e implementation of the plan of action on SUs, HIV/AIDS and HCV - Partners in prevention

Priority Activities (1-2-3) (implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC/CLSC Role of other partners

1 Institute an advisory committee on the plan of Together with the partners, appoint mem- Appoint a person within the institu- action coordinated by the regional respondent bers of the plan of action advisory com- tion to participate in the plan of ac- on STIs, HIV/AIDS and HCV which will include mittee. tion advisory committee. the resource person on the STI, HIV/AIDS and HCV file as well as representatives of partner organizations in the implementation of the plan of action. [1]

Direction de santé publique du Nunavik 74 PART IV : OTHER INFECTIOUS DISEASES

ASSESSMENT OF SITUATION

As a result of the current demographic profile, the Inuit's way of life and the specific environment of the territory, the population has a profile of infectious diseases which is different in many respects from that of other Quebec regions.

Enteric and foodborne diseases

Bacterial and parasitic infections of fecal-oral transmission

Large proportion of children in the population. Several childcare centres, sharp increase in number of childcare places created since 1994.

• Overcrowding in some dwellings and a sometimes limited water supply which can restrict the practice of hand-washing. • Water distribution network with several possible points of contamination. • Relatively recent nutritional intake of store-bought products imported from southern regions (including beef and chicken): began in the late nineteenth century and then became progressively more important; now these foods account for majority of calo- ries consumed;72. • 14 cases/10 years of Campylobacter infection. • 2 cases/10 years of E. coli 0157:H7 gastroenteritis. The Quebec Public Health Labo- ratory (LSPQ) has expressed doubt about the confirmation of this diagnosis. • 3 cases/10 years (all since 2000) of Yersinia Enterolitica gastroenteritis. • 11 cases/10 years of Salmonella infection. • 47 cases/10 years of giardiasis. • Outbreaks of Shigella gastroenteritis in 2000 and 2001: 240 confirmed cases (MADO) but up to 769 persons affected in total.

Botulism

The Nunavik region accounts for almost all cases of foodborne botulism in Quebec.73 Thus, half of the outbreaks documented in Canada since 1970 occurred in Nunavik, particularly in Ungava Bay. Between 1990 and 2002, 62 cases of botulism were reported (the last death attributable to botulism occurred in 1987). Most of these cases result from eating igunak, a traditional home-made Inuit dish which involves hanging the meat and fat of marine mam- mals, mainly seal or walrus, to preserve it.

72 HODGINS Stevens. - Health and what affects it in Nunavik: how is the situation changing? -1997... 73 GOVERNMENT OF QUEBEC. - Sun/eillance des maladies infectieuses et des intoxications à déclaration obligatoire • Quebec 1990- 1999. -2003 ...

Direction de santé publique du Nunavik sa 75 Diseases transmitted through direct contact or respiratory tract

Tuberculosis

• In the 1950s and 1960s, tuberculosis was still endemic in the Inuit population; in 1957, one in seven Canadian Inuit was resident in a tuberculosis treatment centre/4 • This period was followed by massive screening campaigns in the 1970s and 1980s. • There was a sharp decline in the incidence of active tuberculosis after the 1980-1984 period, decreasing from 166 cases/100,000 per year to 86 cases/100,000 per year in the 1990-1994 period.75 • For the last 10 years, an average of 6.1 cases per year have been reported in the Nunavik population, representing 4 to 5 new cases for each reactivated case (MADO). • The distribution of cases among villages is very uneven.76 • The incidence remains cieariy higher than that of the rest of Quebec and the QPHP objective (to reduce the annual incidence of active tuberculosis to 3.5/100,000 for Quebec, and more specifically to 2.0/100,000 for regions outside Montreal). • One village is systematically screening preschool-aged children. • Little resistance to INH: iess than 4 % of strains found in Nunavik (MADO). • Currently, treatments are administered under direct observation.

Respiratory infections among children

Diseases of the respiratory system are the main cause of hospitalization of 1-5 year-old chil- dren, the majority resulting from pneumonias or influenza. It is estimated that nearly 50 % of children are hospitalized with wheezing (recurrent bronchiolitis) within the first 3 years of life; in almost all children the problem disappears by the age of 3.n

Vectoral diseases and zoonoses

Rabies

Although according to public health record, no case of human rabies has ever been reported in Nunavik, the region is recognized as enzootic for rabies because of the continuous pres- ence of the disease within the population of arctic foxes. An immunization program against rabies, carried out by MAPAQ, is offered annually to the municipalities and dog owners; in 1992, 61 % of Inuit dog owners reported having their dog vaccinated within the last 3 years.

