The Nunavut Child Health Network

1
The Nunavut Child Health Network
2
The People and the Challenge

• MRC becoming the CIHR (Canadian Institutes for
  Health Research)
• Within the CIHR, a transitional program called
  the Community Alliances for Health Research have
  been formed
• The NCHN is being planned to address the unique
  health problems of young Inuit children

3
Nunavut

• Nunavut covers 1.994 million square kilometers
  the largest landmass of any province or territory
  in the country.
• Nunavut has a birthrate more than double the
  Canadian rate 2.9 vs. 1.2 for Canada.
• 56 of the population is lt 25 years of age.
• The population by ethnic identity is 85 Inuit
  and 15 non-aboriginal.

4
Nunavut

• Many of the Inuit are unilingual, speaking
  Inuktitut or Inuinactun.
• 3 regions Baffin, Keewatin and Kitikmeot
• Total of 28 communities.
• The total population in 1999 is approx. 27,300
• Each community in Nunavut has a community health
  centre
• One hospital in Iqaluit.

5
Nunavut Burden of Illness

• The infant mortality rate in Canada's north is
  the highest in Canada
• Northern aboriginal children are at high risk for
  hospitalization requiring medical transportation.
  
• Children in Nunavut suffer from a significantly
  increased burden of illness compared with similar
  Canadian children living south of the 60th
  parallel

6
Nunavut Burden of Illness

• The increased burden of illness is possibly due
  to
• a high prevalence of smoking
• low socioeconomic status
• geographical isolation
• unstable health care infrastructure
• poor nutrition
• overcrowded housing

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Nunavut Data Collection Challenges

• Limited information on the burden of illness in
  Nunavut.
• Most health information is collected through a
  system of paper forms filled by hand at the
  nursing station following each visit.
• There are significant practical problems with
  this method

8
Nunavut Burden of Illness

• 1992 Survey of the Keewatin Region
• higher rates of hospitalization in Keewatin
  children
• higher infant mortality rates compared with other
  Canadian children
• Aboriginal infants around the world have high
  rates of hospitalization for LRTIs
• LRTIs in this population are responsible for more
  hospital admissions than all other diagnoses
  combined

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Nunavut Bronchiolitis

• Nunavut Loosely population-based rate of 296
  admissions for bronchiolitis per 1000 children lt
  1 year of age for March 1995 to February 1996.
• Ten children (12.8) had illness severe enough to
  require intubation and transfer south

10
Nunavut Smoking

• Smoke exposure in utero causes SGA, and is
  associated with prematurity and increased risk of
  respiratory tract infections
• Nunavut has the highest rate of smoking in Canada
  at 64 vs. 27 overall
• The highest rate was in the 15-24 year group
  (78)
• Prevalence of smokers in the aboriginal
  population of Nunavut is almost twice that of
  than non-aboriginal population.

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Nunavut Smoking, Adoption

• Nunavut all mothers of infants with
  bronchiolitis smoked during their pregnancies and
  all of the infants had been exposed to
  second-hand smoke at home
• 11 of 27 infants (40.1) were adopted by a
  relative
• Thirteen of the non-adopted infants were
  breastfed, whereas none of the adopted children
  were breastfed.

12
Nunavut Adoption, Breastfeeding

• The health effects of the adoption on infants and
  children in Canada's north, especially relating
  to their opportunities to breastfeed, have not
  been studied.
• Studies of other aboriginal populations have
  found that infants who were breastfed have less
  severe disease and a shorter period of
  hospitalization related to respiratory tract
  infections.

13
Nunavut Nutrition

• Nutritional deficiencies in Canadian aboriginal
  people may play an important role in adverse
  health events.
• There is clear evidence that aboriginal people
  have low intakes of many nutrients such as iron,
  vitamin D, calcium, folate, vitamin A, and
  fluoride.

14
Nunavut Crowded Living Conditions

• Risk of various infant diseases may also be
  increased by crowded living conditions
• Overcrowded conditions have been previously
  implicated in respiratory tract infections in
  other studies of aboriginal children.
• The average home of a child admitted with
  respiratory disease contained 6.4 members (Can.
  average of 2.6 and the Nunavut average of 3.9)

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Nunavut CHEO Experience

• Pediatric Datashare Data also indicates that
  LRTIs in Nunavut carry a high burden of illness
• From April 1998 to March 1999, 15 children from
  Nunavut and 28 local children with bronchiolitis
  or viral pneumonia were admitted to the CHEO PICU
• Children from Nunavut had longer PICU stays
  compared with local children and longer total
  hospital stay

