Setting the Context

Public Safety Canada has reported that natural disasters are increasing in frequency and severity across Canada. [1] As a result of climate change, Canadians can expect to experience more extreme weather events such as heat waves, heavy rainfalls and related flooding, droughts, forest fires, serious winter storms, hurricanes, and tornados with greater frequency and severity than in the past.[2] Over the past decade between 2009 and 2019, there were 157 major disasters identified in the Canadian Disaster Database (CDD), including both natural and manmade disasters.[3] These include Hurricane Igor in Newfoundland in 2010, the 2011 Prairie floods, the 2011 Slave Lake fire, the 2013 Lac-Mégantic rail disaster, the 2013 Southern Alberta floods, the 2013 Toronto urban flood, the 2014 Saskatchewan and Manitoba flooding, the 2016 Fort McMurray wildfire, the 2017 Atlantic Canada telecommunications outage, and the 2017 British Columbia flood and wildfire seasons.[4] Disaster preparedness refers to the capacity to respond to a range of public health threats. In addition to natural disasters, preparedness is crucial for infectious disease outbreaks, such as the COVID-19 pandemic.

The Public Health Agency of Canada (PHAC) acknowledges that before, during and after a disaster, older adults are more vulnerable and more likely to experience adverse outcomes as a result of improper emergency planning, preparation and management, and a lack of training for health care professionals and front-line responders with regards to the special needs of the older population.[5] Research shows that older adults are always disproportionately affected, with people over the age of 60 having the highest death rates of any group during a natural disaster.[6] In 2010, for example, more than half of all deaths from the Quebec heat wave were people aged 75 and older.[7] Case studies from the World Health Organization have shown that in large scale disasters, older adults have higher mortality and morbidity. [8] For example, 71% of deaths during Hurricane Katrina occurred in people over the age of 60.[9] These outcomes have also been linked to the fact that the occurrence of a natural disaster can disrupt access to essential home and community services and have a marked impact on quality of life and independence for older adults. More recently, the COVID-19 pandemic recorded the highest number of deaths and hospitalizations among adults ages 75 years and older.[10],[11] Around 1,280 outbreaks were reported in LTC and retirement homes across Canada, accounting for approximately 80% of all COVID-19 deaths in Canada.[12],[13]  Age-related challenges such as chronic health conditions, co-morbidities, social isolation, and declines in sensory, cognitive and physical functions are also exacerbated during a disaster and can put older adults at risk of harm.[14],[15]

In emergency situations, people often come to rely on their support networks such as family, friends, and neighbours for help. A survey in 2014 conducted by Statistics Canada found that older adults were less likely to have a large support network to turn to in an emergency. While a quarter of people between ages 15 to 34 report having at least 5 people to turn to in an emergency, only 13% of older adults reported having more than 5 people to turn to.[16] A lack of support networks adds to the challenges that older adults may face during a disaster. Emergency preparation and management that includes special consideration for older adults will be important in the face of increasing frequency of crises and disasters, and their greater impact on older people. While the International Federation of the Red Cross (IFRC) released interim guidance for staff and volunteers on working with older adults during the COVID-19 pandemic, older adults and their unpaid caregivers should be provided with easy-to-access information and resources related to emergency preparedness for future pandemics.[17],[18],[19] The NIA and the Canadian Red Cross will publish 29 evidence-informed expert recommendations to improve disaster preparedness, response and recovery for older adults across Canada in their upcoming 2020 white paper.

What Are the Issues?

1. Current Federal Legislative and Regulatory Frameworks Do Not Adequately Recognize the Needs of Older Adults, and Data Collection is Insufficient
   

   Canada’s legislative and regulatory frameworks around disaster management are complex. Canada’s system of managing emergencies is a bottom-up approach, starting at local levels of government with first responders and local authorities who then request assistance from provincial and territorial governments if required. The provinces and territories can then seek assistance from the federal government if needed. The Emergency Management Act is currently the only federal legislation in place addressing emergency planning, it designates roles and responsibilities of federal departments in emergencies and identifies Public Safety Canada as a main coordinating body.[20]

   To supplement the Emergency Management Act, Canada also has an Emergency Management Framework whereby all provincial and territorial governments have agreed upon principles set out in the framework. The framework was revised and approved by federal/provincial/territorial Ministers in 2017. It establishes a common approach for a range of collaborative emergency management initiatives in support of safe and resilient communities.[21] However, each province and territory has its own emergency management process, and these vary. Neither the federal framework nor the federal legislation contains a clear recognition of the unique needs of older adults in emergency management.

