Module 5 - Exercise Builder for First Nations, Inuit and Métis Communities

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Table of Contents

• Section 1 - Introduction
• Section 2 – Exercise Framework
• Appendices
  • Inject Inventory
  • Sample Exercise Schedule
  • Working with Aboriginal Communities – Hints for Exercise Planners
  • Background on Pandemic Preparedness for Exercise Facilitators
  • Principal References

Section 1 - Introduction

General

This module provides planning tools to assist with the design and conduct of a simple pandemic influenza tabletop exercise, tailored to meet the requirements of First Nations, Inuit and Métis communities and supporting organizations. Although this module is designed for aboriginal¹ communities, many of the scenarios and questions would also be applicable to non-aboriginal communities that are small and/or remote.

This document is Module 5 in a series, and may be used in conjunction with Modules 1-4. Module 1 is a slide presentation that introduces tabletop exercises; Module 2 provides exercise planning and development tools, including key templates and guidelines; Module 3 is an extensive list of references for pandemic planning and exercising; and Module 4 is a general exercise builder that provides exercise scenarios and alternate questions.

Objectives

This module provides the framework for a pandemic influenza tabletop exercise within an aboriginal community. The community exercise could be adapted to achieve any of the following objectives:

1. provide an opportunity to review plans and/or procedures for responding to a pandemic emergency;
2. engage elected leaders and other key decision makers on the issue of an influenza pandemic;
3. identify key issues and/or gaps related to pandemic planning;
4. promote interaction and linkages among organizations and programs likely to be involved in a pandemic event;
5. review logistics preparedness related to a pandemic emergency; and/or
6. enhance understanding of public health measures required during a pandemic emergency.

Background

Communities across Canada have been preparing for an influenza pandemic, in collaboration with their local government and non-government supporting organizations. Exercising of pandemic plans is a key step in the preparation and validation process.

Aboriginal communities also need to prepare, but may need to consider factors in this planning beyond those of other Canadian communities, including the distinctiveness of culture, value systems, jurisdictional differences, economics and community infrastructure relative to the rest of the Canadian population. Many First Nations, Inuit and Métis communities are also small or remote, factors that need to be considered in any emergency planning.

Accordingly, the development of a pandemic influenza tabletop exercise must be adapted to the unique characteristics of the community for which it is designed. Development of the exercise will require the input, understanding and direction of the community and its leaders.

A holistic approach to health has always been the preferred approach for aboriginal communities, and planning for exercises must recognize this principle. Each community should be considered a unique cultural entity in the planning and conduct of the exercises, and the structure of the community leadership and administration must be recognized and respected. Pandemic planning is also a part of overall emergency planning for a community, so pandemic exercises should fit into an overall schedule of emergency planning and exercising.

The scenarios and questions in this module have been developed considering the special characteristics of aboriginal communities. For example, the culture of a community must be considered in emergency planning, including communication styles and preferences, views on illness and health, and roles of elders or traditional healers. There may also be jurisdictional factors that need to be accounted for, such as for some First Nations communities who obtain primary health services from the federal government. This exercise builder aims to provide questions that pandemic planners can choose from that relate to their particular situation.

Remoteness Factor

Along with issues of culture and jurisdiction, many aboriginal communities must also consider pandemic planning challenges that result from being remote. Among the issues that may need to be considered are:

1. timely transportation of medical supplies from a central depot;
2. lack of available human resources in the community;
3. lack of suitable storage capacity (for vaccines or supplies);
4. difficulty in obtaining timely information;
5. transport of critically-ill patients to treatment;
6. effects of weather on movement of people and supplies in or out of the community.

Suggested Exercise Structure

The scenario and situations within the exercise framework in Section 2 are designed for a tabletop exercise that can be completed within one working day.

There is no set number of participants, but the framework would be most suitable for a small tabletop exercise of 5-15 players, including community leaders and individuals with responsibility for emergency preparedness. In small communities, participants may each assume more than one role during the exercise, according to their responsibilities in the community.

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Section 2 – Exercise Framework

General

This section contains an exercise framework which planners can use to develop and conduct a simple pandemic influenza tabletop exercise suitable for their own community.

