March 2014

Canadian Healthcare workers’ experiences during pandemic H1N1 influenza: Lessons from Canada’s response A Review of the Qualitative Literature

Judy Hodge, BSc, DVM, MPH

Background study of Canadian patients critically the vaccine (Drolet, Ayala et al. ill with pH1N1 found that the 2013). Although Canada’s response In 2009, a novel influenza A groups of people most affected to pH1N1 has been praised as (H1N1) virus subtype emerged to were young adults, females, and improved compared to the response become the first global pandemic Aboriginals, all without significant to the 2003 outbreak of Severe to be declared in over four decades comorbidities (i.e., relatively healthy) Acute Respiratory Syndrome (Charania and Tsuji 2011). The (Kumar, Zarychanski et al. 2009). (SARS) (Silversides 2009), the World Health Organization (WHO) A systematic review of clinical and effectiveness of Canada’s response first reported the novel influenza epidemiological factors of pH1N1 to pH1N1 has also been critically strain on March 18th, 2009 and also reported a high infection rate reviewed to identify key challenges declared the global outbreak of in children and young adults, and opportunities for improvement influenza A (H1N1) a pandemic with fewer elderly people infected during the next disease outbreak on June 11th, 2009 (Standards (Khandaker, Dierig et al. 2011). (Spika and Butler-Jones 2009, 2010). By the end of that year, the Kendal and MacDonald 2010, pandemic had caused over 16,000 Canada’s public health response Low and McGeer 2010, Standards deaths worldwide (Wynn and Moore to pH1N1, recommended by the 2010, Moghadas, Pizzi et al. 2011). 2012). In Canada, the 2009 H1N1 Public Health Agency of Canada In particular, the disproportionate influenza pandemic (pH1N1) (PHAC), was prevention through impact among Canada’s Aboriginal caused 8,678 hospitalizations, vaccination, which led to the highest (First Nations, Inuit, and Métis) 1,473 (17.0%) intensive care unit mass immunization campaign in populations is well documented admissions, and 428 (4.9%) deaths the nation’s history, with 40-45% (Rubinstein, Predy et al. 2011, (Scott 2010). Responding to this of the population vaccinated for Richardson, Driedger et al. 2012), pandemic cost Canada an estimated pH1N1 (Scott 2010). Health with studies investigating upstream $2 billion (Health and King 2010, Canada approved the adjuvanted factors potentially contributing to the Standards 2010, Wynn and Moore pH1N1 vaccine on October 22nd, uneven pH1N1 impact (Lowcock, 2012). Prior to official pandemic 2009 and by October 29th, 2009, Rosella et al. 2012, Navaranjan, status, on May 1st 2009, Canada the first long lines for vaccines had Rosella et al. 2014). had reported 51 confirmed cases formed (Standards 2010). The of pH1N1 (Standards 2010). federal government was responsible Additionally, the critical role filled Canada’s first peak occurred in June for purchasing and distributing by healthcare workers (HCW) 2009, primarily in Manitoba, and the vaccine to the provinces, and in responding to a public health the second from mid-October to the provinces were responsible for emergency has been recognized, mid-November (Embree 2010). A determining how to best administer with several studies investigating

knowledge that’s contagious! Des saviors qui se transmettent! HCWs’ willingness to work during a (CINAHL), Scopus, Web of Science, Results pandemic (DeSimone 2009, Balicer, Web of Knowledge, JStor, and Barnett et al. 2010, Bennett, Carney ProQuest Dissertations and Theses. Three studies met the inclusion et al. 2010, Devnani 2012) and the In addition, relevant articles were criteria: 1) a qualitative study focused ethics of expecting HCWs to put searched for by topic through NYU’s on isolated Northern First Nations themselves at personal risk (Simonds BOBST library under the following communities; 2) a thesis using and Sokol 2009, Devnani, Gupta et subjects: sociology, anthropology, qualitative methods to explore the al. 2011). Furthermore, the impact nursing/medicine, social work, and lived experiences of public health of this ethical dilemma on HCWs public health. Finally, additional nurses (PHN) in Manitoba; and such as nurses has been investigated literature was searched for using 3) a mixed-methods online survey through studies considering moral Google Scholar and by scanning investigating the experiences of distress among nurses and their bibliographies of included studies specialty physicians in Quebec. The perceptions of working during an and relevant reviews (Simonds and specific focus of each study’s region emergency (O’Boyle, Robertson et Sokol 2009, Balicer, Barnett et al. or population is consistent with al. 2006, Oh and Gastmans 2013). 2010, Pahlman, Tohmo et al. 2010, the directed nature of qualitative Understanding the opinions and Tigert Walters 2010, Devnani, research. behaviors of HCWs working in Gupta et al. 2011, Boldor, Bar- pandemic situations will improve Dayan et al. 2012, Devnani 2012, Charania and Tsuji (2011) effectiveness of pandemic response Rossow 2012). interventions. This paper reviews Charania and Tsuji (2011) used all relevant qualitative research a community-based participatory that looks at Canadian healthcare The critical role filled by approach to address the workers’ lived experiences during the disproportionate impact of pH1N1 2009 H1N1 pandemic. This is the healthcare workers in in First Nations communities . A first review of the qualitative research community-based advisory group on this subject undertaken by the responding to a public was formed with five participants, National Collaborating Centre for representing the health sector and Infectious Diseases (NCCID) to health emergency has been Band Councils, to ensure the study date. recognized. Understanding was addressing the communities’ needs using culturally appropriate their opinions and methodology. This group assisted in developing the study’s objectives, Methods behaviors in pandemic design, and data collection instruments, and participated Studies that used qualitative situations will improve in validating the results and research methods to investigate the effectiveness of pandemic disseminating the findings. experiences of healthcare workers in Canada during the 2009 – 2010 response interventions. Study Methodology and Analysis influenza “A” (H1N1) pandemic were included in this review. The objective of this study was Relevant studies were identified to identify barriers experienced using the following medical subject Once identified, studies were by healthcare providers during headlines (MeSH) and key words: reviewed to ensure that the inclusion pH1N1, and culturally appropriate “H1N1,” “pandemic,” “influenza criteria were met, including that data opportunities to improve in advance A,” “healthcare worker,” “health collection was specific to the 2009 of the next pandemic, in three care worker,” “public health,” influenza A (H1N1) pandemic in remote and isolated Subarctic “public health nurs*,” “experience,” Canada. The paucity of available First Nation communities. Semi- “Canad*,” and “qualitative”. The literature meant that studies that structured interviews were conducted search timeframe was limited from included qualitative analysis of open- with 13 key informants in February January 2009 to present. Databases ended survey questions were also 2010, when community-illness searched were those available included, in addition to studies using rates had returned to baseline. through New York University more standard qualitative methods, Each community has a federally (NYU) School of Medicine and such as interviews and focus groups. funded community public health BOBST library, including Ovid, centre and a primary care facility Medline, PubMed, Embase, EBSCO equipped with 24-hour nursing

2 National Collaborating Centre for Infectious Diseases staff. The communities are located and availability in the community authors recommended that they in Northern Ontario and their to general supplies, and 3) increase should focus on recruiting full-time, estimated populations are 850, funding for community education. permanent nurses who are oriented 1700, and 1800 people, respectively. to the hardships of the job and are Study participants were purposively Human resources culturally sensitive. In addition, selected to represent the three key if required during a pandemic, an sectors responsible for health care HCW participants representing all interdisciplinary team of healthcare services: 1) federal health centres, three communities reported that a providers should be sent to the 2) provincial hospitals, and 3) Band shortage of human resources created communities to provide services such Councils. Interview questions were a shortage of staff in health facilities as mental health, respiratory therapy, based on relevant academic literature and the staff feeling over-worked. and disease education. discussing pandemic readiness. HCW participants reported that Data analysis used a combination sufficient vaccine doses were received HCW participants also mentioned of deductive and inductive thematic and that their communities accepted the importance of an alternative analysis to create both “theory- the vaccine. One community’s care site (ACS) to provide necessary driven” codes (using the existing estimated vaccine uptake was health care services as a satellite pandemic response framework 80%, considerably higher than clinic during a pandemic. There outlined in the regional First Nations Canada’s national immunization was unanimous agreement that for and Inuit Health Branch (FNIHB) rate of 40 – 45%. However, HCWs ACS to be feasible, funding and pandemic influenza plan) and “data- from one community stated that human resources need to be secured driven” codes (which emerged as new the community experienced an before the next pandemic situation. codes from the data) respectively. H1N1 outbreak before vaccine It was noted that government The final codes were presented was available. HCW participants officials have a responsibility to on paper to each community’s from two communities reported secure the necessary funding and pandemic committee (consisting efficient vaccination clinics. This human resources to implement of 8 – 10 study participants per efficiency was credited to having ACS if healthcare facilities are community) and verbally validated. received extra support workers from overwhelmed during a disease Health Canada and implementing outbreak, as recommended by the Study findings a modified immunization certificate Canadian Pandemic Influenza course to train additional health Plan for the Health Sector. Despite From the in-depth interviews with care personnel. Workers in these this recommendation, the authors healthcare workers and health communities used personal mention that the Ontario Health sector key informants (from here protective equipment (PPE) and Plan for an Influenza Pandemic says on collectively referred to as separated patients with clinical that funding sources for equipment “HCW”), Charania and Tsuji (2011) symptoms of H1N1. HCW and infrastructure for ACS are not identified three main barriers and participants representing the yet identified. three areas for improvement in the community they described as having communities’ pandemic responses. an inefficient vaccination clinic Infrastructure and supplies These findings were based on eight cited a lack of human resources as codes that emerged during data the primary problem. A shortage Unanimously, HCWs from all analysis, the first six of which were of staff meant that nurses became communities reported that some further discussed in the paper, exhausted and did not have time public health measures were difficult including: vaccine, antivirals, health to implement safety precautions, to enact due to their communities’ services, supplies, public health such as PPE, and consequently infrastructure, such as overcrowding measures, and communication. The became sick. In addition, nursing in homes preventing segregation codes surveillance and emergency shortages were further stressed by of sick family members. HCWs response were not discussed in the a lack of training in how to run a collectively agreed that government paper. Barriers to effective pandemic mass immunization clinic (MIC) officials have an obligation to response include: 1) insufficient and a lack of auxiliary staff for continue to focus efforts on human resources, 2) overcrowding in positions such as security and crowd improving housing infrastructure houses, and 3) a lack of community control. Health Canada’s FNIHB is and living conditions in First awareness. Areas to be addressed for responsible for providing public and Nations communities, noted to be improvement in future pandemic primary health care (when provincial their legal and moral responsibility as responses include: 1) strengthen services are unavailable) when First outlined by the 1876 Indian Act. human resources, 2) ensure access Nations are living on reserve. The