Rabies can also be transmitted by bats; however, we do not have data on the presence of bats in the region. A study is currently being conducted to document the presence and spe- cies of bats found in the territory.

74 HODGINS Stevens. - Health and what affects it in Nunavik: how is the situation changing? - Kuujjuaq: Nunavik Regional Board of Health and Social Services, Public Health Department - 1997. - 321 p. 75 Ibid. 76 Ibid. 77 Dr. Johanne Morel, pediatrician, Montreal Children's Hospital (personal communication)

... JQ Direction de santé publique du Nunavik ••'»» ^•.«.••^••w ii». Mt.wuH.»,.i».wijii.iwpplui-ii.mHMHJtM«iw.....! Trichinellosis

Trichinellosis is a parasitic disease contracted as a result of eating raw or inadequately cooked meat that is infected by Trichinella nativa, the arctic strain of Trichinella. Since 1982, there have been 11 outbreaks of trichinellosis in the region, totaling 86 cases, none of which resulted in death. Most cases (97 %) can be attributed to eating walrus meat.78 Following a pilot project carried out in 1992 in Salluit, a regional system of screening for the parasite on the tongue of walruses was implemented and in 1996 all municipalities where walrus is hunted were included in the screening. The number of human cases of trichinellosis was reduced through this program. In fact, only 6 cases were, recorded between 1996 and 2002 (MADO). The current program requests that hunters send the animal's tongue for analysis before distributing the meat. The results of the analysis are available within 24 hours after the samples arrive at the Nunavik Research Centre, Makivik of Nunavik, Makivik (Makivik Corporation) in Kuujjuaq.

A screening test using direct trichinoscopy could be done on board the boats, which would allow hunters to reduce their losses by leaving behind animals that have been documented as carrying the parasite (since the beginning of the program, analysis by enzymatical diges- tion has found that 4 % of walruses caught tested positive). This new tool could be intro- duced through the intervention of Makivik and the Hunting-Fishing-Trapping Association.

Toxoplasmosis

The prevalence of the T.gondii infection in the Inuit population is 48 % (study conducted from 1984 to 1986 based on the analysis of 2600 consecutive nonselected serums). There are few members of the feline species in the region and the case study of seroconversion during pregnancy showed no link between contacts with this species and conversion for T.gondii. Moreover, skinning animals as well as eating dried seal meat, raw caribou meat more than once a week during pregnancy and seal liver were associated with seroconver- sion.

The data compiled during the screening for immunological markers of T.gondii in the 1990s led to the conclusion that the incidence of seroconversion during pregnancy was between 1.2 and 8.6 %. A recent retrospective analysis of perinatal files (Proulx, Larrivée, Couillard and Poirier 1997) with a prescription for Spiramycin (Hudson 1996-1997) or suspected of seroconversion (Ungava, Arbour 1989-1994) revealed three cases of confirmed seroconver- sion and 18 cases of probable or possible maternal infection during pregnancy.

Demonstration of seroconversion and/or fetal infection during pregnancy makes it possible to offer induced abortion or prophylactic antibiotic therapy in order to decrease the risk of se- rious defects associated with maternal infection. This program was introduced in 1988-1989 following the sudden occurrence of cases of infant infection in Ungava Bay. The program was reviewed jn 1999 by a group of experts from university hospitals,79 Public Health and the QPHL. Since 1990, despite implementation of the program, at least two children have shown clinical signs of congenital infection.

" PROULX. Jean-François ; LECLAIR, Daniel and GORDON, Sandy. - Trichinellosis and its prevention in Nunavik, Quebec. - n.d.... 8 McGil) University and Université de Montréal

Direction de santé publique du Nunavik ••'»» ^•.«.••^••wii». Mt.wuHui-ii.mHMH.»,.i».wijii.iwppl MJt !«iw...... JQ West Nile virus

West Nile virus (WNV), which appeared recently (2002) in Quebec, is expected to progress northward. In fact, an infected bird was found on the North Shore in summer 2002. The high number of mosquitoes could put the population at risk if the virus reaches the territory. We do not know to what extent the different types of local mosquitoes may be carriers of the vi- rus. Since WNV is present in the Montreal urban area and members of the local population often go to Montreal, it is wise to inform travellers about the risks and protection measures with respect to WNV.