   Currently data collection regarding disasters in Canada is managed by Public Safety Canada in the Canadian Disaster Database (CDD). The CDD is a publicly accessible website containing information on disasters since 1990. The database contains information on where and when a disaster has occurred, who was affected and a rough estimate of the cost which could include various government (federal, provincial, territorial) relief and recovery payments, municipal costs, insurance claims, and cost of supplies and assistance provided by non-governmental organizations.[22] While the database does provide information on injuries, evacuation and deaths associated with a disaster, it does not break down data demographically to understand which particular sub-populations are being most impacted and in what areas services may need to be more tailored to better meet the unique needs of communities.[23]

2. Older Adults with Sensory and Physical Impairments, Chronic Health Issues and Dementia Require More Support During Evacuation
   

   There are many challenges experienced in evacuations during emergencies. Many older adults still live in regions or communities with little or no capacity for the provision of routine emergency services, and no system or capacity to locate older people who are unable to be evacuated from the area.[24] In addition to this, older adults may be isolated or housebound, frail, and may have continuing care needs that cannot be easily met during an evacuation putting their health at risk by making evacuation especially difficult.[25]

   In particular, older adults with chronic health issues, sensory and/or physical impairments and dementia require more support during evacuation. Impairments in vision and hearing can affect an older adult’s ability to effectively perceive an emergency warning or to respond appropriately during a disaster. Older adults with sensory impairments may have difficulty hearing disaster updates, emergency instructions and communicating in noisy environments.[26],[27] Individuals with visual or mobility impairments may experience challenges in navigating surroundings and unfamiliar places during evacuation, resulting in a slower response.[28]

   For individuals with chronic health issues, power outages can interrupt medical interventions such as the ongoing operation of life support devices and medications that require refrigeration. Evacuation for older adults with dementia can be particularly challenging. There are over half a million Canadians living with dementia with approximately 25,000 new cases diagnosed every year. The Alzheimer’s Society of Canada predicts that by 2031, 937,000 Canadians will be living with dementia, which represents a 66% increase from 2018.[29] Dementia impacts cognitive functions causing decline in memory, and impairment in ability to filter information making it difficult for people with dementia to identify a disaster situation, comply with instructions for disaster preparedness, adapt to changes in routine or environment or follow emergency warnings and instructions.[30] Older adults living with dementia can also experience behavioral problems that may become exacerbated or rapidly deteriorate due to interruption of medication during an emergency.[31] In addition, dementia can be compounded by delirium, whereby there is an onset of a state of confusion resulting in a lack of ability to think clearly, pay attention, and maintain awareness of surroundings.[32]

   It is necessary for those who provide care who usually assist individuals with dementia in carrying out activities of daily living (ADLs) to have proper knowledge of emergency management principles and procedures when caring for an individual living with dementia. Those who provide care need to be aware of best practices for mitigating upset feelings, anxiety, wandering, confusion and agitation. Overall, there are many complex health needs prevalent amongst the ageing population that must be considered in emergency management to ensure the safety and wellbeing of this population during a disaster.