Centre de collaboration nationale des maladies infectieuses 3 HCWs representing all communities Communication and required adjusting cultural practices. reported that although they generally community awareness Community educational sessions had enough supplies, the supplies to emphasize the meaning of were not always delivered in a timely HCW participants unanimously vaccination and general infection manner. HCWs representing one lauded each community’s formation control, together with region- and community reported that their of a “community pandemic community-specific influenza health centre needed to charter committee” to promote effective mitigation information would be a plane at their own expense teamwork and communication. helpful in improving community to bring in necessary supplies. While HCW representatives attitudes to a pandemic response. HCW participants from all three of one community reported Further, the study participants communities reported receiving this committee was successful, felt that pandemic preparedness enough antiviral medication, participants representing the other should be made a political priority but again noted that distribution two communities stated that key at all levels of government with needs to be timely and further, the committee members could have representation from First Nations medication expiry dates should not improved the pandemic response communities and communication of be short-dated. Additionally, HCW by taking a more active role the plans to communities in advance participants mentioned a lack of and providing added support to of the next pandemic. available medical equipment, for the committees’ efforts. Many example, mechanical ventilators participants noted that they were Study limitations for severely ill patients. Largely, also in constant communication HCW participants agreed that the with their neighbouring coastal The authors do not include a section general community lacked basic communities to exchange on study limitations, however infection control supplies, such as information and provide mutually it appears to be a well-designed surgical masks and hand sanitizers. beneficial support. One participant and appropriately analyzed study Purchasing these items was said said that their weekly teleconferences with appropriate representation to be a financial burden for low- were effective for sharing of and participation from the income families. Participants called information. Most participants also communities. As is ideal, two for increased funding from the believed that some media sources researchers conducted the analysis, federal and provincial governments provided misleading information which is noted to have been done to ensure adequate supplies, that contributed to unnecessary several times to increase rigour. especially for low-income families. anxiety or information that was In addition, their methodology They suggested that government irrelevant to their situation in remote for developing the codes is officials establish an emergency isolate communities. well described and community fund that could be accessed to representatives validated the codes in purchase supplies in times of disease All participants mentioned a lack a systematic manner. Rigour could outbreak. Moreover, participants of community awareness and have also been strengthened through noted that transportation to knowledge of the pandemic. Despite triangulation of data sources, such as remote communities was often distributing information through including community focus groups unpredictable, and especially various sources, some community or document analysis, to further vulnerable to hostile weather, and members remained unaware of support findings from the interviews. stockpiling supplies when possible, influenza pathogenesis, pandemic such as food, ahead of the next vaccine effectiveness, and the Study conclusions pandemic was recommended. significance of community infection Well-timed distribution is necessary control measures. A few participants The main barriers to an effective for resources (vaccines, antiviral noted that even some healthcare pandemic response in these First medication, pandemic supplies), facility staff did not follow isolation Nations communities that were as many participants felt that even recommendations, as they were seen identified included overcrowding in though supplies were adequate, they in the community after they had houses, insufficient human resources arrived too late. It was also suggested been sent home sick and community (such as nurses), and inadequate that all government levels collaborate events had been cancelled. Despite community awareness of disease to assess resource distribution plans, this, HCW participants reported processes. The main areas identified particularly with respect to difficult that community residents generally for improvement of future pandemic to access communities to ensure observed recommended infection responses include increasing human equality and efficiency. control measures, even those they resources and funding. Additional considered unnecessary or that funding is required to improve

4 National Collaborating Centre for Infectious Diseases community education and awareness Communication and Consequently, this often resulted of health and disease issues and to dissemination of information in upset and frustrated community ensure there are sufficient general members and the PHNs feeling supplies in the community facilities Within the theme of communication that their personal credibility was and homes. and dissemination of information in jeopardy, as they had no control are two sub-themes: 1) sources over the quality of the information and influences of information and they were providing. The PHNs 2) credibility and consistency of agreed that a single public health Long (2013) information. The first sub-theme information source to provide describes the significant variation in timely and clear guidance to health As a requirement for the Master of the source of the information the professionals and to members of the Nursing degree at the University of PHNs received and the impact of general public would have been more Manitoba, Long (2013) conducted a this information. PHNs described effective. qualitative study to determine both how the information was changing the lived experiences of public health by the hour and how limited access A lack of credibility and consistency nurses (PHNs) in Manitoba during to computers at the clinics meant of the information surrounding pH1N1 and their current role in that they were often receiving their both availability and safety of pandemic planning activities. She information from the media, for the pandemic vaccine was also a found that PHNs are connected to example in their cars on the way challenge. The initial limited supply their communities and are trusted to work. They also described the of vaccine created difficulty in being sources of information for the flow of information and decision able to recommend it to eligible community members. This, together making as often unidirectional and recipients. The PHNs reported with the PHNs’ appreciation for top-down, without regard for their that it was difficult to balance their the importance of their roles in the existing experience and knowledge of knowledge of the pandemic with the community, makes them valuable running immunization clinics. communities’ perceptions. Alarming assets for the health regions, who media reports about the risks of should involve PHNs in planning The PHNs also recognized their role infection created high demand for the pandemic response interventions as a trusted source of information vaccines and at other times public to improve efficiency. PHNs need for their communities and expressed perception saw the pandemic as support from their managers, concern at not having a more “overblown,” with the PHNs then community, and in their personal prominent role in public education, struggling with how to encourage relationships to ensure maximum such as calming the public after vaccination without creating hysteria. effectiveness in fulfilling their roles. alarming media reports. The PHNs Other PHNs reported experiencing In addition, ethical dilemmas that from all three regions described long internal conflict when they create moral distress among PHNs lineups of individuals and families questioned vaccine safety themselves, should be anticipated and planned at immunization clinics as likely but were required to recommend it for in the pandemic preparedness having been influenced by media within their communities. activities. reports, for example about a young otherwise healthy hockey player who Personal and professional challenges Study findings died suddenly from the influenza pandemic strain and the vaccine Within the theme of personal and Long addressed the following shortages reported in the United professional challenges experienced research questions: 1) What is the States. by PHNs, two sub-themes emerged: perceived experience of public health 1) obligations to others and 2) nurses in Manitoba in responding to The second sub-theme dealt with challenging work conditions. the 2009 H1N1 influenza pandemic; credibility and consistency of As discussed above, all study and 2) generally, what is the extent information, and largely stemmed participants reported difficulty in of the PHNs’ current involvement from the PHNs’ reported lack of meeting their obligation to provide in pandemic preparedness? From ability to provide clear and consistent clear consistent communication these, five themes emerged: 1) information to their communities. regarding vaccine availability and communication and dissemination The PHNs reported that vaccine safety, and the risk of pH1N1 of information; 2) personal and eligibility criteria reported by public infection. The PHNs were frustrated professional challenges; 3) personal health officials was constantly by the lack of vaccine when demand face of the pandemic; 4) regional changing and was as confusing was high, and then, by the time support; and 5) lessons learned. for them as for the general public. vaccines were available, public

Centre de collaboration nationale des maladies infectieuses 5 perception had changed to view the oriented and comfortable giving the public directed at the PHNs disease as overblown. vaccines by intramuscular injection. was challenging and some PHNs The PHNs discussed the rewarding felt harassed for information for The study participants also discussed side of traveling to train other the first time in their career, such their feelings of inadequate personal nurses (for example, from hospitals that they avoided contact with protection from pH1N1 infection and long term care facilities) and people. The PHNs discussed the and the overwhelming workload. ambulance drivers, and that this was stress related to counting vaccine Especially at the beginning of enabled using an “H1N1 binder” doses and calculating the number the pandemic when the vaccine which was provided as a base for of people present and if the vaccine eligibility was strict, PHNs were training. However, conflict arose supply would be adequate. Nurses unable to vaccinate their family when inexperienced managers, reported a feeling of having an members, colleagues, or themselves managers who were not nurses, and/ audience as people in lines watched and thus felt it was necessary to or other administrative staff wanted the process and their actions closely. develop contingency plans. For to process vaccine recipients as fast as This, together with the cramped example, one nurse said that if she possible, even if the newly recruited space and the already high tension, thought she might be infected, nurses were not yet comfortable was especially difficult given the she would go to a hotel instead or needed their regular breaks. need to process people in a timely of going home, to protect her The PHNs noted that they felt fashion. Dealing with children was unvaccinated family. Even when responsibility to act as advocates particularly difficult as, in contrast H1N1 vaccination was available, it for the new nurses so that the work to typical immunization clinics for was made inconvenient: for example, could be done safely. PHNs also kids at schools, parents were present PHNs reported having to get reported stress surrounding a lack and often pushed for the vaccination seasonal flu shots and H1N1 shots of cultural sensitivity in training to be quick or were sometimes on different days, although they also and orientation: for example, one short with their kids, contributing reported that this policy was changed PHN reported being told to provide to the overall tense atmosphere. later in the pandemic. In addition, education on hand-washing on First Without enough time to reassure the study participants said that they Nations’ reserves where she knows kids, the nurses sometimes felt it took the initiative to encourage that there is no water. Contradiction was necessary to restrain them to fellow PHNs who were pregnant between meeting obligations to administer the vaccine, which was to avoid working at immunization superiors and management and the done as the public watched and clinics. obligations PHNs felt towards their further contributed to the situational colleagues and patients contributed tension. Cramped spaces at the immunization to stress experienced by the PHNs. clinics made it difficult to maintain The long line-ups and quick pace their practice standards, such as Study participants also discussed meant that nurses often felt unable maintaining patient confidentiality. challenging work conditions as a to keep up with the workload, often The study participants reported stress result of relating to the public, the forgoing their breaks. Additional in being responsible for patient safety quick pace of the clinics, personal pressure resulted when other public when enforcing the mandatory, safety, and power issues within health programs did not stop, so the standard 15-minute post-vaccination clinics. The mood and behavior of regular workload continued. Even if period: some patients lied about the public tended to create stress other nurses were left behind at the having waited the required time and, at the clinics, especially at the office to carry out these programs, although they were aware this was a beginning of the pandemic, when these nurses were burdened with lie, the nurses felt powerless to make vaccine eligibility was restricted. As extra work to cover for the nurses them stay. Long hours at the clinics discussed above, PHNs struggled at the clinics, which was stressful also significantly affected the nurses’ to enforce vaccine eligibility criteria for all the nurses. PHNs reported daily lives, making it difficult to get that were constantly fluctuating, feelings of isolation when they were enough sleep or carry out normal creating tension among the clinic pulled from their regular teams and household duties, such as getting attendees. One PHN said that she reassigned to other areas. Although groceries. was told it would be her fault if the they understood the need to go denied community member died where they were needed, they worked Study participants felt a sense of and that sometimes people waiting 16 hour days for 5 days a week and obligation to ensure that fellow in line became uncharacteristically felt disconnected from the activities non-PHNs, recruited to help with hostile. Although these incidents of their regular teams, resulting in a immunizations, were properly were infrequent, hostility from loss of support that would typically