The framework consists of an adaptable exercise scenario, with an opening narrative to set the stage, a series of situation summaries, and a number of related key questions (also referred to as ‘injects’) which can be used to facilitate the discussion of the scenario. Planners should select injects which apply to their own community, and also consider the additional questions provided in Appendix 1 for alternate inject questions.

The exercise covers the onset of the pandemic outside Canada, the first wave in Canada and the subsequent inter-wave period, as illustrated in the diagram.

Opening Narrative

For the purpose of the exercise, a fictional strain of influenza virus is used. It is assumed to be transmitted between humans primarily by droplet transmission (coughing and sneezing) and by indirect contact through unwashed hands and articles previously handled by an infected individual.

The virus can survive for up to 48 hours on hard surfaces and up to five minutes on exposed skin. Infected individuals can transmit the virus to others for up to five days after infection.

An outbreak of respiratory virus develops in a Central American country. There are a number of cases of severe respiratory illness. Surveillance in the surrounding areas is being increased and new cases are being identified.

Following investigation, the World Health Organization (WHO) determines that the virus is a new strain of influenza that appears to be capable of transmitting easily between people.

New cases are then reported in a second and third country in the region; both in Central America.  Although cases are present in all age groups, young adults appear to be the most severely affected and some fatalities are reported. WHO declares that the world is at Pandemic Level 4 (see Table 1).

 

Phase	Significance	Level
Inter-pandemic phase New virus in animals, no human cases.	Low risk of human cases	1
	Higher risk of human cases	2
Pandemic alert New virus causes human cases.	No or very limited human-to-human transmission	3
	Evidence of increased human-to-human transmission	4
	Evidence of significant human-to-human transmission	5
Pandemic	Efficient and sustained human-to-human transmission	6

 

One month after the initial reports, influenza cases have now appeared in several South American and Caribbean countries and fatality rates are increasing. No cases have yet been reported in the United States or Canada. WHO declares Pandemic Level 5.

Quarantine stations at Canadian ports of entry and provincial health authorities are on the alert for passengers arriving with signs of respiratory illness.

The possibility of a pandemic is in the headlines in all major newspapers, and is the lead story on major news networks. An advisory has been issued to aboriginal communities, providing information about the situation and reminding community leaders about protective measures that should be taken.

Situation Summaries

The following pages contain five Situation Summaries that set out a scenario to follow on the opening narrative, and provide some questions to encourage discussion.

Exercise planners and facilitators may use the Situation Summaries ‘as is’ or may adapt them to their specific community. The number of summaries used will depend on the time available and the amount of time Facilitators wish to allocate to discussion.

Additional discussion questions are provided in the Inject Inventory at Appendix 1. These may be added or substituted as appropriate to the community and the exercise objectives.

Specific answers to the questions are not provided, as answers will depend on the community and whether or not it has a current pandemic plan. Notes for Exercise Facilitators are provided in Appendix 4 to assist in guiding the discussion, however it is important to understand that these notes are not prescriptive. Management structures and circumstances will vary among communities and the notes will not apply in all situations.

Situation Summary 1

Time for Consideration: 20 minutes

Time for Discussion: 40 minutes

There have been media reports that the influenza initially reported in Latin America is now present in Canada, having been carried by airline passengers arriving at international airports across the country.
 
Local outbreaks of a flu-like illness are being reported in several cities in your province/territory, however since it is the flu season it is not yet clear if at least some of the reported cases are simply the normal seasonal flu activity. Seasonal flu vaccines are available at clinics.

Members of your community are asking questions about pandemic preparedness and whether they are in danger. There is confusion about whether the ‘normal’ flu shot will provide protection if a pandemic is imminent.

Key Questions – Situation Summary 1

1. What is the critical information that your community requires to prepare properly and to keep all community members advised of the situation as it unfolds?
2. Where will this critical information be obtained?
3. How can this critical information be passed accurately and quickly to members of the community?
4. What steps should your community take now (at the community and the individual or family level) to prepare for the possibility of an imminent influenza pandemic?
5. What additional resources, if any, can you expect from your supporting health services agency?

Situation Summary 2

Time for Consideration: 20 minutes

Time for Discussion: 40 minutes

Pandemic influenza has reached your community and several families have members who are displaying symptoms.