Other zoonoses

The incidence of other zoonoses remains low. There has been only one case of brucellosis since 1990. Knowledge of the animal population is not sufficient to assess the risk of other zoonoses.

Nosocomial infections

Nunavik has a Health Centre on each coast in which patients are hospitalized. However, 28 % of hospitalizations occur outside the territory, the vast majority in Montreal. Of course, fol- lowing a stay in a Montreal hospital, a patient may be colonized by a multiresistant bacte- rium. Certain patients are readmitted to one of the region's health centres after their Mont- real hospital stay and may constitute a source of colonization and infection for vulnerable hospital patients. Recently, a first case of death as a result of an MRSA septicemia was re- ported in Nunavik.

Travel, health

Most of the people who travel frequently are members of the region's non-lnuit population, although we do not have data to validate this information. However, it would seem that, in- creasingly, Inuit are travelling outside the territory. Because of the direct air link with south- ern Quebec and the many services that are delivered there for the regional population, trips to these regions are frequent. Travellers may be exposed to risks that are rare or not well known in the region: WNV, bat rabies, diseases transmitted through the sharing of used needles, etc.

Antibiotic resistance

Currently, other than the cases of multiresistance originating from Montreal hospitals, there is relatively little antibiotic resistance in Nunavik. The prevalent pneumococcus strains in the population generally develop little resistance to penicillin. Moreover, despite the number of cases, tuberculosis also shows little resistance to INH. Currently the situation is similar for gonococcus.

Direction de santé publique du Nunavik ••'»» ^•.«.••^••wii». Mt.wuH.»,.i».wijii.iwpplui-ii.mHMHJtM«iw.....! ... JQ CHALLENGES AND OPPORTUNITIES

• Susceptibility to new outbreaks of gastro-intestinal infections of fecal-oral transmission - need to improve hand-washing practices. • Housing conditions and available quantity of water which facilitate outbreak of transmis- sible gastro-intestinal infections and respiratory infections. • Possibility of enhancing public knowledge of the means to reduce risks associated with consuming store-bought food from the south. • Find means to intervene effectively in the production of igunak, so as to reduce the inci- dence of botulism. Ensure early management of cases of botulism to reduce morbidity linked to poisoning by the botulinum toxin. • Document vectors of rabies, toxoplasmosis, and giardiasis in the region. • Trichinellosis prevention program which could be modified by introducing another type of test with a lower threshold. • Monitor West Nile virus. • Resistance to antibiotics, which remains low for the moment. • Given the close relationship between the population and the small hospitals which serve several functions, nosocomial infections could potentially spread in the general popula- tion.

OBJECTIVES

• Maintain at their current basic level (excluding outbreaks) the incidence of isolated transmissible enteric infections. • Reduce the incidence of botulism in the Inuit population. • Maintain at zero deaths due to poisoning by botulinum toxin. • In the effort to eradicate tuberculosis, reduce to 50 % the proportion of incident cases of tuberculosis attributable to a new transmission of the disease (which means that a reac- tivation results in a maximum of one new case). o Maintain at zero the cases of human rabies in the Nunavik population. • Maintain at current rates the incidence of trichinellosis in the Inuit population. • Prevent increase of the incidence of nosocomial infections. • Maintain at their current levèl the rates of infections contracted outside the territory. • Reduce to zero indigenous rubella infection during pregnancy and congenital rubella. • Reduce congenital toxoplasmosis. • Reduce invasive group B streptococcus infections in newborns. • Maintain at their current level the vertical transmission of HIV and syphilis. • Maintain at their current levels resistance to antibiotics.