6 National Collaborating Centre for Infectious Diseases have been provided by these stable, for them to acknowledge that the Personal face of the pandemic longer-term working relationships. pandemic response plan included defined roles for each profession The study participants reported PHNs also experienced risks to their that must be respected. One nurse feeling as if they were the “personal personal safety. Northern PHNs disclosed that she actually had had face of the pandemic” because of reported that they were pressured to to “learn how to sit back a little their personal and professional travel in adverse weather conditions bit” and trust others to arrange the connections to the community. they normally would not travel logistics. PHNs perceived themselves to be key in to hold immunization clinics. sources for information within their Many PHNs also discussed a risk At clinics where the leadership communities, especially in small of infection with the pandemic team was described as positive and towns, which was thought to be both virus due to working in cramped, helpful, tension was considerably a positive and challenging experience. unfamiliar spaces and not having less prominent. One PHN described Some rural nurses disclosed that they been vaccinated. Several participants how her manager trusted her avoided community settings such as noted that because most nurses were completely to run the day-to-day churches and grocery stores when not vaccinated and the clinics were clinic operations and he provided the vaccine was unavailable. Others so crowded, if there had been a case support by making coffee. There described difficulties in convincing of H1N1, all the immunization staff were also examples of nurses being friends and family to accept their would have gotten sick and been innovative in improving clinic professional advice. In contrast, other unable to continue working. efficiency when they were supported nurses described feeling honoured and allowed to implement their to provide important vaccine Power issues in managing the own ideas. One group of PHNs information for family and friends. clinics were also challenging for established a designated kids’ table so PHNs identified their strong linkages PHNs. Some nurses felt pressured that nurses who were not as skilled to the community as an asset that to vaccinate medical doctors who at administering vaccinations would provided community members with wanted the vaccine, even though not have to handle kids, and another an avenue to have their individual they were not eligible for vaccination PHN group arranged the process so needs met. For example, a group at that time. Inter-professional that nurses inexperienced with giving of urban PHNs identified a need tensions resulted when managers injections could do other tasks, to provide information for new who were not nurses wanted to such as drawing up the vaccines. Canadians in their native language. take over certain components of the In response to frequently changing They created specialized clinics, such vaccine clinics. The PHNs sometimes venues, PHNs who felt supported as one that provided 300 vaccines in felt challenged by their perceived and able to act autonomously were a day and “not a word of English was obligation to question the managers’ better equipped to identify context- spoken.” PHNs also described the decisions, for example to advocate specific techniques to help them stay importance of taking time to reassure for their public health training flexible and adapt to new situations people, noting that the community and ability to organize and run a daily or within the day, such as has faith in them and trusts the successful immunization clinic, or efficiently setting up a clinic and information they provide. to advocate for inexperienced fellow keeping clinic documents organized. nurses who were not comfortable Other challenges that the nurses The pandemic also provided giving injections. A key difference discussed included lack of material PHNs with a positive opportunity between H1N1 immunization clinics resources, lack of nursing staff for to strengthen and expand their and the seasonal flu vaccination the clinics, insufficient help for the professional networks, forming clinics was that PHNs had to depend physical set up the clinics, and little lasting relationships with other on a central team with Manitoba financial support. PHNs reported nurses and other disciplines, within Health to order the necessary having to borrow supplies from other their region and across different supplies in a timely manner. This was facilities and ask other departments regions. Interacting with other taxing when mistakes were made, for help. Despite these challenges, healthcare workers, through training such as ordering incorrect quantities, the nurses also discussed the other nurses in administering the wrong items (e.g., type of importance of maintaining a sense of vaccines and interacting with needle), or unnecessary items (e.g., humor and ability to marvel at the professionals from other disciplines sterile drapes that went unused). situation. (such as pharmacists), created an The nurses reflected that they are atmosphere of supportive teamwork. generally used to being in control of Study participants noted that this situations, so it was often difficult type of atmosphere has always been

Centre de collaboration nationale des maladies infectieuses 7 an integral part of public health, felt that nurses should be responsible at immunization clinics. Further, particularly during crisis situations. for drawing up the vaccines, as they PHNs also noted the success of One northern PHN noted the have more experience in this. immunization clinics was enhanced satisfaction of being part of a global when they received support from team: for example, they received Finally, the PHNs also reported interdisciplinary team-members, vaccine for pregnant women from feeling a sense of pride and such as clerical and maintenance Australia. This nurse emphasized that accomplishment that they could staff assisting in setting up clinics she could really see that they were provide a valuable service to their in unfamiliar venues as well as part of a global team, working on the community and act as advocates for pharmacists providing their expertise same problem as the World Health their profession’s important role in with vaccines at immunization Organization. society. clinics. Some study participants indicated that while PHNs are used PHNs were required to fill Regional support to working with interdisciplinary various roles depending on the groups, other regional staff might circumstances, and thus had to Long (2013) found that, in order for not be and this should be accounted be flexible during a single clinic PHNs to effectively fulfill their roles, for when preparing emergency and from clinic to clinic. They they require a variety of support response plans. Finally, a number of learned to recognize team members’ systems, including an existing nurses indicated that they received individual strengths so that efficiency regional pandemic plan and team, fundamental support from their and safety was maximized. Roles directives from management, access families and friends while they included answering phone calls to timely updates, access to expertise worked stressful, extended hours at at public health offices, managing such as medical officers of health, immunization clinics. immunization clinics, administering and regular meetings to distribute vaccines, observing clients post- updates. Lessons learned vaccination, obtaining informed consent, educating the public Northern PHNs stated they Long (2013) observed that growth and other regional staff, drawing had support from the region occurred at the professional and up vaccines, and planning clinic immunization coordinator and organization levels as PHNs operations, such as setting up access to an “H1N1 binder,” which incorporated certain lessons to clinics and managing immunization outlined the roles and responsibilities be better prepared for the next supplies. Some PHNs also reported specific to PHNs and was said to pandemic and expressed a sense being tasked to act as clinic leads be a valuable tool when planning of pride in having “survived” given their existing knowledge and implementing immunization the pandemic, increasing their of immunization programs clinics and training non-PHN team confidence in their ability to respond and experience with rolling out members in giving immunizations. even more efficiently during the next community based immunization While some nurses identified pandemic. Most study participants clinics. Several PHNs described their continuing to provide basic reported they are now more prepared frontline experience with other mass public health services concurrent to face another pandemic-like immunization clinics and previous with pandemic interventions as event because they have a clearer seasonal flu vaccine clinics, although challenging, several nurses felt understanding of what is expected of on a smaller scale, as valuable supported by their health region’s them during a pandemic response, experiences that had adequately management to prioritize pandemic such as large immunization clinics. prepared them for coordinating the public health services in their Their experience with pH1N1 has much larger scale H1N1 vaccine communities. also contributed to the PHNs feeling clinics. PHNs also applied their more competent, and thus confident, experience in handling and properly Many nurses reported that being in contributing to future pandemic storing vaccine, as once a vaccine vial recognized as trusted and valuable response plans for their health was punctured, the nurses ensured team members by the regional regions and communities. Challenges all 10 doses were used. In contrast, team, and especially management, in quality of communication and PHNs reported their frustration was an essential source of support disseminating information to the when they observed other team during a stressful time. PHNs noted public, as discussed above, prompted members incorrectly handle the that it is imperative that regional nearly all study participants to report vaccine, which led to wastage, This managers appreciate PHNs’ roles that, for the next pandemic, each situation increased tension among and responsibilities in order to region requires a comprehensive the team, because the other PHNs more successfully provide support

