The Nevada State Health Division’s collaborative relationship with area American Indian tribes and the addition of a tribal liaison position led to a successful H1N1 response in this population. As the H1N1 virus started to affect local populations, the Nevada State Health Division took an aggressive approach to working with the state’s health authorities and tribes.
In the summer of 2009, the Nevada State Health Division hired a tribal liaison to work with tribes on public health preparedness issues. The liaison, Chad Williams, is a former tribal leader with skill, knowledge, and practice in working on tribal health issues at tribal, state, and federal levels. His experience includes working with the National Indian Health Board, National Congress of American Indians, and Indian Health Service. As tribal liaison, he implemented the state’s plan for tribes. This included building connections by attending meetings, such as the Inter-Tribal Council of Nevada, Nevada Indian Health Board, Indian Health Service, and Tribal Emergency Response Committee, to listen and provide information. The liaison role provided tribes with a voice in the health division, and evolved into an advocacy role for tribal needs.
From the beginning, the liaison worked with Nevada tribes on writing point-of-dispensing (POD) plans. This was a challenging effort because many of the smaller tribes lacked the resources to write detailed plans. A basic POD plan template was developed to assist tribes. The tribal liaison attended meetings with tribes, adjacent rural communities, and IHS clinics, and worked with regional emergency personnel to assure that all tribes had adequate vaccination plans in place.
The Nevada State Health Division has numerous employees who are knowledgeable on the language and protocols needed to build thriving collaborations. For example, the Public Health Preparedness Program provided mass vaccination trainings for the tribes and other rural communities of Nevada. The State Health Officer, Dr. Green, attended the Indian Health Service officers meeting to discuss strategies to combat the H1N1 outbreak with tribal doctors, nurses, and pharmacists. Dr. Green also explained how to compound Tamiflu to make pediatric doses during the shortage of pediatric oral suspension. Luana Ritch, Bureau Chief for Health Statistics, Planning and Emergency Response, also attended meetings with tribes as the plans for vaccine distribution were developing. Finally, the Nevada State Health Division collectively met with tribes to discuss vaccine safety and necessary supplies coming through the state. Sharing information and involving the tribes in decision-making made tribal members more comfortable with working with the state and forged stronger relationships.
Another key factor in the relationship between the tribes and the state was the Indian Health Board of Nevada (IHBN). IHBN is an organization whose board of directors is comprised of tribal chairmen and health directors from Nevada tribes. They are funded through the state Public Health Preparedness Program, which receives funds from the Assistant Secretary for Preparedness and Response and the Centers for Disease Control and Prevention grant programs to serve American Indian populations. Through these funding sources, IHBN has been able to provide equipment and services at rates that are proportionately the same as the health districts and counties of Nevada.
IHBN did not represent all of Nevada’s tribes; therefore, other efforts were made to include all tribes in the decision-making process. These additional efforts included engaging federal Indian Health Service Clinics and several tribes that reside on the state borders of Idaho, Oregon, Utah, and California. This included making contacts with public health preparedness programs in other states to coordinate coverage. The state reassured tribes in border regions that their needs were being met by Nevada or other states. Tribes were encouraged to contact the Nevada State Health Division with any unmet needs and efforts were made to fill any gaps.
In preparation for the influenza season, the tribal liaison began to prepare the tribes by checking their antiviral stockpiles and distributing antivirals to those in need. In the spring of 2009, the tribes were distributed 75mg dosages of Tamiflu and 5mg dosages of Relenza; by the fall, the state was able to deliver 30mg and 45mg dosages for smaller patients. This was done to make it easier for tribal pharmacists to compound the antiviral into a pediatric suspension.
At the same time, efforts were started to make sure all tribes were registered with the state of Nevada’s Immunization Program to ensure they received an adequate supply of vaccine throughout the response. Special attention was focused on the tribal enrollment forms, as they were coming in at the same time and location as enrollment forms from all providers throughout the state. This was also the process by which the vaccines would be ordered, so the tribal providers were separated out and inserted into the formula Nevada used for vaccine distribution. During this process, it was necessary to change some of the existing, customary procedures to satisfy tribal needs. This procedural change involved allowing the tribal liaison to work as the central point of contact for the tribes, the Public Health Preparedness Program, and the Immunization Program. The ability for the tribal liaison to cross between the programs to follow up on tribal requests was a central part of Nevada’s successful vaccine distribution to tribes.
Clearly, the success that Nevada has seen in working with tribes has come from many factors. The health division maintains open communication and honors its commitments to the tribes, as well as providing access to its programs, staff and administration, and honoring its government-to-government relationship. The addition of a tribal liaison with knowledge of tribal governance, health systems and collaborations has greatly enhanced Nevada’s ability to better meet tribal communities’ needs. The liaison position gave the tribes someone with whom they were comfortable working, furthering the development of a good relationship with the Nevada State Health Division. This relationship greatly improved the ability to address tribal needs during the H1N1 outbreak.
Nevada’s tribal liaison continues to work with the Nevada tribes on current needs and to prepare for a possible third wave of H1N1. At the same time, outcomes are being closely evaluated from the first two waves to determine what adjustments need to be made.