Direction de santé publique du Nunavik sa 79 REGIONAL ACTION PLAN EVltClIC 311(1 f00db0lî)6 (HSGSSGS

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC / CLSC Role of other partners 1 Include activities to promote hand-washing Plan a communication campaign on hand- techniques in healthy lifestyle campaigns. [1] washing as part of activities to promote a healthy lifestyle related to diet. Produce (trilingual) tools needed to pro- mote hand-washing techniques. 1 Promote hand-washing techniques among Support network partners and other part- Train childcare centre and restau- Childcare centres workers who may be vectors of enteric dis- ners in providing training in hand-washing rant workers in hand-washing tech- eases. [C] to childcare centre and restaurant work- niques. Schools ers. 1 Inform population about risks associated with Integrate notions of adequate cooking and COOP and other retail food stores store-bought food (salmonella, E Coli) and proper handling of store-bought foods into prevention measures as part of healthy life- nutrition promotion and training activities. style campaigns. [1] Prepare (trilingual) instructional material. 2 Conduct research on vectors of giardiasis in Conduct research aimed at identifying Makivik the population. [1] vectors of giardiasis in Nunavik. INSPQ

Direction de santé publique du Nunavik 80 Enteric and foodborne diseases — Botulism

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC / CL.SC Role of other partners

1 Conduct research on safe methods of igunak Introduce and participate in research on Communities and individuals who preparation in order to decrease the risk of the the preparation of igunak with the partici- prepare igunak presence of botulinum toxin and/or tests to pation of partners. check the safety of these foods before they Canadian Food Inspection Agency are consumed, p] Makivik, Nunavik Research Centre, Makivik of Nunavik, Makivik MAPAQ INSPQ Health Canada Avataq Cultural Institute KRG

1 Remind clinicians and population annually Disseminate information annually in media Communities and individuals who (before summer) about known measures to and to clinicians. prepare igunak reduce incidence of botulism and early symp- toms of botulism. [M] Media

1 Support clinical practices to prevent botulism. Disseminate recommendations for the Identify cases early and treat them [M] diagnosis and treatment of botulism cases appropriately. (update Internet site and protocols). Ensure availability and management of botulism antitoxins.

Direction de santé publique du Nunavik 81 Diseases transmitted through direct contact or respiratory tract - Tuberculosis

Priority Activities Role of HC/CLSC Role ofother partners (1-2-3) (Implement, Consolidate, Maintain) Role of PHD / RBHSS 1 Maintain clinicians' vigilance regarding the Integrate notions on importance of tuber- Early identification of cases of tu- importance of assessing symptomatic patients culosis in Nunavik into support activities berculosis disease. for the presence of Koch's bacillus. [C] for clinical preventive practices.

1 Manage the close contacts of persons who Support and provide guidance to clinicians Conduct case studies of the close have contagious tuberculosis. [M] in activities to manage at-risk individuals. contacts with tuberculosis disease cases.

Support prescription of a chemoprophy- Monitor patients under chemopro- laxis to PPD-positive persons. phylaxis throughout the required period.

1 Offer tuberculin screening test to HIV-infected Integrate notions of tuberculosis linked to Conduct PPD screening as needed. individuals and treatment to infected individu- HIV as part of support to clinical preven- als. [C] tive practices.

Direction de santé publique du Nunavik a 82 Vectoral diseases and zoonoses - Rabies Priority Activities (1 -2-3) (Implement Consolidate, Maintain) Role of PHD /RBHSS Role of HC/CLSC Role of other partners 2 Collaborate with our partners to identify un- Support and collaborate on research to Nunavik Research Centre, Makivik of recognized risks of rabies transmission. [C] identify types of bats present in Nunavik Nunavik, Makivik and their potential for rabies transmission.

1 Promote measures to protect against rabies Consult with occupational health team to among persons susceptible to exposure (front- inform workers about the risks of rabies, line workers) and provide post-exposure pre- means to prevent transmission and ac- vention measures. [I] tions to take in the event of possible expo- sure to the virus. 1 Inform the population about the risks associ- Develop a strategy with partners based on Nunavik Research Centre, Makivik of ated with rabies and measures that should be vectors identified. Nunavik, Makivik taken to reduce its transmission, taking into account the evolution of knowledge in this area. [C] MAPAQ Canadian Food Inspection Agency Hunting-Fishing-Trapping Associa- tion 1 Support clinical practices to prevent rabies. Disseminate and update post-exposure Provide counselling on protection [CJ intervention protocol. measures. Ensure availability of immunizing products Treat possible contacts according and rabies immune globulin. to protocol. Disseminate recommendations on protec- tion measures

Direction de santé publique du Nunavik 83 Vectoral diseases and zoonoses Trichinellosis Priority Activities (1-2-3) (implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role pf other partners

Pursue program to identify trichinella on wal- Evaluate current program. Nunavik Research Centre, Makivik rus tongues. [M]