3. Geriatric Education and Training for Health Care Professionals and Emergency Response Personnel are Needed
   

   Geriatric education and training in disaster management are also important for health care professionals and emergency management and response personnel. Geriatric training will ensure that health care professionals and emergency response personnel understand the needs of older adults and best practices for assisting older adults with complex needs during a disaster. It is important for health care professionals and first responders to be trained in dealing with cognitive decline and how to mitigate associated impacts, especially in situations where medical records and resources are unavailable.[33]

   In a 2012 study assessing the disaster knowledge of nurses working in a nursing home, the participants had no formal disaster planning and response training and scored 28% on average based on their proficiency ratings.[34] After completing training, however, their proficiency ratings increased to 76% with a majority of participants reporting that they planned to include the training in future workshops and courses for students, colleagues and clients. This study suggests that health care professionals would benefit from geriatric training when caring for older adults in disasters.[35]

   In a 2008 report by PHAC, Building a Global Framework to Address the Needs and Contributions of Older People in Emergencies, it is outlined that the development of integrated training approaches are needed for emergency managers, responders, service providers, and volunteers to gain a firm understanding of the special needs and capacities of older people.[36] The report recommends that training be built on expertise from the emergency management, health, and gerontology sectors with input from allied agencies and service sectors such as social services, home care, community care, and nursing homes, along with the perspective of older adults as well.[37]

4. Current Licensing Procedures for Out of Province Support Causes Delays in the Availability of Services from Health Care Professionals

   During disasters or emergencies, rapid response and deployment of medical and nursing services personnel is vital and often lifesaving. In Canada, licensing of medical and nursing professionals is provincially and territorially regulated with all 13 jurisdictions having separate licensing requirements and fees.[38] In emergencies, these jurisdictions usually utilize their own medical service personnel resources first; however, if their resources are overwhelmed, out of province or territory resources can be activated through PHAC. PHAC has the mechanisms to call on extra resources, and clear health professionals; however, additional measures can be undertaken to remove licensing procedure barriers that result in the delay in availability of health care professionals to ensure a more rapid response, such as a national licensure process for medical and nursing personnel. To better address this issue in the United States, an Interstate Medical Licensure Compact (IMLC) has been agreed to by 29 states and the District of Columbia[39] while an enhanced Nursing Licensure Compact (eNLC) has been agreed to by 34 states[40], and 20 states are licensure compact states for emergency management services (EMS) personnel[41]. These help create a voluntary expedited pathway to licensure for qualified physicians, nurses, and EMS personnel who wish to practice in multiple states. These compacts allow them to quickly and easily respond to provide medical and nursing services during disasters in other compact states.

Evidence-Informed Policy Options

In collaboration with the Canadian Red Cross (CRC), the NIA conducted a systematic review of existing gaps in emergency and disaster preparedness and management efforts for older Canadians. After extensive consultation with experts, the following policy recommendations were made to improve emergency and disaster preparedness and response for older Canadians.

1. A National Advisory Committee Should Be Established to Inform Emergency and Disaster Preparedness Strategies for Older Canadians
   

   The Government of Canada should look for ways to embed a recognition of the needs of older adults and their caregivers in emergency management planning in Canada. It is recommended that a federal advisory committee be created to inform the development of a disaster/emergency preparedness program and strategies for older Canadians at the national level. Federal groups such as Public Safety Canada may also have a role in the management and operation of this committee. The representation of older adults and their caregivers must be included in the committee to ensure the perspectives of older adults are reflected. The committee should work to identify strategies to support emergency preparedness and infection/disease prevention at various levels – older adults and their caregivers, community-based services and programs, care institutions, provinces and territorial governments. This work could be supported by enhancing current data collection procedures that feed into the Canadian Disaster Database (CDD) to collect more demographic information, which would enable a better understanding of which particular sub-populations are being most impacted to better inform what areas services may need to be more tailored to better meet the unique needs of communities.

2.  Provincial and Territorial Governments Should Require Congregate Living Environments Such as Nursing Homes, Assisted Living Facilities, and Retirement Homes to Regularly Update and Report Their Emergency Plans
   

   Current rules and regulations around emergency and contingency plans differ across the country. It is recommended that all provinces and territories create and enforce legislation that will mandate congregate living spaces for older adults to regularly update and report their emergency and contingency plans in the event of an emergency or disaster in accordance with Public Safety Canada’s 2019 Report Emergency Management Strategy for Canada: Toward a Resilient 2030.[42] Consultation with experts on this issue concluded that the plans should include the provision of backup generators in the event of power outages and coordinated plans with relevant community agencies in the event that an evacuation is required. While in Ontario, the 2017 Long-Term Care Homes Act[43] mandated all nursing homes to have air conditioning and back-up generators to provide power for all support and life-supporting equipment in the case of an emergency, not all provinces and territories have included this in their legislation.

