WINNIPEG/MONTREAL -- The coronavirus pandemic is racing through Canada's remote and rural regions, as isolation, a crucial buffer during the first wave, left their limited healthcare systems vulnerable once the virus arrived.

The latest spread opens a new front for the world's second-largest country by area as it prepares for a logistically difficult vaccination program with COVID-19 infections now threatening to overwhelm hospitals.

Though the virus spared many small communities in the spring, it is now exposing their deficiencies: from their long distances away from critical health equipment, to high levels of underlying sickness and cramped housing.

"We're playing cards with half a deck," said Health Minister Lorne Kusugak of the Arctic territory Nunavut.

Nunavut's government has sent additional health workers, along with Canadian Red Cross personnel, to support the six nurses who work in Arviat, a town of 2,600 people, said its mayor, Joe Savikataaq Jr. The hamlet accounts for 49 of Nunavut's 51 active cases.

"Everyone knew that if it did come here the numbers would rapidly increase," Savikataaq Jr. said.

He blamed housing shortages and Arviat's ties to hotspot Winnipeg, Manitoba, to which residents travel for routine healthcare.

Mike Stopay, director of Pacer Air Freight, said his company has delivered more testing materials in recent weeks to northern communities.

Nunavut has one of the highest rates of coronavirus cases in the past 14 days among Canadian provinces and territories - 222 infections per 100,000 people.

Savikataaq Jr. said it's premature to plan for distribution of a vaccine. "At this point we're still fighting a fire."

DOG SLED DELIVERIES

Vaccine shipments would need to transfer on small, multiple flights to reach each remote community, Stopay said. Some airports are so remote that dog sleds and snowmobiles transport deliveries to local hospitals, he said.

Nunavut's Chief Public Health Officer Michael Patterson said ultra-cold storage required for Pfizer's COVID-19 vaccine makes it impractical for distribution across the territory.

He said Moderna's competing vaccine would comprise "most or all" inoculations in Nunavut, which is on a priority list for early shipments.

Pfizer's shots could ship within 24 hours of Canadian approval, pharmaceutical company BioNTech said on Sunday. The first batch are expected to arrive in Canada this month.

Manitoba has purchased 20 portable ultra-cold freezers and intends to use a small number of "super sites" to vaccinate people around the province.

Grand Chief Arlen Dumas of the Assembly of Manitoba Chiefs said that regional approach is poorly conceived as forcing people to travel during a pandemic raises health risks. Indigenous communities already have a system for transporting medication, including by air, that would work for vaccines, he said.

'LEFT TO FEND FOR OURSELVES'

One infected Saskatchewan visitor to a late-October wedding at Opaskwayak Cree Nation set off transmission quickly through the northern Manitoba community of 3,800 people.

Eventually, every one of the 28 seniors at Opaskwayak's care home was infected, said Onekanew (Chief) Christian Sinclair.

A dozen soldiers arrived to support care home staff and Opaskwayak installed checkpoints to limit visitors.

"What this showcases is the gaps in our medical system," Sinclair said. "We鈥檙e left to fend for ourselves."

Northern Manitoba patients who need critical care are transferred to Winnipeg, said Amy McGuinness, spokeswoman for Shared Health, a Manitoba government organization.

The government has parked a refrigerated trailer in The Pas, adjacent to Opaskwayak, to temporarily store bodies. The local morgue and funeral home both hit capacity after a funeral ban led to funeral homes storing bodies longer than usual, she said.

In Shamattawa, a Manitoba First Nation of 1,000 reachable only by ice road and air, 50% of COVID-19 tests are positive, said member of Parliament Niki Ashton.

Its infections include two entire households, of 12 and 15 people, she said, adding that an infected woman in her 60s with underlying diabetes and tuberculosis was flown south for intensive care. The Canadian Armed Forces deployed six soldiers to help the community.

TRIAGE IN CARS, 16-HOUR DAYS

Southern rural communities are also swamped.

In hard-hit Steinbach, Manitoba, severely ill patients must travel elsewhere because it has no intensive care beds or staff trained to operate ventilators, said Dr. Paul Foster.

"Finding an ambulance or helicopter to transport them is a challenge," said Foster, who became infected himself. "We're getting close to where we're going to see bad outcomes."

The virus multiplied so fast that Steinbach nurses at times triaged patients in their cars.

In Quebec's Saguenay Lac-Saint-Jean, which produces one-third of Canada's aluminum, the region raised alarm last month when it recorded more daily cases than Montreal, which has eight times the population.

Julie Bouchard, president of a Saguenay nurses' union local, said some nurses were working up to 16 hours a day, due to absent staff and limited capacity.

In Nunavut, Health Minister Kusugak said the immediate challenges are pressing.

"You're expecting people to isolate in a house with a dozen people ... with one washroom barely bigger than a broom closet," he said.

"We just hope that this doesn't get any worse."

Editing by Denny Thomas and Aurora Ellis