Evaluate impact of use of direct trichino- Nunavik Research Centre, Makivik scopy screening test at hunting sites. Hunting-Fishing-Trapping Associa- tion 2 Conduct campaign to inform the population Develop and disseminate material. about the steps that must be followed to en- sure safe consumption of walrus meat. [C]

2 Support clinical practices related to the prob- Establish and disseminate an intervention Implement protocol in the event of lem of trichinellosis. [C] protocol on measures to be taken in the consumption of meat that is possi- event of human consumption of walrus bly contaminated. meat that is possibly contaminated, spe- cifically among asymptomatic consumers and within 7-10 days after exposure.

Direction de santé publique du Nunavik 84 Vectoral diseases and zoonoses - West Nile virus Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners 1 Monitor progression of virus. [C] Passive monitoring of birds: dissemination Media of posters, information pamphlets and announcements on local radio and in newspapers. Monitor progression in other regions.

2 Characterize species of mosquitoes in the region through a specific research project. 1 Monitor and manage clinical cases of WNV. Inform clinicians about the disease's dif- Diagnose and treat cases. [C] ferent transmission mechanisms, diagno- sis and treatment. Report diagnosed cases to public health.

Vectoral diseases and zoonoses - Nosocomial infections Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC/CLSC Role of other partners 1 Learn about the regional epidemiology con- As part of the new provisions on report- Report MADOs and participate in cerning nosocomial infections. [C] able diseases, ensure monitoring of noso- activities to update system. comial infections by supporting and in- forming network on procedures for Screen for nosocomial infections. reporting these infections.

Provide feedback to institutions on current situation. 1 Disseminate recommendations and prevention Support interventions to prevent and con- Establish measures to control guides on these infections and definition of INSPQ trol nosocomial infections. nosocomial infections. means to facilitate implementation of these recommendations, p]

Direction de santé publique du Nunavik 85 Vectoral diseases and zoonoses - Travel health Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC / CLSC Role of other partners

3 Ensure that travellers have access to a travel Establish a partnership with the regional Provide services to travellers with health service to promote preventive behav- network and an institution specialized in partners' support. iours through chemoprophylaxis, vaccination travel health to support travel health activi- and transmission of advice to travellers. [I] ties provided in Nunavik.

Manage required immunizing products.

2 Protect the health of Nunavimmiut who travel Create information tools (such as pam- Transmit information and tools to First Air to more southern areas of Quebec through phlets and posters) on risks and protection travellers. transmission of information on the risks spe- measures. Air Inuit cific to these regions: WNV, bat-rabies, STIs and risks associated with injection drugs. Disseminate these tools in key locations. Airport

Design and implement a strategy to raise KSB awareness among young people who are going to study in other Quebec regions. Schools

Vectoral diseases and zoonoses Resistance to antibiotics Priority Activities d-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners

1 Support clinical preventive practices related to Raise awareness of institutions and or- Apply guidelines. antibiotic resistance. [I] ganizations that monitor the quality of medical acts regarding the consequences of antibiotic prescription practices.

Promote guidelines and stimulate discus- sions about antibiotic prescription prac- tices.

Direction de santé publique du Nunavik 86 Vectoral diseases and zoonoses - Maternal and infant health Priority Activities (1-2-3) (Implement Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners 2 Research vectors responsible for transmission Identify a partner to carry out this project INSPQ of toxoplasmosis in Nunavik. p] and support the research. Nunavik Research Centre, Makivik Centre d'étude nordique 1 Maintain program to monitor toxoplasmosis Evaluate current application and rele- Participate in program evaluation. seroconversion during pregnancy. [M] vance of program.

Update clinicians on program and offer QPHL support needed in terms of measures to be taken and recommendations to be INSPQ made to pregnant women. 1 Support clinical preventive practices related to Maintain monitoring program of rubella Verify rubella vaccination status of [C] risks of infection during pregnancy. vaccination status of pregnant women and pregnant women and administer post-partum vaccination when indicated. post-partum vaccination as needed. Support screening (and interventions indi- Carry out screening and follow up cated) of STIs, HIV, group B streptococ- (HIV, streptococcus and hepatitis cus and hepatitis B during prenatal moni- B). toring.