   Care institutions and other organizations should strive to develop comprehensive emergency plans that include effective response strategies for protecting older adults against communicable disease outbreaks and reflect evidence-based standards supported by organizations such as Infection Prevention and Control Canada (IPAC)[44],[45]<[46],[47] To ensure effective pandemic response, community-based programs that provide in-home health and personal care for older adults should integrate strategies that minimize unnecessary personal contact and leverage resources (e.g. personal protective equipment such as gowns, masks, gloves, hand sanitizer etc.) in their emergency preparedness plans and protocols.[48],[49],[50] An outline of staffing levels that should be maintained during emergencies to minimize care and/or service interruptions. Care institutions should also regularly assess and address any barriers they identify that could affect the implementation of their emergency plans that build on their routine practices.[51],[52] All provinces and territories should work towards standardizing requirements for emergency plans in congregate living settings and ensure the requirements are aligned with directives outlined in their provincial/territorial pandemic and emergency plans.

3. Provinces and Territories Should Support the Creation of a National Licensure Process for Physicians, Nurses, Allied Health Professionals, and Other Emergency Medical Service Personnel to Allow Them to Easily Provide Voluntary Emergency Medical Support Across Jurisdictions During Declared States of Emergency
   

   In order to create more rapid response to emergencies where extra resources and out of province health professionals maybe required, it is recommended that all provinces and territories support the creation of a national licensure process or program for nurses, physicians, and other emergency medical service personnel who want to volunteer to allow them to provide emergency medical support across provincial/territorial boundaries during declared states of emergencies.

   In response to infectious disease outbreaks, Health care providers and emergency management and response personnel should receive training on providing geriatric care relevant to their discipline and how best to assist older adults and their unpaid caregivers before, during, and after disasters emergencies. The additional education and training should also increase their awareness of best practices and precautions to minimize the risk of infectious disease transmission or spread while responding to emergencies.[53],[54],[55],[56],[57],[58],[59]

References

[1] Public Safety Canada. (2020). The Canadian Disaster Database. Retrieved April 14, 2020, from https://www.publicsafety.gc.ca/cnt/rsrcs/cndn-dsstr-dtbs/index-en.aspx

[2] Public Safety Canada. (2019). Emergency Management Strategy for Canada: Toward a Resilient 2030. Retrieved February 16, 2019, from https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/mrgncy-mngmnt-strtgy/index-en.aspx

[3] Public Safety Canada. (2019). Emergency Management Strategy for Canada: Toward a Resilient 2030. Retrieved February 16, 2019, from https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/mrgncy-mngmnt-strtgy/index-en.aspx

[4] Public Safety Canada. (2019). Emergency Management Strategy for Canada: Toward a Resilient 2030. Retrieved February 16, 2019, from https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/mrgncy-mngmnt-strtgy/index-en.aspx

[5] Public Health Agency of Canada. (2008). Building a global policy framework to address the needs and contributions of older people in emergencies: A report based on the 2007 Winnipeg International Workshop on Seniors and Emergency Preparedness, Winnipeg, Manitoba, February 6-9, 2007. Ottawa: Division of Aging and Seniors, Public Health Agency of Canada.