8 National Collaborating Centre for Infectious Diseases communication strategy to effectively several revisions since 2009 and impacted the data and should be respond to the public. were likely not the same as those noted. used during the pandemic; and 5) Strategies that proved effective the CHNC practice standards and Despite these limitations, study during pH1N1, such as pairing professional practice model (CHNC strengths include: 1) representation junior nurses with experienced nurses 2011) and the CHNC public from a diverse group of PHNs that and incorporating interdisciplinary health nursing discipline specific also met specific inclusion criteria teamwork into pandemic competencies (CHNC 2009), all and from distinct health regions preparedness plans, should be scaled of which have been in use for a few in Manitoba; 2) maintenance of up, given the importance of effective years and which study participants an audit trail during data analysis; collaboration experienced during appear to have used to some degree, 3) peer-debriefing; 4) member pH1N1. should be further evaluated in checking to verify results; and 5) public health nursing research to triangulation of qualitative data Study participants were questioned determine their worth for systematic with documents (pandemic response about their knowledge of the use in emergency preparedness and plans, the published standards Community Health Nurses of response by health regions. and competencies relevant to the Canada (CHNC) Professional profession). These strategies are Practice Standards (CHNC Although Long discussed the number important in maintaining rigour 2011) and Public Health Nursing of study participants as a limitation, in qualitative research, increasing Competencies (CHNC 2009) small sample size is inherent in the trustworthiness of the results specific to reportable communicable qualitative research, the objective (Charmaz 2006, Padgett 2012). disease prevention and control and of which is achieving depth of data responses varied. Approximately rather than breadth, as is typical for Study conclusions half of the study participants were quantitative studies (Padgett 2012). familiar with the CHNC practice Although Long discussed the final Long’s thesis found that, in response standards, noting that the standards themes with her thesis advisor and to the 2009 H1N1 pandemic, PHNs are used in current job descriptions verified them with study participants, drew on their nursing knowledge, and orientation packages for newly co-coding from the beginning of data community knowledge and hired PHNs and are sometimes analysis would have added additional connections, professional code of referenced during staff meetings. rigour (Padgett 2012). In addition ethics, the CHNC practice standards Other participants felt they should to having only three Northern PHN and public health nursing discipline know these standards, but were participants (as opposed to four competencies, and professional and unable to list them or provide further urban and six rural participants), personal partners. Study participants details. All three regions submitted these nurses participated via applied their nursing experience, an electronic copy of their regional individual telephone interviews innovation, and sense of humor pandemic plan to the researcher rather than in-person focus groups. to overcome challenges such as upon request, however, none of the Although Long justified this managing public demands for pandemic plans mentioned either discrepancy with issues of cost and information and supporting fellow the CHNC Professional Practice convenience, the difference between nurses who were newly trained and Standards or the Public Health an in-person interaction versus over inexperienced in administering Nursing Competencies. the telephone (and consequently injections. Long’s study documents an assumed decreased ability to the lived experiences reported by Study limitations read facial expressions and body Manitoban PHNs to improve language) may have impacted the understanding of their roles for Long acknowledged the following data. Furthermore, the dynamic of the next pandemic and advocate limitations to her study: 1) the study an individual interview versus as a for their inclusion when preparing includes only 13 participants, and focus group with peers is different, for the next pandemic. Although only three from Northern regions; with an advantage of focus groups several challenges at the personal, 2) recall bias is possible, as data were for non-sensitive material being that professional and organizational being collected four years after the interaction with peers can stimulate levels were noted, all of the study event; 3) the study participants were memory and bring up topics that an participants indicated they felt proud not asked directly if they would individual may not have thought of of their accomplishments in planning like to be included in pandemic alone (Padgett 2012). This variation mass immunization clinics for their planning; 4) the pandemic plans in data collection methods may have communities in a time of crisis. received for analysis had undergone

Centre de collaboration nationale des maladies infectieuses 9 Nhan, Laprise et al. (2012) pandemic-like emergencies. For prioritization of high-risk groups for question three, there was a checklist vaccination. More than half of the Nhan, Laprise et al. conducted a of 22 items in seven categories PHPMS respondents identified issues mixed-methods web-based learning and at the end of each category with the top-down management needs assessment to describe participants were asked to freely style, communication processes, and Quebecois physicians’ perceptions describe issues they encountered. patient management at the public of management of pH1N1 at the The seven categories include aspects health level (expert committees, physician level and identify areas of pH1N1 management at 1) the case reporting, and epidemiological for improvement. The survey clinic level, 2) the public health investigation). consisted of multiple-choice and level, 3) overall crisis management, open-ended questions to collect both 4) communication process, 5) Of the 102 respondents, 62 (60.7%, quantitative and qualitative data. vaccination, 6) overall management 37 IDMM and 25 PHPMS) The results were intended to inform of the two pandemic waves, and respondents provided written the agenda of an interdisciplinary 7) issues not covered in previous comments. Two central themes continuing education session to categories. emerged: 1) coordination, for address knowledge gaps surrounding example of protocols, roles, and the World Health Organization Qualitative data were analyzed using communication; and 2) resource- (WHO) guidelines for responding inductive, open coding methodology related difficulties, such as laboratory to health care emergencies and to create themes. Three researchers resources, patient management, and on the perceived implementation first independently coded the data the vaccination process. More open issues during pH1N1. When the and created the themes, upon which codes related to coordination preliminary results were shared at the team consensus was met. As a (n = 180) than to resources (n = 64). meeting, the association members team, the researchers used concept encouraged the authors to seek mapping to further refine the Coordination publication of the results. themes. Issues related to the coordination Study methodology and analysis Study findings of the pandemic response were the most common difficulties Appropriate ethics approval was Only the respondents who had identified by the physicians. obtained. All physicians who were personally experienced the pH1N1 Inadequate collaboration across members of either the Quebec outbreak while serving in a levels of pandemic management, association of infectious diseases and professional capacity were eligible; especially between expert advisors medical microbiologists (AMMIQ) 102 of 317 (32.2%) respondents and workers in the field, resulted or the Quebec association of public met these criteria and were included in poor communication and health and preventive medicine in the analysis. Of the 102 eligible subsequent confusion surrounding (AMSSCQ) were invited to respondents, quantitative analysis information received and decision- participate. The surveys were emailed revealed that 85.3% reported making processes. A lack of clarity in April 2010 and submissions were negative experiences with pH1N1 surrounding the distinct roles and closed May 2nd, 2010. management. Physicians from both inadequate communication between specialties identified issues with physicians in the field and expert The researchers developed the the communication process (e.g., advisory committees was cited as survey based on their individual dissemination of clinical practice a significant barrier to efficient expertise and on the literature and guidelines [CPG] and route of pandemic management. Some two members of AMMIQ and three communication). Specialty-specific physicians questioned the committee members of AMMSSCQ reviewed issues identified by infectious members’ credentials and the validity it. It was composed of four broad diseases/medical microbiologists of their decisions. Additionally, questions, which included both (IDMM) primarily involved physicians were frustrated by the multiple choice and open-ended laboratories and infection prevention lack of transparency in the decision- sub-questions: 1) participation and control, vaccine availability, making process and by a lack of in pH1N1 management; 2) and overall management of the two personal autonomy. Many physicians their practice profile; 3) types of pandemic waves. Specialty-specific attributed the ineffectiveness of the frustrations/difficulties during the issues identified by public health/ top-down management model and pandemic; and 4) an open-ended preventive medicine specialists the slow decision-making processes question asking for suggestions (PHPMS) primarily involved the to the large number of people at for improvements for future decision-making process in the the top administrative level. They

10 National Collaborating Centre for Infectious Diseases suggested including more medical campaigns. In laboratory settings, education seminar and not for specialists at the decision-making physicians noted limited access publication. level and allowing for greater to supplies, such as diagnostic autonomy at the regional and local material and tests, as well as a lack of Study conclusions level. human resources (staff). Physicians also noted that emergency rooms Responses to healthcare The primary communication were frequently overwhelmed emergencies can be strengthened problems identified included a and criticized that patients with through improving transparency slow dissemination of information influenza-like symptoms were not and reinforcing relationships and an overwhelming number of evaluated prior to being sent to between physicians and health information sources and divergent, the ER. They recommended that authorities. Further involving often unclear, messages. As an patients be evaluated elsewhere, the professional associations in example, the content of Clinical number of single hospital rooms be planning responses and as a Practice Guidelines (CPGs) was increased to accommodate patients communication channel should noted to be inconsistent and with pH1N1, and the process be considered. Further qualitative frequently changing, and sometimes for transferring patients be made studies would help describe how contradictory, between distinct more efficient. Several issues were to improve the implementation pandemic management levels and identified with the vaccination of emergency response plans, advisory committees, creating process, including late delivery of empower stakeholders, and identify confusion among physicians over vaccines after the onset of the second discrepancies between pandemic which ones to follow. In addition, pandemic wave and late notification plans and the actual events. the CPGs were disseminated of their arrival. Physicians too slowly and were inflexible recommended an improved risk to accommodate certain specific assessment process in determining situations or regions. Inefficiency high-risk groups for vaccination Discussion was also identified regarding the prioritization, particularly with epidemiologic investigations respect to the elderly and school- Although the above studies are protocols, specifically: changing aged children, both of which were specific to distinct populations of requirements of the case report form; targeted late in the vaccination healthcare workers and/or regions, lack of timely feedback at the local campaign. Physicians proposed that common themes emerged across level; and the inconsistent handling the vaccine be available earlier for them, including: 1) improving timely of surveillance and modeling data, the general public, available to the availability and access to resources, and data analysis. It was suggested chronically ill through special clinics, including human resources, vaccines, that centralizing communication and that more information on the and specific supplies required by management and using the Internet vaccine be available to healthcare each discipline to fulfill their roles instead of teleconferences could workers. (such as infection control supplies, strengthen the consistency of supplies for MICs, and laboratory communicated information. Greater Study limitations supplies); 2) issues of self-care transparency and access to collected among healthcare workers; 3) data at the local level was also seen The authors acknowledge the improved communication, notably as important. Finally, the increased following limitations of this study: increased consistency of messages, workload created by pandemic relying on a convenience sample; consolidated sources of information, activities, such as attending using a survey that lacked established and targeted communication to inefficient meetings, was noted to be construct validity; and possible be context specific; 4) improved unmatched by additional financial recall bias among the participants. collaboration and teamwork across compensation. Although the qualitative data were disciplines, particularly with not collected with traditional in- respect to definitions of roles and Resource-related difficulties person qualitative research methods responsibilities and transparency in (such as in-depth interviews, focus decision-making. Problems were identified groups), the thematic content surrounding the issue of availability analysis of the open-ended questions Availability of resources of required resources, including was robust and appropriate, laboratory resources for diagnosis, especially as the data were originally HCW participants in all the managing ill patients efficiently, collected only to inform a continuing studies reviewed mentioned a and ensuring effective vaccination lack of resources as inhibiting the

Centre de collaboration nationale des maladies infectieuses 11 Table 1: Key findings of included studies

Year Study Key Findings

2011 Charania and Tsuji Main barriers identified: overcrowding in houses, insufficient human resources, and inadequate community awareness. Main areas for improvement identified include increase human resources and funding for community education and general supplies.