Direction de santé publique du Nunavik 87 COMPONENT 5 - ENVIRONMENTAL HEALTH

ASSESSMENT OF SITUATION

Because of their way of life, hunting and fishing activities as wéll as consumption of tradi- tional foods, the Inuit have a close connection to plant and animal life. A number of studies have focused on the contaminants contained in traditional foods and their effects on health. However, other than sporadic interventions, we have little data on the risks related to the territory's environment. Climate, population size and organization within these very commu- nities result in regional characteristics that are largely specific to Nunavik.

Quality of outdoor air

Since there is currently no pollutant-emitting industry, there are few sources of air pollut- ant emissions in the region (fossil fuel power generation, increase in the number of mo- tor vehicles), but they have been the subject of little evaluation.

Building sanitation and quality of indoor air

During the 1980s, the Government undertook large housing construction projects; this construction kept a steady pace until 1995 when the number of housing starts dropped sharply. Currently, new social housing construction projects have started but the pace remains slow and the supply of social housing does not meet the demand. Thus, dwell- ings are often overcrowded (according to the 1991 Census, 40 % of households in- cluded 6 or more people).

In the analysis of the quality of indoor air, the presence of tobacco smoke in the envi- ronment cannot be overlooked even though many Nunavimmiut are in the habit of smok- ing outside their houses. The quality of certain dwellings and the long winters (with the effects of enclosed spaces) could contribute to the growth of mildew. There seem to be few asthmatics in the population - asthma accounts for less than 1 % of hospitalizations in the region. However, the high prevalence of infectious and chronic obstructive respira- tory disorders indicates that the pulmonary health of the Nunavimmiut could be im- proved.

Asbestos fireproofing

Public buildings in Nunavik were constructed after the 1980s and therefore it is unlikely that they contain asbestos fireproofing, but some older buildings require attention. The review of asbestos in schools carried out by the MEQ in 1999 did not include schools in Nunavik.

Exposure to ultra-violet radiation

Since at least 1996, there have been no deaths due to skin cancer recorded in the mor- tality data for the region.

Direction de santé publique du Nunavik Waterborne diseases

Because of permafrost, rather than being distributed via aqueduct, the drinking water in Nunavik is delivered daily to tanks in individual buildings. Water may be chlorinated at the pump station, or in villages without a pump station, directly in each tanker truck. This therefore creates many possible sources of contamination: initial water source, tanker truck (inadequate chlorination, cross contamination from distribution hoses) and individ- ual tanks.

Environmental poisonings

A few cases of carbon monoxide poisoning (ice machines in arenas and a school in 2000) have been reported; The presence of an oil furnace in each building, camping practices in the territory and the presence of an indoor skating rink in each community are conditions that are conducive to carbon monoxide poisoning. In addition, there have been reports of lead poisoning episodes which, based on epidemiological investigations, were caused by the presence of shot lead in game meat. The intervention carried out in the late 1990s resulted in a reduction of the levels of blood lead concentration in new- borns. Furthermore, there are few reports of chemical poisoning. A phenomenon that is a concern to both the population and researchers is the contamination of traditional foods by heavy metals and organochlorine compounds, which are used in more south- ern regions and then transported northward by ocean and air currents.

Climate changes

Current climate changes are of particular importance to the health of Nunavimmiut. In fact, changes in plant and animal life can have an impact not only on the supply of tradi- tional foods, but also on the solidity of the ice and presence of mosquitoes (consider WNV, for example).

Direction de santé publique du Nunavik sa 89 CHALLENGES AND OPPORTUNITIES

• Waterborne diseases: desired advances in the safety and monitoring of the drink- ing water distribution network. • Environmental poisonings: strengthen the network for reporting lADOs (report- able intoxications); provide information on carbon monoxide and support installa- tion of CO detectors; pursue studies and public information on food contami- nants. • Quality of indoor air/building sanitation: in addition to documenting the quality of indoor air and the problems that are possibly related to it, underline the impor- tance of continuing to construct housing to meet population growth and mainte- nance requirements. • Continue research on climate changes. • Given the population growth and the continued import of commercial products from the South, waste and wastewater management may become a major chal- lenge related to the populations' health.