[6] Centers for Disease Control and Prevention. (n.d). CDC’s Disaster Planning Goal: Protect Vulnerable Older Adults(Rep.). Retrieved February 16, 2019, from https://www.cdc.gov/aging/pdf/disaster_planning_goal.pdf

[7] Bustinza, R., Lebel, G., Gosselin, P., Bélanger, D., & Chebana, F. (2013). Health impacts of the July 2010 heat wave in Québec, Canada. BMC Public Health, 13(1), 13–56. doi: 10.1186/1471-2458-13-56

[8] World Health Organization. (2008). Older persons in emergencies: an active ageing perspective. Available at: https://www.who.int/ageing/publications/EmergenciesEnglish13August.pdf

[9] World Health Organization. (2008). Older persons in emergencies: an active ageing perspective. Available at: https://www.who.int/ageing/publications/EmergenciesEnglish13August.pdf

[10] Canadian Institute for Health Information. (2020). Pandemic Experience in the Long-Term Care Sector: How Does Canada Compare with Other Countries? Toronto: Canadian Institute for Health Information. Retrieved from https://static1.squarespace.com/static/5c2fa7b03917eed9b5a436d8/t/5f071dda1fbff833fe105111/1594301915196/covid-19-rapid-response-long-term-care-snapshot-en.pdf

[11] Government of Canada. (2020, July 16). Coronavirus disease 2019 (COVID-19): Epidemiology update. Retrieved from Government of Canada: https://health-infobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html#a5

[12] Canadian Institute for Health Information. (2020). Pandemic Experience in the Long-Term Care Sector: How Does Canada Compare with Other Countries? Toronto: Canadian Institute for Health Information. Retrieved from https://static1.squarespace.com/static/5c2fa7b03917eed9b5a436d8/t/5f071dda1fbff833fe105111/1594301915196/covid-19-rapid-response-long-term-care-snapshot-en.pdf

[13] National Institute on Ageing. (2020). NIA Long-Term Care COVID-19 Tracker. Available at: https://ltc-covid19-tracker.ca/. Updated September 17, 2020. Accessed September, 2020.

[14] Katherine M. Kosa, Sheryl C. Cates, Shawn Karns, Sandria L. Godwin & Richard J. Coppings (2012) Are Older Adults Prepared to Ensure Food Safety During Extended Power Outages and Other Emergencies?: Findings from a National Survey, Educational Gerontology, 38:11, 763-775, DOI: 10.1080/03601277.2011.645436
[15] Aldrich N, & Benson WF. (2007). Disaster preparedness and the chronic disease needs of vulnerable older adults. Prev Chronic Dis,5(1), a27. Retrieved February 16, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2248769/

[16] Taylor- Butts, A. (2014). Emergency preparedness in Canada (Rep.). Retrieved February 16, 2019, from Statistics Canada website: https://www150.statcan.gc.ca/n1/pub/85-002-x/2015001/article/14234-eng.htm

^[17] International Federation of Red Cross. (2020). Interim guidance for Red Cross and Red Crescent staff and volunteers working with older people during COVID-19 response. Internal document.

[18] Al-Rousan, T. M., Rubenstein, L. M., & Wallace, R. B. (2014, March). Preparedness for Natural Disasters Among Older US Adults: A Nationwide Survey. American Journal of Public Health, 104(3), 506–511

[19] Centre for Disease Control and Prevention. (2020). COVID-19 Guidance for Older Adults. Available here: https://www.cdc.gov/aging/covid19-guidance.html

[20] Public Safety Canada. (2019). Emergency Management. Retrieved February 16, 2019, from https://www.publicsafety.gc.ca/cnt/mrgnc-mngmnt/index-en.aspx

[21] Government of Canada. (2011). An Emergency Management Framework for Canada (Rep. No. Section edition). Retrieved February 16, 2019, from Public Safety Canada. website: https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/mrgnc-mngmnt-frmwrk/mrgnc-mngmnt-frmwrk-eng.pdf

[22] Public Safety Canada. (2018). The Canadian Disaster Database. Retrieved February 16, 2019, from https://www.publicsafety.gc.ca/cnt/rsrcs/cndn-dsstr-dtbs/index-en.aspx

[23] Public Safety Canada. (2018). The Canadian Disaster Database. Retrieved February 16, 2019, from https://www.publicsafety.gc.ca/cnt/rsrcs/cndn-dsstr-dtbs/index-en.aspx

[24] Public Health Agency of Canada. (2008). Building a global policy framework to address the needs and contributions of older people in emergencies: a report based on the 2007 Winnipeg International Workshop on Seniors and Emergency Preparedness, Winnipeg, Manitoba, February 6-9, 2007. Ottawa: Division of Aging and Seniors, Public Health Agency of Canada.

