Many mountain communities here in Canada and around the world are located remote and isolated areas. Remote and isolated areas are often not as exposed to public health awareness campaigns compared to urban communities, who have widespread media coverage and unlimited internet access. The messaging for remote communities also needs to be specifically tailored their circumstances (e.g. limited access to water, health care and supplies) and consider culture, health literacy, and language preferences, which can present barriers to adoption of public health advice.
In this context, we are sharing this guidance from the Public Health Agency of Canada that is intended to support such communities in their COVID-19 preparedness efforts.
Considerations for remote and isolated communities
This guidance is intended to support indigenous leaders, public health departments, regional health authorities and federal, provincial and territorial governments in their COVID-19 preparedness efforts for remote and isolated (RI) communities. The considerations included in this appendix are based on principles outlined in the Canadian Pandemic Influenza Preparedness Guidance.
A multitude of factors can influence the health status of an individual or a population. For many indigenous communities, culture and tradition are integral components of a holistic approach to health and well-being and it is critical to recognize their unique strengths which contribute to their resiliency e.g. teachings from Elders, nurtured relationships of family and community, revitalization of language and culture, connections to the land, traditional healing and cultural ceremonies.
The overall health of Canadians living in RI communities can be affected by social, environmental and economic factors, including housing, water quality or access, food security, pre-existing health conditions, limited access to health care, education and income. These factors, in addition to limited accessibility to health care are important to consider in the context of mitigating the spread and impacts of COVID-19.
Provincial/Territorial variations with respect to infrastructure, human resource capacity, and planning principles should be taken into account when reading this document. It is recommended that this guidance be considered in conjunction with relevant federal, provincial and territorial guidance and planning documents, which should take into consideration existing treaties, agreements and relationships.
Public health measures mitigation strategies
RI communities, and in particular indigenous communities, can be at risk of infectious disease outbreaks due to multiple predisposing factors (e.g. overcrowded or poor housing conditions, poor water quality or lack of clean water access, food insecurity, pre-existing health conditions, limited access to health care). As such, even in the absence of confirmed cases, it is important to prepare for the potential importations into and rapid spread within RI communities. It is recommended that early outbreak investigation and management occur collaboratively with the local public health unit. Community-based public health measures, such as voluntary self-isolation for ill persons, travel advisories and, if necessary, school closures and cancellation/postponement of public gatherings may be considered, depending on the local circumstances. Guidance for caring for someone at home with COVID-19 has been developed and includes considerations with may be applicable for remote and isolated communities.
Challenges and potential strategies for implementing community-based public health measures in remote and isolated communities are listed below:
Lack of availability of non-medical supplies
Delivery and transportation of non-medical supplies (e.g. soap, food, household items) in RI communities can be challenging due to limited or disrupted transportation in and out of the community and other factors such as inclement weather and/or illness precluding individuals from being able to access supplies.
Strategies to consider:
Encourage and increase awareness of individuals, families and communities to (where feasible considering economic resources and storage space) have a backup of supplies to maintain their needs (e.g. soap, household cleaning products, non-perishable food and fluids, tissues).
Crowded or poor housing conditions
RI communities typically experience higher rates of overcrowding, and housing standards are often below adequacy and suitability standards. This is of concern because overcrowding and inadequate housing conditions contribute to increased likelihood of transmission of communicable diseases. Guidance to address the unique challenges for caring for someone in the home is available in Public Health Management of cases and contacts associated with novel coronavirus disease (COVID-19) guidance.
Limited access to running water
Some RI communities have limited access to running water or clean running water for hand hygiene.
Strategies to consider:
Increase the awareness of individuals and families in RI communities for alternative means for effective hand hygiene if they lack clean running water.
Where tap water is not immediately accessible, a closed water container with a spigot can be used to store water for handwashing.
It is recommended that the container be cleaned prior to filling (no special disinfectants are required for cleaning the container – regular household or commercially available cleaning products are sufficient). The container should be dedicated to water used for hand washing (and not drinking).
Hold hands under the spout of a water container, wetting, washing with soap and rinsing.
A pail can be placed below the container to catch the flowing water.
When clean water is not available (e.g. during a boil water advisory or when water quality/source is unknown) consider boiling available water (e.g. boiling for one minute to a rolling boil and allow to completely cool).
In this case, use two separate containers (e.g. container for holding water supply and bowl for washing one’s hands).
Moving hands around to mimic running water to wet, wash with soap and rinse (additional water may be required for rinsing).
The container used for hand washing should be cleaned and dried after each use.
Alcohol-based hand sanitizer (ABHS) containing at least 60% alcohol can be used for hand hygiene if soap and water is not available. However, if hands are visibly soiled, hand wipes should be used to remove any such soil or organic material; this should then be followed by the use of ABHS.
Transmission of virus in public gatherings
The potential for spread of infection during public gatherings may put undue strain on already limited resources in RI communities.
Strategies to consider:
Communities should consider the presence of illness in the community, as well as the availability of health care providers, basic medical supplies, medications, isolation beds/rooms to assist them in deciding whether or not to cancel or postpone public gatherings.
Impact of illness in schools
School closures in RI areas may have a significant impact on a community. Given limited qualified substitute staff in the community, the school may not be able to implement a business continuity cycle if there is a high attack rate and staff are off sick. Hence, the school closure may be longer than in urban communities.
Strategies to consider:
Where systems are in place, schools in coordination with the public health authority should participate in active school based illness surveillance in order to identify outbreaks or unusual situations such as when absenteeism of students/children or staff is greater than would be expected, or severe illness is observed.
Schools should develop business continuity plans specific to their unique community needs.
Refer to school guidance for prevention and mitigation strategies in school settings.
Need for Tailored Messaging
RI communities may not be exposed to public health awareness campaigns to the same degree as urban communities with unlimited access to internet and public information campaigns. The messaging that RI communities receive is often not suited or tailored to their circumstances (e.g. limited access to water, health care and supplies) and considerations to culture, health literacy, and language preferences can present barriers to adoption of public health advice.
Strategies to consider:
Identify communities where tailored communication strategies are required given the local circumstances.
Tailored strategies could include: mail outs, community radio, working with neighbouring communities to obtain necessary information, posters, door-to-door messaging, and community meetings.
Tailoring may also include messaging from people who are familiar or trusted (e.g. Inuit elders or Indigenous physicians).
Develop and communicate campaigns that are specifically tailored to the circumstances of RI communities.