16
Nunavut CHEO Experience

• Of the 15 CHEO patients during their first
  admission
• 105 MF
• 7 from Igloolik, 3 from Iqaluit, 2 each from Pond
  Inlet and Cape Dorset, 1 from Pangnirtung
• 9 RSV, 6 RSV-
• Average LOS ICU 7 days, CHEO 24 days
• No deaths
• Impression is that overall degree of illness is
  not greater
• Will follow cohort to determine complication rate
• Control group currently being studied

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Nunavut Prematurity and NEC

• Infants born prematurely are at risk for
  developing a broad range of complications such as
  necrotizing enterocolitis (NEC)
• Intestinal perforation in patients with NEC is
  the most common reason for emergency surgery in
  infancy.
• Based on patient data from the CHEO NICU,
  premature infants from Nunavut are at high risk
  for developing NEC

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Nunavut Child Health Network

• The development of a prospective data
  surveillance system
• Determination of health priorities for children
  in Nunavut through broad-based consultation
• Dissemination of health information back to the
  people of Nunavut
• The planning of population-based interventions
  aimed at improving northern children's health

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NCHN action plan

• Network for data collection, analysis and
  intervention at population level
• In Phase 1, we will enroll all children lt 2 years
  of age who are non-electively admitted or
  transferred south.
• Data will be collected relating to diagnosis,
  complications, length of stay and demographic
  information.

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NCHN action plan

• In Phase 2, we will enroll consult broadly and
  plan an intervention aimed at improving the most
  important health issue.
• We will then secure additional funding
• In Phase 3, we will administer our intervention
  and use the data collection network to assess its
  effect

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NCHN Patient Identification and Data Collection

• Study personnel will collect data regarding
  demographic information, diagnosis, length of
  stay, outcomes and adverse events
• Non-elective admissions to Iqaluit, Churchill,
  Yellowknife, Edmonton, Winnipeg or Ottawa
  Hospitals
• The specific elements for collection have yet to
  be determined.
• Data collection sheets will be completed daily
  and entered regularly into a local computer for
  collation in Ottawa by the study coordinator

22
NCHN Data Management

• A study coordinator, based in Ottawa, will be
  responsible for overall study management
  including personnel and payroll issues, data
  transfer and entry into the central database, and
  formulation of regular reports.
• Data will be analyzed in consultation with the
  Biostatistician associated with the Research
  Institute of the Children's Hospital of Eastern
  Ontario.
• Data management will be overseen by the CYCTN.

23
NCHN Community Partner

• As originally planned, The community partner of
  the NCHN will be the DHSS of the Govt of
  Nunavut.
• The Deputy Minister of Health for Nunavut has
  written a Letter of Support.
• Recent contact with the Inuit Tapirisat of Canada
  and the Nunavut Social Development Council
• Hopefully both will become Community Partners

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NCHN Collaborators

• Collaborators University of Manitoba, University
  of Alberta, McGill University, and the Aboriginal
  Health Committee of the Canadian Pediatric
  Society.
• The manager of the multiculturalism program at
  CHEO will serve as a resource
• The NCHN will be administered through the CYCTN
• CHRIMCY has been extremely helpful

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NCHN Completing the Circle

• All data will be made available to all Community
  Partners
• Quarterly reports generated by the study
  coordinator will be sent to each of the
  communities through their community health
  centres
• We represent a neutral player in any political or
  jurisdictional disputes

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NCHN Potential for Future Interventions

• This CAHR will generate data which will be useful
  in planning population-based interventions.
• Given that we believe the Inuit should set health
  priorities for their own population, these
  interventions will be undertaken only following
  extensive consultation with Inuit leaders.
  Potentially efficacious interventions and future
  strategies might include

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NCHN Potential for Future Interventions

• Determination whether Vitamin A or other
  nutritional deficiencies play a role in morbidity
  due to respiratory diseases.
• Analysis of serotypes of Streptococcus pneumoniae
  to see if these serotypes are included in the
  conjugated pneumococcal vaccine.
• Evaluation of methods to reduce exposure of
  children to tobacco smoke and whether use of such
  methods decreases morbidity due to respiratory
  and infectious diseases and premature birth.

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NCHN Potential for Future Interventions

• Determination of risk factors associated with
  prematurity and neonatal diseases
• Prospective collection of information on health
  problems common in Nunavut children but which may
  not be captured through the CAHR surveillance
  system
• Development of methods to educate health care
  workers about traditional Inuit concepts of
  health and healing to ensure health care is
  provided in a culturally appropriate context.

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NCHN Timelines

• May 2000 Results of Letter of Intent stage
  announced
• September 2000 Deadline for submission of
  proposal
• November 2000 Results of full competition to be
  announced
• Spring 2001 Possible commencement date

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NCHN Team

• Dr. David CreeryDr. Robert SlingerDr. Lindy
  SamsonDr. Doris YuenDr. Holly SmithDr. Pranesh
  Chakraborty Dr. Anna Banerji