[25] Public Health Agency of Canada. (2008). Building a global policy framework to address the needs and contributions of older people in emergencies: a report based on the 2007 Winnipeg International Workshop on Seniors and Emergency Preparedness, Winnipeg, Manitoba, February 6-9, 2007. Ottawa: Division of Aging and Seniors, Public Health Agency of Canada.

[26] South Med J. (2013). Caring for elderly adults during disasters: Improving health outcomes and recovery (1st ed., Vol. 106, 94-8, Rep.). doi:10.1097/SMJ.0b013e31827c5157

[27] Cloyd, E., & Dyer, C. B. (2010). Catastrophic Events and Older Adults. Critical Care Nursing Clinics of North America,22(4), 501-513. doi: 10.1016/j.ccell.2010.10.003

[28] Lamb, K. V. (2010). An Overview: Disaster Preparedness for Gerontological Nurses. Geriatric Nursing,31(3).

[29] Alzheimer Society of Canada. (2018). Alzheimer Society of Canada: Latest Information and Statistics. Retrieved February 16, 2019, from https://alzheimer.ca/en/Home/Get-involved/Advocacy/Latest-info-stats

[30] Wyte- Lake, T., Claver, M., Griffin, A., & Dobalian, A. (2014). The role of the home-based provider in disaster preparedness of a vulnerable population. Gerontology,60(4), 336-345.

[31] Cloyd, E., & Dyer, C. B. (2010). Catastrophic Events and Older Adults. Critical Care Nursing Clinics of North America,22(4), 501-513. doi:10.1016/j.ccell.2010.10.003

[32] American Delirium Society. (2015). Patients and Families: What is Delirium? Retrieved February 16, 2019, from https://americandeliriumsociety.org/what-delirium

[33] Lamb, K. V. (2010). An Overview: Disaster Preparedness for Gerontological Nurses. Geriatric Nursing,31(3).

[34] Roush, R. E., & Tyson, S. K. (2012). Geriatric emergency preparedness and response workshops: An evaluation of knowledge, attitudes, intentions, and self-efficacy of participants. Disaster Med Public Health Prep,6(4), 385-392.

[35] Lamb, K. V. (2010). An Overview: Disaster Preparedness for Gerontological Nurses. Geriatric Nursing,31(3).

[36] Public Health Agency of Canada. (2008). Building a global policy framework to address the needs and contributions of older people in emergencies: a report based on the 2007 Winnipeg International Workshop on Seniors and Emergency Preparedness, Winnipeg, Manitoba, February 6-9, 2007. Ottawa: Division of Aging and Seniors, Public Health Agency of Canada.

[37] Public Health Agency of Canada. (2008). Building a global policy framework to address the needs and contributions of older people in emergencies: a report based on the 2007 Winnipeg International Workshop on Seniors and Emergency Preparedness, Winnipeg, Manitoba, February 6-9, 2007. Ottawa: Division of Aging and Seniors, Public Health Agency of Canada.

[38] Picard, A. (2019, January 4). Why isn’t there a single medical licence for all doctors in Canada? The Globe and Mail. Retrieved February 16, 2019, from https://www.theglobeandmail.com/canada/article-why-isnt-there-a-single-medical-licence-for-all-doctors-in-canada/

[39] Interstate Medical Licensure Compact. (2020). The IMLC. Available at: https://imlcc.org/

[40] National Council of State Boards of Nursing. (2020). Nurse Licensure Compact (NLC). Available at: https://www.ncsbn.org/nurse-licensure-compact.htm

[41] The Interstate Commission for EMS Personnel Practice. (2018). The EMS Compact. Available at: https://www.emscompact.gov/

[42] Public Safety Canada. (2019). Emergency Management Strategy for Canada: Toward a Resilient 2030. Retrieved February 16, 2019, from https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/mrgncy-mngmnt-strtgy/index-en.aspx

[43] Government of Ontario. (2017). Long-Term Care Homes Act, 2007. Available at: https://www.ontario.ca/laws/regulation/100079

[44] Inns, Thomas, Keenan, Alex, Huyton, Rita, Harris, John, Iturriza-Gomara, Miren, O’Brien, Sarah J. and Vivancos, Roberto. (2018). How timely closure can reduce outbreak duration: gastroenteritis in care homes in North West England, 2012-2016. BMC Public Health, 18.

