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Canadian Healthcare Workers' Experiences During Pandemic H1N1 Influenza: Lessons from Canada's Response

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Canadian Healthcare Workers' Experiences During Pandemic H1N1 Influenza: Lessons from Canada's Response 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
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