2013 Long PHNs are important assets for the health regions: they are essential sources of information for the community and are connected to the community; they appreciate and need to be supported to fulfill their roles; they should be involved in the planning of pandemic response interventions to improve efficiency and effectiveness; and ethical dilemmas that cause PHNs moral distress should be acknowledged and anticipated in pandemic preparedness activities.

2012 Nhan, Laprise et al. 85.3% of 102 eligible respondents reported negative experiences with pH1N1 management centred around two main themes: 1) coordination, for example of protocols, roles, and communication and 2) resource- related difficulties, such as laboratory resources, patient management, and the vaccination process.

12 National Collaborating Centre for Infectious Diseases Table 2: Research objectives and design of included studies

Study Purpose Method N Population Sampling

Charania To identify barriers Semi-directed 13 Key informants from: Purposive and Tsuji experienced by healthcare interviews; 1) federal health centres; providers and community- 2) provincial hospitals; opportunities for based and 3) Band Councils improvement during participatory pH1N1 in 3 remote and approach isolated Subarctic First Nation communities

Long To understand the lived 2 Focus groups 13 4 urban PHNs (FG), Targeted public experience of Manitoban (FG), 3 telephone 6 rural PHNs (FG), health regions Public Health Nurses (PHN) interviews 3 Northern PHNs (urban, rural, during pH1N1 (interviews) and Northern); the study was advertised by posters in the regions’ offices and on their websites.

Nhan, To describe Quebecois Web-based 102/317 Infectious disease All physician Laprise physicians’ perceptions of needs (32.2%) specialists/medical members et al. pH1N1 management at assessment as a microbiologists, public of either physician level and identify survey with both health/preventive the Quebec areas for improvement. multiple-choice medicine specialists association and open-ended of infectious questions. diseases and medical microbiologists (AMMIQ) or the Quebec association of public health and preventive medicine (AMSSCQ).

Centre de collaboration nationale des maladies infectieuses 13 effectiveness of the pH1N1 response, sense of teamwork and community investigating the vaccine response particularly their ability to fulfill across the country is positive during of Aboriginal populations found their individual role. HCWs noted emergencies, it is important to that vaccination effectively induced that ensuring timely and equitable remember that agreements and protective titres, even among the access to supplies is of paramount decisions about sharing or moving critically ill (Rubinstein, Predy et importance, whether these be healthcare personnel to other al. 2011). However, timely delivery laboratory supplies to run diagnostic locations or roles should be made of effective interventions is essential tests (Nhan, Laprise et al. 2012), in advance of a pandemic or health for overall success in response to supplies and human resources to emergency occurring. The studies a pandemic. Charania and Tsuji’s set-up and run mass immunization found that this also applies to tasks qualitative study (2011) specifically clinic (Long 2013), or basic infection such as vaccine administration set out to identify barriers to care control supplies that may be too during mass immunization clinics that contributed to the marked expensive for some groups to access (MIC). If healthcare workers such as vulnerability of First Nations during on their own (Charania and Tsuji pharmacists or paramedics are to be the 2009 pH1N1. The federal and 2011). HCWs unanimously noted trained to administer immunizations, provincial governments, as well as that the required funding for the difficult decisions of when and the Band Council, which consists resources and plans for accessing and how should be made before a crisis of the locally elected Chief and distributing them must be in place occurs. Band Council members, share before the next pandemic. Charania responsibility for healthcare in First and Tsuji (2011) suggested that Nation communities. However, stockpiling resources in difficult to Common themes that the authors found a lack of federal access locations may be effective. emerged include: funding and inadequate social policies left communities with In particular, HCWs noted that improving timely inadequate primary healthcare, shortages of human resources community-level disease surveillance, influenced the effectiveness of availability and access to and community infrastructure, their response. Using lay people including housing (Charania and for nontechnical support (such resources; issues of self- Tsuji 2011). While isolation can as set-up and security at vaccine care among healthcare initially act as a buffer to pathogen clinics), implementing rapid training exposure during an infectious programs to increase personnel able workers; improved disease pandemic, once introduced, to administer immunizations, and a pathogen may be transmitted sharing trained personnel among communication; improved more quickly within communities regions with different levels of where overcrowding, impoverished demand were among interventions collaboration and environments, and difficulty found to be effective (Charania teamwork across disciplines. transporting supplies occurs. and Tsuji 2011). Having trained Pandemic responses of remote and personnel move to work in more isolated First Nation communities affected regions is not a novel idea. Members of Aboriginal communities may have been affected by the When the first pandemic wave were affected disproportionately by disparities found in the communities quickly overwhelmed Manitoba’s pH1N1 (Kumar, Zarychanski et themselves, such as crowded living emergency service capacity, al. 2009, Zarychanski, Stuart et al. conditions, as well as their geospatial the Winnipeg Regional Health 2010, Charania and Tsuji 2011). isolation, and unique culture and Authority (WRHA) declared a They experienced a 2.8 times higher governance (Spence and White state of emergency on June 7th, hospitalization rate after infection 2010, Charania and Tsuji 2012). 2009. In response to the potential with H1N1 and 3 times higher HCW shortage, British Columbia rate of admission into an intensive Charania and Tsuji (2011) also and Ontario offered intensive care care unit than non-Aboriginal cite the responsibility governments nurses to Manitoba if required, peoples (Richardson, Driedger et have for addressing the needs of perhaps also as a show of solidarity, al. 2012), although they were not vulnerable populations to prevent as Manitoba nurses and physicians statistically more likely to die than any injustice that may occur during had gone to British Columbia and other populations once infected, a public health emergency, and Ontario to support their health according to a study of critical care note that the Assembly of First systems during the 2004 SARS patients by Kumar, Zarychanski Nations has criticized the lack of outbreak (Embree 2010). While a et al. (2009). Additionally, a study inclusion of First Nations’ input to

14 National Collaborating Centre for Infectious Diseases government pandemic plans. There younger HCWs is supported by a to willingness to work during a is an ethical obligation to protect survey of HCWs’ behaviors during public health emergency among vulnerable populations during public pH1N1 in British Columbia where HCWs has been investigated health emergencies (Falconi and HCWs with more than 11 years of (O’Boyle, Robertson et al. 2006, Fahim 2012, Wynn and Moore experience were more compliant with Oh and Gastmans 2013). Although 2012), which is consistent with the using personal protective equipment not specific to pH1N1, a recent recognition that pH1N1 disease is than those with fewer than 11 years qualitative study in Ontario influenced by social determinants of experience (Mitchell, Ogunremi et conducted in-depth interviews with of health, such as poverty and al. 2012). public health nurses to explore their lack of education, in addition to expectations of working during a the more widely accepted clinical All of the studies included in this pandemic, specifically with respect factors (O’Sullivan and Bourgoin review discuss HCWs’ concerns to expected conflicts between 2010, Lowcock, Rosella et al. 2012). regarding not being eligible or having personal care-giving and family Qualitative studies in Aboriginal access to vaccination for themselves responsibilities (female identity) and communities outside of Canada or their loved ones as a source of professional obligations (professional have also found that access to timely stress. Indeed, prioritization of identity) (Tigert Walters 2010). health services and infection control frontline HCWs is a central part of A grounded theory was developed supplies in already underserved, Canada’s pandemic response plan to explain the evolution of the impoverished communities is (Kendal and MacDonald 2010), as nurses’ self-identity from a core critical (Massey, Pearce et al. 2009). recommended by organizations such female and professional identity For example, similar to issues as the World Health Organization and the subsequent “reassortment” identified in Canada, challenges in (WHO) and the Centre for Disease of this identity over their lifetime accessing health care were noted to Control (CDC) in the United based on their experiences. Tigert be a concern during focus group States (CDC 2009, Zarocostas Walters (2010) noted that nurses’ discussions with six Aboriginal 2009). Multiple studies and reviews dominant self-identity at the time communities in Australia and have been conducted to investigate of a pandemic will impact their recommendations such as stockpiling HCWs’ willingness to work during perception of duty, which has essential resources (e.g., Tamiflu) and pH1N1 (Balicer, Barnett et al. 2010, potentially significant relevance to ensuring medical care (e.g., nurses, Wong, Wong et al. 2010, Devnani their willingness to work in a public drivers for transport to hospitals) was 2012, Wong, Wong et al. 2012), health emergency. This insight to available after hours were suggested building on earlier work on HCWs’ HCWs’ identity construction will be by the community members (Massey, perceived likeliness that they and valuable for employers, governments, Pearce et al. 2009). colleagues would report to work in and policy makers when securing an emergency (DeSimone 2009). A a critical workforce for the next Personal and professional study in the US found approximately pandemic (Tigert Walters 2010). sense of duty to care half of all HCWs were likely to not report for work in an emergency, Finally, all of the HCWs in the Responding to a pandemic, or any but that this was linked to feelings of studies included in this review public health emergency, as a HCW importance in the workplace, such recognized the significant influence on the frontlines can cause stress and that clinical staff were significantly of contextual factors (e.g., media bring to light personal convictions more likely to report to duty than coverage, limited resources, and and morals. Pandemic readiness technical or support staff (Balicer, inter-disciplinary collaboration) on plans must take into account HCWs’ Omer et al. 2006). As such, HCWs overall planning and implementation willingness to report to duty in an should be recognized as valuable of local pandemic responses. HCWs’ emergency and take steps to ensure assets for community health and flexibility in responding to local their protection as much as possible. regional health protection plans and contexts and their demonstrated HCWs in the studies included in this involved in planning for the next commitment to community review discussed extreme working pandemic. Public recognition and health strongly supports the conditions, although HCWs who support for their critical role will inclusion of HCWs in pandemic felt supported were also comfortable increase HCWs’ ability to feel pride response planning and managing implementing innovative solutions, in their profession and identification implementation of interventions. such as pairing junior nurses with with their role (Long 2013). those that have more experience (Long 2013). That more experienced The role of moral distress and ethical HCWs make ideal mentors for decision-making in connection