[45] Lum, Hillary D., Mody, Lona, Levy, Cari R. and Ginde, Adit A. (2014). Pandemic influenza plans in residential care facilities.

[46] Rainwater-Lovett, K., Chun, K. and Lessler, J. (2014). Influenza outbreak control practices and the effectiveness of interventions in long-term care facilities: a systematic review. Influenza Other Respir Viruses, 8(1)

[47] Ontario Agency for Health Protection and Promotion (Public health Ontario). IPAC recommendations for use of personal protective equipment for care of individuals with suspect or confirmed COVID‑19. Toronto, ON: Queens’s Printer for Ontario; 2020.

[48] Bloomfield SF, Exner M, Carlo Signorelli C, Nath KJ, Scott EA. (2012). The chain of infection transmission in the home and everyday life settings, and the role of hygiene in reducing the risk of infection. Available at: http://www.ifhhomehygiene.org/IntegratedCRD.nsf/111e68ea0824afe1802575070003f039/9df1597d9058 89868025729700617093?OpenDocument

[49] Mills WR, Buccola JM, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M, Phipps J, White L, Howard, DHA S. (2020). Home-Based Primary Care Led-Outbreak Mitigation in Assisted Living Facilities in the First One Hundred Days of COVID-19, Journal of the American Medical Directors Association (2020), doi: https://doi.org/10.1016/j.jamda.2020.06.014

[50] Ontario Ministry of Health. (2020). COVID-19 Guidance: Home and Community Care Providers: Available at: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_home_community_care_guidance.pdf

[51] Huhtinen, E., Quinn, E., Hess, I., Najjar, Z. and Gupta, L. (2019). Understanding barriers to effective management of influenza outbreaks by residential aged care facilities. Australia’s J Ageing, 38(1)

[52] Lee, M. H., Lee, G. A., Lee, S. H. and Park, Y. H. (2020). A systematic review on the causes of the transmission and control measures of outbreaks in long-term care facilities: Back to basics of infection control. PLoS One, 15(3)

[53] Dyer, C. B. (2008). SWiFT: A rapid triage tool for vulnerable older adults in disaster situations. Disaster Med Public Health Prep, 45-50.

[54] Kraushar, M. L., & Rosenberg, R. E. (2015). A community-led medical response effort in the wake of Hurricane Sandy. Disaster Medicine and Public Health Preparedness, 354-358.

[55] Ochi, S., Hodgson, S., Landeg, O., Mayner, L., & Murray, V. (2014). Disaster-driven evacuation and medication loss: A systematic literature review. PLoS Currents, 6, currents.dis.fa417630b566a0c7dfdbf945910edd96. doi:10.

[56] Kulig, J., Pez, K., Karunanayake, C., MacLeod, M., Jahner, S. & Andres, M. E (2017). Experiences of rural and remote nurses assisting with disasters. Australasian Emergency Nursing Journal 20: 98-106.

[57] Roush, R. E., & Tyson, S. K. (2012). Geriatric emergency preparedness and response workshops: An evaluation of knowledge, attitudes, intentions, and self-efficacy of participants. Diaster Medicine and Public Health Preparedness, 6(4), 385-392.

[58] Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Routine Practices and Additional Precautions in All Health Care Settings. 3 rd edition. Toronto, ON: Queen’s Printer for Ontario; November 2012

[59] Ontario Agency For Health Protection and Promotion. Provincial Infectious Diseases Advisory Committee. Best Practices for Infection Prevention and Control Programs in All Health Care Settings, 3rd edition. Toronto, ON: Queen’s Printer for Ontario; May 2012