OBJECTIVES

• Reduce morbidity due to waterborne diseases. • Reduce environmental poisonings and their effects on health. • Reduce the effects on health of environmental emergencies and disasters. • Reduce morbidity and mortality due to poor quality of indoor air and poor sanita- tion (and overcrowding) in residences and public buildings. • Monitor the possible effects on health of the presence of contaminants in tradi- tional foods. Diseases due to quality of indoor air - REGIONAL ACTION PLAN Problems due to building sanitation

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC / CLSC Role of other partners

1 Systematically document the quality of indoor Conduct investigation to evaluate the Municipalities air in the dwellings of the communities. [1] quality of indoor air in dwellings. KRG Makivik Office municipale d'habitation du Quebec Société d'habitation du Quebec 1 Organize epidemiological investigations and Document reported health problems due Participate in investigations. KSB-schools appropriate activities whenever there are re- to air quality and, if deemed necessary, ports on health problems due to the quality of take measures needed to correct problem. Childcare centres indoor air or sanitation in schools, childcare centres and institutions of the health and so- cial services network. [C]

Direction de santé publique du Nunavik 91 Waterborne diseases

Priority Activities Role of PHD/RBHSS Role of HC/CLSC Role of other partners (1-2-3) (Implement, Consolidate, Maintain) 1 Ensure a safe supply of drinking water in Nun- Meet with regional and local partners to Municipalities avik. [C] make them aware of the importance of a KRG safe supply of drinking water (according to the Quebec regulation on drinking water). Ministère de l'environnement

1 Promote awareness and collaboration so that Alert municipal partners to raise their Report cases of poisoning or infec- Municipalities the Public Health Department can have timely awareness of problems and support them tious disease that may originate in KRG access to reports on outbreaks, poisonings or in taking control measures (research on sources of drinking water supply. exceedances related to water quality. These cleaning methods, staff training). Laboratories reports are necessary for early intervention to protect the population's health. [C] Encourage reporting of cases. Raise awareness of laboratories regard- ing the reporting of contaminations of the water distribution network. 1 Organize epidemiological investigations and Receive reports. Report cases of poisoning or infec- Municipalities appropriate activities when water-related out- tious disease that may originate in KRG breaks or poisonings are reported and conduct Coordinate and support epidemiological sources of drinking water supply. investigation. epidemiological investigations into all cases of Laboratories exceedance of fecal E. coli in the water distri- Collaborate in investigation. bution systems. [C]

Direction de santé publique du Nunavik 92 Environmental poisonings

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners

1 Strengthen mechanisms for reporting lADOs Raise awareness of clinicians and labora- Participate in training sessions. H FT A (reportable intoxications). [C] tories regarding the importance of report- ing lADOs. Report intoxications. Outfitting operations Arenas 1 Conduct epidemiological investigations in the Conduct investigation Participate in epidemiological inves- event of intoxications. [M] tigations. 2 Promote introduction of carbon monoxide de- Conduct activities with the population and Arenas tectors. [I] partners involved to promote use of car- bon monoxide detectors. Municipalities KRG Office municipal d'habitation du Que- bec 1 Ensure that ice machines are well maintained. Remind arena managers of the impor- Municipalities [M] tance of preventive maintenance of ice machines. Arenas 2 Document the possible effects on health of the Guide research. Participate in certain research ac- CHUL research teams presence of contaminants in traditional foods. tivities. [M] Disseminate information to the population.

Problems due to climate changes

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD /RBHSS Role of HC / CLSC Role of other partners 2 Identify the risks to the health of Nunavimmiut Participate in defining research priorities. CHUL and ACADRE research linked to climate changes. [C] teams.

Direction de santé publique du Nunavik 93 All environmental diseases

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC / CLSC Role of other partners 3 Develop an environmental health emergency plan that includes activities related to nuclear, Collaborate in regional processes. Participation, as needed, in the KRG - Environment sector event of an environmental emer- biological and chemical hazards. [C] Provide a regional environmental gency. emergency response system. Consult with partners about the risks associ- ated with refuse and wastewater management Raise awareness among local and KRG systems. [1] regional leaders regarding health is- sues related to waste and wastewater Municipalities management. Makivik

Direction de santé publique du Nunavik 94 COMPONENT 6 - OCCUPATIONAL HEALTH

ASSESSMENT OF SITUATION

Actions in the area of occupational health come under an agreement between the MSSS and CSST (Commission de la santé et de la sécurité du travail) pursuant to the Act respect- ing the Ministère de la santé et des service sociaux and the Act respecting occupational health and safety. Since 2000, in Nunavik, these actions have developed through the im- plementation of a regional occupational health program.