Centre de collaboration nationale des maladies infectieuses 15 Communication quality sensational stories. Finally, the public of the pandemic response overall. itself was noted to share the blame The benefit of allowing “bottom All of the included studies as despite receiving considerable up” feedback to successfully tailor highlighted themes of ineffective information that pH1N1 was a prevention policies to a specific communication, identifying serious threat and being able to pandemic situation has been contradicting messages to HCWs obtain credible information to make reported by others, for example and the public, information from too an informed decision, two-thirds of when addressing university students many sources, questionable decision- Ontario residents opted to not get completing program practicum making by policy-makers, and vaccinated for pH1N1 (Laing 2011). requirements in healthcare settings information that lacked applicability Other Canadian studies analyzing during pH1N1 (Drolet, Ayala et to local situations. Canadian media pH1N1 communication strategies al. 2013). Furthermore, a lack of coverage of pH1N1 in 2009 was also found media messaging was transparency in the decision-making particularly intense, receiving more often inconsistent, sensationalist, process by public health authorities media attention than all other or not clearly supported by reliable was also frustrating for HCWs and health issues combined that year and facts (Lam and McGeer 2011, contributed to suspicion and lack generating approximately double the Rachul, Ries et al. 2011). This type of confidence in the top level of volume of media as the 2003 SARS of messaging from the media created management. crisis (Laing 2011). Long (2013) unnecessary panic and confusion discussed how media coverage in some communities, increasing Concerns regarding the transparency affected PHNs’ experiences during distrust and making it difficult for and explicitness of decision-making pH1N1, particularly influencing HCWs to effectively fulfill their processes were also found to create the public’s demand for vaccination duties (Charania and Tsuji 2011, confusion by a Canadian policy and contributing to the often tense Long 2013). analysis (Rosella, Wilson et al. 2013). atmosphere of mass immunization Compared to other emergencies such clinics. For example, in late In addition to contradicting media as the 2003 SARS outbreak, pH1N1 October 2009, mixed-messages in reports regarding pH1N1, HCWs was unique in that there had been the media reported both 1) that in all studies reviewed mentioned advance preparation and pandemic H1N1 is of serious concern and contradiction in the information plans were in place to provide 2) that it would be difficult to get they received from health authorities. practical guidance for the response. a flu vaccine due to prioritization For example, PHNs in Manitoba However, Rosella et al. (2013) note of high-risk groups, long line-ups, reported that criteria for vaccination that pandemic plans, developed from and vaccine shortages (Laing 2011), priority groups was sometimes complex assumptions and varied and this was consistent with PHNs changing by the hour during evidence, can sometimes constrain reporting increased concern in the immunization clinics (Long 2013) policymaking. Indeed, it was public over access to vaccination and physicians in Quebec were discovered that as pH1N1 progressed and confusion surrounding the exasperated by the over-whelming and evidence indicated that the priority groups for vaccination (Long variability of messages received level of severity did not match 2013). Laing’s study (2011) of the (Nhan, Laprise et al. 2012). HCWs that of the models, policymaking role of the media in pH1N1 found also reported frustration with a continued to be informed by those mistakes made by all three groups lack of flexibility in policies that models. The researchers explain this analyzed, including public health restrained their ability to tailor discrepancy between the original administration, the media, and policies to specific local needs. In pandemic plan and the new data the public. Specifically, the public particular, physicians typically enjoy based on on-the-ground happenings health communication strategy a great deal of autonomy in decision- using cognitive dissonance theory did not respond appropriately to making, and may find it difficult (Rosella, Wilson et al. 2013). HCWs changes in the pandemic progression, to adjust to a new role (i.e. strictly have suggested that including more creating confusion and mistrust following policy) during a pandemic medical specialists, and also HCWs when government messages were (Nhan, Laprise et al. 2012). While with clinical experience with the inconsistent with media reports recognizing the necessity of a top- disease, in decision-making would and the public’s experiences. down style of management during a allow for greater responsiveness Additionally, the media often pandemic (Standards 2010), HCW and effectiveness of the pandemic did not support its stories with participants in the studies of this response (Nhan, Laprise et al. 2012, verified facts, for example negatively review suggested that accepting a Long 2013). portraying the vaccination campaigns degree of flexibility at the local level based on weak scientific studies and would improve the effectiveness

16 National Collaborating Centre for Infectious Diseases In Canada and globally, it has been updates to public and health care given the zoonotic origin of noted that communication during professionals during a public health the virus, none of the studies public health emergencies must be emergency. She suggests that a reviewed here directly advocate understandable and context specific, repository could be staffed with for improved collaboration across as well as culturally sensitive and existing trained personnel and human and animal health sectors. account for Aboriginal traditions, infrastructure from Health Links- Greater awareness of the benefits such as attending community Info Santé, and that messaging and of interdisciplinary teamwork and funerals and other social gatherings updates could be developed with encouragement of a “One Health” (Massey, Pearce et al. 2009, Charania input from local, regional, and culture in research and surveillance and Tsuji 2011). In addition, provincial PHN representatives. efforts would likely improve Charania and Tsuji (2011) note that PHNs would need to be supported prevention, detection, and mitigation information could be disseminated by their managers, medical officers of infectious diseases (Meslin, Stohr to communities through means of health, and other regional staff et al. 2000, Merianos 2007). specific to First Nations, such as members (Long 2013). Several pandemic awareness and/or planning PHNs specifically cited that receiving Collaboration within meetings with attendance mandated information and directives from their the healthcare system by the Band Council. Input from region assisted them in carrying out First Nations communities is their duties at immunization clinics All of the studies reviewed here required to develop and implement and public health offices. In contrast, discussed a need for greater pandemic readiness plans to ensure PHNs who reported a lack of timely collaboration and improved cultural appropriateness (Massey, updates appeared to experience definition of roles and responsibilities Pearce et al. 2009, Rubinstein, Predy greater challenges, such as when within the healthcare system, et al. 2011, Richardson, Driedger et enforcing vaccine priority groups which is consistent with earlier al. 2012). (Long 2013). Long notes that it is work investigating disease outbreak well-documented in the literature emergencies (Johnson, Bone et al. Communication strategies should that during infectious disease 2005). Although some groups of be improved through incorporating outbreaks, access to various sources HCWs are accustomed to working nurse managers and/or further and forms of support is essential for with other healthcare professions, increasing the involvement of frontline nurses to perform their such as public health nurses nurses. Long (2013) noted that duties (Bergeron, Cameron et al. (PHNs), others may not be and electronic technology needs to be in 2006, O’Boyle, Robertson et al. training provided in advance of an place earlier to facilitate providing 2006) and that employers and their emergency situation would allow accurate and timely information administrators have a responsibility HCWs to better understand the about the influenza pandemic to to prepare nurses both professionally abilities of other professions (Long frontline staff so they, in turn, can and ethically to respond to public 2013). Indeed, Long (2013) found disseminate the information to their health emergencies (Balicer, Omer that PHNs cited the formation of communities. Clear communication et al. 2006, Jakeway, LaRosa et al. new working relationships with from healthcare workers regarding 2008). colleagues from other departments pandemic interventions was essential and other cities as a positive in instilling and maintaining trust Interdisciplinary teamwork outcome of pH1N1. However, among community workers. when working with new groups, Together with improved quality roles and responsibilities change Long (2013) supports this and consistency of communication, and some HCWs found it difficult recommendation with the literature, the studies reviewed in this paper to adjust to their new role during citing Lee and Basnyat that, after recommend the capacity for pH1N1 (Nhan, Laprise et al. 2012, vaccination, effective communication interdisciplinary teamwork should Long 2013). In addition to HCW by both government and public be strengthened. In addition to teams, increased collaboration was health officials is the second most increased collaboration among found to be required across different critical intervention for responding healthcare workers (such as government groups responsible to a vaccine preventable disease physicians, nurses, social workers, for healthcare, such as diagnostic pandemic (Lee and Basnyat 2013). pharmacists, first responders), laboratories, epidemiological Long also suggests that regional one study (Long 2013) called investigation units, and primary care administrators consider the creation for increased multi-disciplinary providers (Nhan, Laprise et al. 2012) of a central information repository collaboration within academia and and federal, provincial, and Band to provide timely and consistent clinical healthcare. Surprisingly, Council governments serving First

Centre de collaboration nationale des maladies infectieuses 17 Nations communities (Charania and student practica. The researchers tailoring pandemic responses to be Tsuji 2011). recognize that universities are effective within their specific context potentially of particular concern (Drolet, Ayala et al. 2013). Although A model for HCW collaboration during pandemic influenza because the role of academia in pandemic was demonstrated between public of the large congregation of young preparedness and response seems health and primary care providers adults who typically have high levels to be neither widely understood in southeastern Ontario, where of close social contact. Collaboration nor optimized in Manitoba, Long an effective response to pH1N1 between academia and field agencies (2013) advocates for further occurred when integrated, was found to increase effectiveness of collaboration between faculty with interdisciplinary family health interventions to ensure student safety technical expertise and healthcare teams (FHT) were used as the and limit viral transmission (Drolet, providers. Long (2013) suggests primary care providers (PCP) Ayala et al. 2013). that academia and health regions (Wynn and Moore 2012). FHTs are could jointly perform real time described as including physicians, Participants identified two primary research during emergency planning nurse practitioners, social workers, sources of pandemic information and response-related activities. pharmacists, and dieticians, and (such as policies detailing absenteeism, She believes that the knowledge they promote rapid, timely, and sneezing/coughing etiquette, generated from such collaborative efficient communication between existing school/agency protocols, work could inform both public physicians and public health leaders. and vaccination) for students: 1) the health nursing practice and curricula Pandemic H1N1 was the first public university, through field directors and in post-secondary institutions in health emergency that used the FHT faculty liaisons; and 2) through the ways that surpass the documented structure to facilitate collaboration field agency itself. Less than half of barriers to this type of collaboration, between primary care and public the participants recommended H1N1 such as lack of awareness of each health and its success indicates vaccination before a practicum. Field others’ organizational capacities, this model has great potential directors and coordinators particularly differences and competitiveness in for scale-up in other regions. In emphasized communication of the institutional culture, financial particular, because PCPs could easily pH1N1 precautions as students restraints, and legal technicalities communicate their patients’ needs also reported accessing information between public health and academia to public health, the two sectors on the Internet that pH1N1 was (Dunlop, Logue et al. 2012). were then able to work together to not as serious as reported and that coordinate care for all citizens. This vaccination was either ineffective Long also proposes that nursing mindful coordination promotes or harmless. Overall, more than faculties could also work to increase equality in healthcare opportunities, one-third of respondents said that awareness of the importance and making this an especially potentially practicum activities were altered benefits of interdisciplinary groups useful model for vulnerable by pH1N1 and social work field among student nurses, potentially via populations such as First Nations education programs were found invited guest speakers such as PHNs communities (Wynn and Moore 2012). to have taken on the responsibility with pH1N1 experience. of preparing students, through Collaboration with academia increasing awareness and developing Collaboration through “One Health” appropriate policies and educational As Long (2013) suggested, materials. Despite the well-know animal origin interdisciplinary teamwork and of this novel influenza virus (Smith, inter-sectoral collaboration between This study highlights the importance Vijaykrishna et al. 2009, Pasma academia and the health sector of collaboration between academia 2011, Smith, Harper et al. 2011, could potentially have significant and field agencies during public Vijaykrishna, Smith et al. 2011), positive impacts on a pandemic health emergencies via exploring the relatively few Canadian studies response. However, few studies exist experiences of social work faculty and investigate the potential for virus that examine the role of disciplines field instructors during pH1N1. As transfer between pigs and humans. outside of the traditional medical discussed earlier, although top-down Modern swine production brings care-based sector. One exception management of human pandemics together humans and concentrated is Drolet, Ayala et al. (2013), is the norm (Barnett, Balicer et populations of pigs, which are who used a web-based survey of al. 2005, Kendal and MacDonald known to have potential as “mixing Canadian social work field directors 2010), bottom-up responses by vessels” for creating novel influenza and coordinators to investigate the post-secondary institutions and viruses through hosting, and impact of pH1N1 on social work their partner agencies are essential in allowing the re-assortment of, swine,