The local health services agency has sent out a communication regarding the pandemic which advises that the seasonal flu shots are not effective against the new strain and urges communities to activate their pandemic plans. There is not yet a vaccine against the pandemic strain of influenza.

Antiviral medications are available for people who are ill with flu symptoms. These should be taken within 24-48 hours of first experiencing symptoms to be effective in minimizing the severity of the illness. Community members who have risk factors for severe illness have been advised to seek treatment at the initial onset of symptoms.

Key Questions – Situation Summary 2

1. What is your plan for community members to access antiviral medication? Do you need to consider storage and distribution? Do you need to consider transporting community members to their health provider?
2. How will information be provided to the community about the availability of antiviral medications and their use?
3. What alternate care arrangements are in place for community members who are not well enough to look after themselves?
4. How will community members who have influenza-like symptoms be separated from other members of the community if this is the guidance received from public health officials?
5. What should be done at this stage to help the community emotionally and spiritually to cope with the potential effects of a pandemic, including the possibility of severe illness or death of a significant number of its members?

Situation Summary 3

Time for Consideration: 20 minutes

Time for Discussion: 40 minutes

The WHO has declared Pandemic Level 6, and pandemic vaccine production has started. An influenza pandemic in Canada has been declared by the Chief Public Health Officer, and the effects are being felt throughout your province/territory.

The virus has been confirmed in your community. Most of the ill community members are being cared for at home by family and community volunteers.

Services such as physician visits and medical transportation, including air ambulance, are disrupted. Reports indicate that hospitals are reaching capacity. Antiviral medications are available but no vaccine has been produced yet.

Currently there is one nurse available for the community but she had had to prioritize her activities. Your health manager is ill and confined to his home.

Community members have been encouraged to practice self care activities and be as independent as possible, however some community members require urgent medical attention. Some members who normally reside outside the community are returning home to be with family at this difficult time.

Key Questions – Situation Summary 3

1. What should the local health services agency do to assist the community in view of the decrease in delivery of regular services?
2. How should community members be kept advised of changes to normal medical services and procedures?
3. What steps should the community take to ensure that the local health services agency is aware of the situation and provides the maximum support possible?
4. How will your community promote and provide information about self care activities for individual households?
5. What arrangements should be made for family members arriving from outside the community?
6. What can be done to assist the lone nurse working in the community, to make sure emergency services can still be provided and the nurse can get adequate rest?
7. What services are the most critical for your community to maintain during this time?  What services are less critical?  How will business continuity and essential services be maintained?

Situation Summary 4

Time for Consideration: 20 minutes

Time for Discussion: 25 minutes

Twelve weeks have passed since the start of the pandemic. The first shipments of the vaccine are now available and ready for distribution within your province/territory.

Your community has been advised by the local health services agency that the vaccine is being shipped and immunizations can begin shortly. It is suggested that communities make the necessary preparations for their members to be immunized.

Key Questions – Situation Summary 4

1. How and where will community members be vaccinated? How will they be notified?
   
2. How will your community ensure that other vulnerable individuals, such as shut-ins, are vaccinated?
   
3. If vaccines are shipped to your community, what arrangements need to be made for storage?
   
4. If vaccines are shipped to your community, who can give vaccinations and are there others who could be trained to do so if necessary?
5. Who is responsible for keeping records of who has been vaccinated and who still needs to be vaccinated?
6. How might your plans be affected by bad weather?

Situation Summary 5

Time for Consideration: 20 minutes

Time for Discussion: 25 minutes

Fifteen weeks have now passed since the start of the pandemic in Canada and the number of ill persons in the community has begun to decline. This is known as the ‘inter-wave period’ and, although there will be some respite, it can be expected that a new wave of infections will start sometime in the next three to six months.

Antiviral medications and vaccines are now readily available.

Key Questions – Situation Summary 5

1. The turnout at vaccination centres is lower than expected as community interest shifts away from the pandemic during the inter-wave period. What can you do to increase awareness of the likelihood of a recurrence and convince community members who require vaccinations to obtain them?
   
2. Community leaders, health workers and other key community members have been working flat out during the pandemic period and badly need a break. What arrangements can be made to provide this break during the inter-wave period?
   
3. What key activities should be undertaken by community officials now to prepare for the expected second wave of illness?
4. What should individuals and families in the community do to prepare themselves for the second wave?

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