In 1998, there were 2114 full-time jobs in Nunavik, distributed by industry sector as follows:

• 26.3 % local, regional and provincial • 4.4 % air transportation administration* • 1.4 % communications and culture* • 18.8 % mining and construction • 1.5 % power* • 18.4 % education • 0.4 % hunting, fishing and tourism* • 13.1 % businesses and hotels* • 2.9 % other services

* Most of these jobs are held by the beneficiaries under the James Bay Agreement.60

It is estimated that 44 % of full-time jobs are held by non-lnuit.

Although most jobs are in the public sector, there are different groups of workers in the pri- vate sector such as sculptors and workers employed in boatbuilding, fish smokehouses, re- tail businesses and outfitting operations. The Raglan mine has approximately 462 emplo- yees, 19 % of whom are Inuit.

80 Jobs in Nunavik in 1998, Employment, Training, Income Support and Child Care Department. Kativik Regional Government 1999.

Direction de santé publique du Nunavik sa 95 CHALLENGES AND OPPORTUNITIES

• Since the labour market is concentrated on specific activities, occupational health problems do not all have the same importance in the region as they do in the rest of Quebec. • Nearly 60 % of workers in Nunavik are employed in the public and parapublic sectors. • The problems of berylliosis and asbestosis do not appear to be a threat to Nun- avik workers1 health. • There has been no claim related to repetitive strain injury since 1995. • Workers' knowledge of protection and prevention measures in the workplace should be enhanced.

OBJECTIVES

• Limit the appearance of occupational infectious diseases among workers ex- posed to biological agents. • Decrease the incidence of occupational deafness and its consequences by re- ducing workers' exposure to noise in the workplace. • Decrease the frequency of problems that can lead to an adverse pregnancy out- come due to the workplace (prematurity, spontaneous abortion, stillbirth) and growth delays or physical health problems in children. • Improve lifestyles and decrease the incidence of chronic diseases. • Reduce suicide and drug and alcohol problems.

Direction de santé publique du Nunavik sa 96 REGIONAL ACTION PLAN Occupational health

Priority Activities (1-2-3) (Implement, Consolidate, Maintain) Role of PHD/RBHSS Role of HC/CLSC Role of other partners

1 Continue to implement the Workplace Safety Provide expertise for assessing applica- Assist pregnant or breastfeeding CLSC Haute-Ville-des-Rivières for Expectant Mothers program. [M] tions for protective re-assignment. women in applying for protective re- assignment

1 Carry out the Specific Health Program for the Develop activities to be implemented. Participate in pre-hiring assessment Société minière Raglan du Quebec Raglan mine. [M] of applicants. Provide preventive services. Institut de recherche en santé et sé- Provide emergency medical ser- curité du travail (IRSST) vices (Tulattavik). 1 Continue the training program for workers Develop activities. Provide recommended pre- Municipalities exposed to biological risks. [M] exposure vaccinations and post- Identify and train targeted workers. exposure consultation. KRPF 1 Continue the training program for workers Develop activities. H FTA exposed to noise. [M] Identify and train targeted workers. 1 Meet ad hoc requests related to occupational Receive requests from workers or em- As applicable health. [M] ployers. Assess requests and suggest interven- tions based on their relevance. 2 Carry out activities to promote physical activ- Include in the PSSE (Specific Health Pro- Société minière Raglan du Quebec ity, healthy eating and smoking reduction at gram for an Establishment). the Raglan mine, p] Assess the possibility of including healthy alternatives in the menu and support sports activities, p] 2 Assess relevance of implementing the Em- identify and contact employers concerned Employers as applicable. ployee Assistance Program (EAP) for employ- in order to suggest this approach. ers' associations. The EAP would target sui- cide as well as drug and alcohol abuse problems, p]

Direction de santé publique du Nunavik 97 BIBLIOGRAPHICAL REFERENCES

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Direction de santé publique du Nunavik sa 101 NUNAVIK REGIONAL BOARD OF HEALTH AND SOCIAL SERVICES RÉGIE RÉGIONALE DE LA SANTÉ ET DES SERVICES SOCIAUX NUNAVIK

P.O. BOX 900 KUUJJUAQ (QUÉBEC) JOM ICO Tel.: 1800 563-2227 (819)964-2222 Fax:(819)964-2888