18 National Collaborating Centre for Infectious Diseases human, and avian influenza viruses and the primary care physicians and References (Ma, Kahn et al. 2009, Haque, public health staff who may interact Balicer, R. D., D. J. Barnett, C. B. Bari et al. 2010). Support for the these groups. These studies could Thompson, E. B. Hsu, C. L. Catlett, C. M. “One Health” ethos will improve further inform both surveillance and Watson, N. L. Semon, H. S. Gwon and J. collaboration between human, early response policies to assist in M. Links (2010). Characterizing hospital animal, and environmental health preventing novel zoonotic disease workers’ willingness to report to duty in practitioners improving efficiency outbreaks. an influenza pandemic through threat- and of policy decisions (Tanner and efficacy-based assessment. BMC Public Zinsstag 2009). Health 10: 436. Balicer, R. D., S. B. Omer, D. J. Barnett An Albertan study investigated the Limitations and G. S. Everly (2006). Local public health transmission of pH1N1 between workers’ perceptions toward responding to swine workers and pigs on Hutterite Although an extensive search was an influenza pandemic. BMC Public Health colonies and found that, although conducted for relevant studies, it is 6(1): 99. the pH1N1 influenza virus is possible that one or more studies Barnett, D. J., R. D. Balicer, D. R. Lucey, G. thought to have reassorted in swine, may have been overlooked as the S. Everly, Jr., S. B. Omer, M. C. Steinhoff the swine herds in this study were subject concerns multiple disciplines and I. Grotto (2005). A systematic analytic likely infected via anthroponosis and studies may appear in various approach to pandemic influenza preparedness (Russell, Keenliside et al. 2009). publications and/or databases. Non- planning. PLoS Med 2(12): e359. The continued emergence of novel English studies may also exist. pathogens from animal vectors Bennett, B., T. Carney and C. Saint (2010). Swine flu, doctors and pandemics: is there a warrants increased surveillance duty to treat during a pandemic? J Law Med in zoonotic disease transmission, 17(5): 736-747. particularly in potentially high-risk Conclusions situations (Morse 1995, Jones, Patel Bergeron, S. M., S. Cameron, M. Armstrong- et al. 2008). Including qualitative While responses to pH1N1 across Stassen and K. Pare (2006). Diverse research methods in studies of Canada varied depending on their implications of a national health crisis: A anthrozoonotic diseases will increase individual context, the HCW qualitative exploration of community nurses’ understanding of how transmission participants identified common SARS experiences. Can J Nurs Res 38(2): 42-54. occurs by investigating knowledge ways for pandemic response plans and attitudes of workers directly to be strengthened in preparation Boldor, N., Y. Bar-Dayan, T. Rosenbloom, J. handling swine and the subsequent for future pandemics. Ensuring Shemer and Y. Bar-Dayan (2012). Optimism impacts on their behavior. timely access to required resources of health care workers during a disaster: (both human and material supplies), a review of the literature. Emerg Health A recent qualitative study has been recognizing and preparing for issues Threats J 5. conducted to identify challenges and such as moral distress among HCWs, CDC (2009). Use of influenza A (H1N1) opportunities for the prevention, improved communication strategies, 2009 monovalent vaccine: recommendations early detection, and mitigation of and improved collaboration and of the Advisory Committee on Immunization zoonotic influenza. In this study, teamwork across disciplines, Practices (ACIP), 2009. MMWR Recomm key Canadian stakeholders in swine were all recognized as areas with Rep 58(RR-10): 1-8. production and health, human opportunities for improvement Charania, N. A. and L. J. Tsuji (2011). health, diagnosticians, and virologists to ensure the response to the next Government bodies and their influence on participated in key informant pandemic is even more effective. the 2009 H1N1 health sector pandemic interviews and the author makes Overall, within Canada and globally, response in remote and isolated First Nation suggestions to improve prevention, there is a sense of relief that pH1N1 communities of sub-Arctic Ontario, Canada. detection, and mitigation of a novel was not more severe and responses to Rural Remote Health 11(3): 1781. virus at the human-animal interface pH1N1 are being carefully analyzed Charania, N. A. and L. J. Tsuji (2012). A (Wisener 2013). Ensuring adequate to identify weaknesses and address community-based participatory approach qualitative methodology will permit knowledge gaps. HCWs who were and engagement process creates culturally effective integration of knowledge, on the frontlines are a valuable appropriate and community informed attitudes, and practices associated source of information and further pandemic plans after the 2009 H1N1 with influenza transmission of qualitative studies should be done influenza pandemic: remote and isolated First the farm and abattoir workers to better understand their unique Nations communities of sub-arctic Ontario, and private and public practice perceptions of Canada’s response to Canada. BMC public health 12(1): 268. veterinarians who handle swine, the 2009 pH1N1.

Centre de collaboration nationale des maladies infectieuses 19 Charania, N. A. and L. J. S. Tsuji (2011). of Child Health and Human Development Long, M. M. (2013). Response to the 2009 The 2009 H1N1 pandemic response 5(3): 373-381. H1N1 influenza pandemic: Manitoba public in remote First Nation communities Haque, N., M. S. Bari, L. Bilkis, M. A. health nurses’ experience. FGS - Electronic of Subarctic Ontario: barriers and Hossain, M. A. Islam, M. M. Hoque, S. Theses & Dissertations (Public) Manitoba improvements from a health care services Haque, S. Ahmed, R. Mirza, A. A. Sumona, Heritage Theses. perspective. International Journal of M. U. Ahmed and A. Ara (2010). Swine flu: Low, D. E. and A. McGeer (2010). Circumpolar Health 70(5): 564-575. a new emerging disease. Mymensingh Med J Pandemic (H1N1) 2009: assessing the Charmaz, K. (2006). Constructing 19(1): 144-149. response. CMAJ 182(17): 1874-1878. Grounded Theory: A practical guide through Health, O. C. M. O. o. and A. King (2010). Lowcock, E. C., L. C. Rosella, J. Foisy, A. qualitative analysis, SAGE Publications, Inc. The H1N1 Pandemic: How Ontario Fared: a McGeer and N. Crowcroft (2012). The social CHNC, C. H. N. o. C. (2009). Public health Report, Ministry of Health and Long-Term determinants of health and pandemic H1N1 nursing discipline specific competencies. Care. 2009 influenza severity. Am J Public Health Version 1.0., Retrieved from: http:// Jakeway, C. C., G. LaRosa, A. Cary and 102(8): e51-58. www.chnc.ca/documents/competencies_ S. Schoenfisch (2008). The role of public Ma, W., R. E. Kahn and J. A. Richt (2009). june_2009_english.pdf. health nurses in emergency preparedness and The pig as a mixing vessel for influenza CHNC, C. H. N. o. C. (2011). Canadian response: a position paper of the Association viruses: human and veterinary implications. Community Health Nursing: Professional of State and Territorial Directors of Nursing. Journal of molecular and genetic medicine: Practice model & standards of practice. Public Health Nurs 25(4): 353-361. an international journal of biomedical Retrieved from: http://www.chnc.ca/ Johnson, M. M., E. A. Bone and G. N. Predy research 3(1): 158. documents/chnc-standards-eng-book.pdf. (2005). Taking care of the sick and scared: Massey, P. D., G. Pearce, K. A. Taylor, L. DeSimone, C. L. (2009). Response of public a local response in pandemic preparedness. Orcher, S. Saggers and D. N. Durrheim health workers to various emergencies. Can J Public Health 96(6): 412-414. (2009). Reducing the risk of pandemic AAOHN J 57(1): 17-23. Jones, K., N. Patel, M. Levy, A. Storeygard, influenza in Aboriginal communities. Rural Devnani, M. (2012). Factors associated D. Balk, J. Gittleman and P. Daszak (2008). Remote Health 9(3): 1290. with the willingness of health care personnel Global trends in emerging infectious diseases. Merianos, A. (2007). Surveillance and to work during an influenza public health Nature 451(7181): 990-U994. response to disease emergence. Curr Top emergency: an integrative review. Prehosp Kendal, A. P. and N. E. MacDonald Microbiol Immunol 315: 477-509. Disaster Med 27(6): 551-566. (2010). Influenza pandemic planning and Meslin, F. X., K. Stohr and D. Heymann Devnani, M., A. K. Gupta and B. Devnani performance in Canada, 2009. Can J Public (2000). Public health implications of (2011). Planning and response to the Health 101(6): 447-453. emerging zoonoses. Rev Sci Tech 19(1): influenza A (H1N1) pandemic: ethics, equity Khandaker, G., A. Dierig, H. Rashid, 310-317. and justice. Indian J Med Ethics 8(4): 237- C. King, L. Heron and R. Booy (2011). Mitchell, R., T. Ogunremi, G. Astrakianakis, 240. Systematic review of clinical and E. Bryce, R. Gervais, D. Gravel, L. Drolet, J., J. Ayala, J. Pierce, F. Giasson epidemiological features of the pandemic Johnston, S. Leduc, V. Roth, G. Taylor, M. and L. Kang (2013). Influenza “A” H1N1 influenza A (H1N1) 2009. Influenza Other Vearncombe and C. Weir (2012). Impact Pandemic Planning and Response: The Role Respi Viruses 5(3): 148-156. of the 2009 influenza A (H1N1) pandemic of Canadian Social Work Field Directors and Kumar, A., R. Zarychanski, R. Pinto, D. on Canadian health care workers: a survey Coordinators Canadian Social Work Review J. Cook, J. Marshall, J. Lacroix, … R. A. on vaccination, illness, absenteeism, and 30(1): 49-63. Fowler (2009). Critically ill patients with personal protective equipment. Am J Infect Dunlop, A. L., K. M. Logue, L. 2009 influenza A(H1N1) infection in Control 40(7): 611-616. Vaidyanathan and A. P. Isakov (2012). Canada. JAMA 302(17): 1872-1879. Moghadas, S. M., N. J. Pizzi, J. Wu, S. E. Facilitators and Barriers for Effective Laing, A. (2011). The H1N1 crisis: Roles Tamblyn and D. N. Fisman (2011). Canada Academic-Community Collaboration for played by government communicators, the in the face of the 2009 H1N1 pandemic. Disaster Preparedness and Response. J Public public and the media. Journal of Professional Influenza Other Respir Viruses 5(2): 83-88. Health Manag Pract. Communication 1(1): 11. Morse, S. S. (1995). Factors in the emergence Embree, J. (2010). Pandemic 2009 (A) Lam, P. P. and A. McGeer (2011). of infectious diseases. Emerging Infectious H1N1 influenza (swine flu) - the Manitoba Communications Strategies for the 2009 Diseases 1(1): 7-15. experience. Biochem Cell Biol 88(4): 589- Influenza A (H1N1) Pandemic, National Navaranjan, D., L. C. Rosella, J. C. Kwong, 593. Collaborating Centre for Infectious Diseases. M. Campitelli and N. Crowcroft (2014). Falconi, M. and C. Fahim (2012). Protecting Lee, S. T. and I. Basnyat (2013). From press Ethnic disparities in acquiring 2009 and supporting high risk populations in release to news: mapping the framing of the pandemic H1N1 influenza: a case-control pandemic: Drawing from experiences with 2009 H1N1 A influenza pandemic. Health study. BMC Public Health 14(1): 214. influenza A (H1N1). International Journal Commun 28(2): 119-132. Nhan, C., R. Laprise, M. Douville-Fradet, M. E. Macdonald and C. Quach (2012).

