Uncovering SARS-COV-2 vaccine uptake and COVID-19 impacts among First Nations,Inuit and Métis Peoples living in Toronto and London,Ontario

Background:First Nations, Inuit and Métis Peoples across geographies are at higher risk of SARS-CoV-2 infection and COVID-19 because of high rates of chronic disease, inadequate housing and barriers to accessing health services. Most Indigenous Peoples in Canada live in cities, where SARS-CoV-2 infection is concentrated. To address gaps in SARS-CoV-2 information for these urban populations, we partnered with Indigenous agencies and sought to generate rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in 2 Ontario cities.Methods:We drew on existing cohorts of First Nations, Inuit and Métis adults in Toronto (n = 723) and London (n = 364), Ontario, who were recruited using respondent-driven sampling. We linked to ICES SARS-CoV-2 databases and prospectively monitored rates of SARS-CoV-2 testing, diagnosis and vaccination for First Nations, Inuit and Métis, and comparator city and Ontario populations.Results:We found that SARS-CoV-2 testing rates among First Nations, Inuit and Métis were higher in Toronto (54.7%, 95% confidence interval [CI] 48.1% to 61.3%) and similar in London (44.5%, 95% CI 36.0% to 53.1%) compared with local and provincial rates. We determined that cumulative incidence of SARS-CoV-2 infection was not significantly different among First Nations, Inuit and Métis in Toronto (7364/100 000, 95% CI 2882 to 11 847) or London (7707/100 000, 95% CI 2215 to 13 200) compared with city rates. We found that rates of vaccination among First Nations, Inuit and Métis in Toronto (58.2%, 95% CI 51.4% to 64.9%) and London (61.5%, 95% CI 52.9% to 70.0%) were lower than the rates for the 2 cities and Ontario.Interpretation:Although Ontario government policies prioritized Indigenous populations for SARS-CoV-2 vaccination, vaccine uptake was lower than in the general population for First Nations, Inuit and Métis Peoples in Toronto and London. Ongoing access to culturally safe testing and vaccinations is urgently required to avoid disproportionate hospital admisson and mortality related to COVID-19 in these communities.

Multigenerational colonial policies that aimed to assimilate First Nations, Inuit and Métis Peoples and appropriate land and resources have led to inequities across most major health outcomes for First Nations, Inuit and Métis living in urban, rural and remote geographies compared with non-Indigenous people in Canada, as well as striking gaps in access to equitable and culturally safe health care.^1,2More than half of Indigenous Peoples in Canada live in urban areas.³ In cities, jurisdictional complexities, including structured exclusion from potentially beneficial government programs, combined with persistent and growing inequities in the distribution of urban health and social resources, have exacerbated pre-existing Indigenous compared to non-Indigenous health inequities during the COVID-19 pandemic.⁴ Dense and multigenerational social networks; barriers in access to culturally safe health care; and a disproportionate burden of poverty, chronic disease and inadequate housing^5–7 create conditions for the spread of SARS-CoV-2 among First Nations, Inuit and Métis living in urban areas in Canada.The quality, comprehensiveness and accessibility of First Nations, Inuit and Métis health and social statistics in Canada, particularly for those living in urban and related homelands, is a critical problem.^4,8 A lack of accurate, inclusive and culturally safe identification processes for First Nations, Inuit and Métis in health service and public health data systems,⁸ and inadequate engagement of Indigenous leadership in the governance and management of their health information, which is essential,^8,9 contribute to this problem. As a result, Indigenous health policy and service responses are commonly implemented without accurate and reliable population-based sociodemographic and health outcomes data.Although First Nations health authorities mobilized quickly to document SARS-CoV-2 incidence and COVID-19 morbidity and mortality in First Nations communities in the early pandemic period, and vaccination campaigns led by First Nations were successful,^10,11 published reports of SARS-CoV-2 outcomes for First Nations, Inuit and Métis living in urban and related homelands remain unavailable more than 2 years into the COVID-19 pandemic.Since 2008, our research team has partnered with urban Indigenous health service providers to address gaps in health and social information for First Nations, Inuit and Métis living in urban and related homelands to produce representative, population-based, community-controlled health information for urban First Nations, Inuit and Métis,^5,6,12 by successfully applying respondentdriven sampling (RDS) methods to generate valid, population-representative cohorts of First Nations, Inuit and Métis adults.¹³ Drawing on 2 of these cohorts (Our Health Counts Toronto and Our Health Counts London), which had existing linkages to health care databases at ICES, we sought to generate accurate and valid rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in Toronto and London, Ontario, and to compare these rates with those in the general populations in each city and Ontario.