20 National Collaborating Centre for Infectious Diseases Coordination and resource-related difficulties Rubinstein, E., G. Predy, L. Sauve, G. W. Tanner, M. and J. Zinsstag (2009). One encountered by Quebec’s public health Hammond, F. Aoki, C. Sikora, Y. Li, B. Health - The potential of closer collaboration specialists and infectious diseases/medical Law, S. Halperin and D. Scheifele (2011). between human and animal health. Berliner microbiologists in the management of A The responses of Aboriginal Canadians Und Munchener Tierarztliche Wochenschrift (H1N1)--a mixed-method, exploratory to adjuvanted pandemic (H1N1) 2009 122(11-12): 410-411. survey. BMC Public Health 12: 115. influenza vaccine. CMAJ 183(13): E1033- Tigert Walters, J. (2010). Public Health O’Boyle, C., C. Robertson and M. Secor- 1037. Nurses’ Perceptions of Duty during an Turner (2006). Nurses’ beliefs about public Russell, M. L., J. Keenliside, R. Webby, Influenza Pandemic: A Qualitative Study. health emergencies: fear of abandonment. K. Fonseca, P. Singh, L. Moss and M. MR71771 M.P.H., Lakehead University Am J Infect Control 34(6): 351-357. Loeb (2009). Protocol: transmission and (Canada). O’Sullivan, T. and M. Bourgoin (2010). prevention of influenza in Hutterites: Vijaykrishna, D., G. J. Smith, O. G. Pybus, Vulnerability in an Influenza Pandemic: zoonotic transmission of influenza A: swine H. Zhu, S. Bhatt, L. L. Poon, S. Riley, J. Looking Beyond Medical Risk; Literature & swine workers. BMC Public Health 9: 420. Bahl, S. K. Ma, C. L. Cheung, R. A. Perera, review prepared for the Public Health Agency Scott, K. (2010). Pandemic influenza H1N1 H. Chen, K. F. Shortridge, R. J. Webby, R. of Canada as a background paper for a 2009--the Canadian experience. J Popul Ther G. Webster, Y. Guan and J. S. Peiris (2011). national consultation meeting on pandemic Clin Pharmacol 17(3): e358-362. Long-term evolution and transmission planning. Available at: http://www.icid.com/ Silversides, A. (2009). Swine flu outbreak dynamics of swine influenza A virus. Nature files/Marg_Pop_Influenza/Lit_Review_-_ tests Canadian preparedness. CMAJ 180(12): 473(7348): 519-522. Vulnerability_in_Pandemic_EN.pdf. E93-94. Wisener, L. (2013). Key Informant Oh, Y. and C. Gastmans (2013). Moral Simonds, A. K. and D. K. Sokol (2009). Interviews: Challenges and opportunities distress experienced by nurses: A quantitative Lives on the line? Ethics and practicalities of for the prevention, early detection, and literature review. Nurs Ethics. duty of care in pandemics and disasters. Eur mitigation of zoonotic influenza at the Padgett, D. (2012). Qualitative and Respir J 34(2): 303-309. swine-human interface in Canada. National Mixed Methods in Public Health, SAGE Collaborating Centre for Infectious Disease Smith, G. J., D. Vijaykrishna, J. Bahl, S. (NCCID). Publications, Inc. J. Lycett, M. Worobey, O. G. Pybus, S. K. Pahlman, I., H. Tohmo and H. Gylling Ma, C. L. Cheung, J. Raghwani, S. Bhatt, J. Wong, E. L., S. Y. Wong, K. Kung, A. W. (2010). Pandemic influenza: human rights, S. Peiris, Y. Guan and A. Rambaut (2009). Cheung, T. T. Gao and S. Griffiths (2010). ethics and duty to treat. Acta Anaesthesiol Origins and evolutionary genomics of Will the community nurse continue to Scand 54(1): 9-15. the 2009 swine-origin H1N1 influenza A function during H1N1 influenza pandemic: epidemic. Nature 459(7250): 1122-1125. a cross-sectional study of Hong Kong Pasma, T. J. (2011). Assessing the feasibility community nurses? BMC Health Serv Res of swine influenza surveillance in Manitoba. Smith, T. C., A. L. Harper, R. Nair, S. E. 10: 107. FGS - Electronic Theses & Dissertations Wardyn, B. M. Hanson, D. D. Ferguson (Public) http://hdl.handle.net/1993/4846. and A. E. Dressler (2011). Emerging swine Wong, E. L., S. Y. Wong, N. Lee, A. Cheung and S. Griffiths (2012). Healthcare workers’ Rachul, C. M., N. M. Ries and T. Caulfield zoonoses. Vector Borne Zoonotic Dis 11(9): 1225-1234. duty concerns of working in the isolation (2011). Canadian newspaper coverage of ward during the novel H1N1 pandemic. J the A/H1N1 vaccine program. Can J Public Spence, N. and J. P. White (2010). Scientific Clin Nurs 21(9-10): 1466-1475. Health 102(3): 200-203. Certainty in a Time of Uncertainty: Predicting Vulnerability of Canada’s First Wynn, A. and K. M. Moore (2012). Richardson, K. L., M. S. Driedger, N. J. Integration of primary health care and public Pizzi, J. Wu and S. M. Moghadas (2012). Nations to Pandemic H1N1/09. The International Indigenous Policy Journal 1(1): health during a public health emergency. Am Indigenous populations health protection: a J Public Health 102(11): e9-e12. Canadian perspective. BMC Public Health 1. 12: 1098. Spika, J. S. and D. Butler-Jones (2009). Zarocostas, J. (2009). Healthcare workers Pandemic influenza (H1N1): our Canadian should get top priority for vaccination against Rosella, L. C., K. Wilson, N. S. Crowcroft, A/H1N1 flu, WHO says. BMJ 339. A. Chu, R. Upshur, D. Willison, S. L. Deeks, response. Can J Public Health 100(5): 337- B. Schwartz, J. Tustin, D. Sider and V. Goel 339. Zarychanski, R., T. L. Stuart, A. Kumar, (2013). Pandemic H1N1 in Canada and the Standards, C. (2010). Voices from the H1N1 S. Doucette, L. Elliott, J. Kettner and F. use of evidence in developing public health Influenza Pandemic Front Lines: A White Plummer (2010). Correlates of severe disease policies--a policy analysis. Soc Sci Med 83: Paper About How Canada Could Do Better in patients with 2009 pandemic influenza 1-9. Next Time. CSA Standards Roundtable on (H1N1) virus infection. CMAJ 182(3): 257-264. Rossow, C. C. (2012). Healthcare workers’ Healthcare and Emergency Service Sector willingness to report to work during an Pandemic Preparedness. D. Doug Morton, influenza pandemic: A systematic literature Health and Safety CSA Standards; Dr. Allan review. 3556375 D.H.A., Central Michigan Holmes, moderator. University.

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