Health Committee on March 7th, 2016

[The Chair, Liberal, Bill Casey]

Ladies and gentlemen, I call the meeting to order.

Thank you to our guests, the Public Health Agency of Canada and Canadian Blood Services. In this 42nd Parliament, you're the very first witnesses we've had at this standing committee; we waited for you.

[Voices]

Oh, oh!

[The Chair, Liberal, Bill Casey]

At any rate, we're very pleased you came.

The issue we are to talk about today is the Zika virus. All of us are members of Parliament, and all of us are hearing from our constituents. We need to have the right answers and we're hoping you can provide us with the right answers.

We'll try to go for an hour and a half. Then, if we've completed all of the questions and everybody's happy, we'll get into our steering committee report at about five o'clock.

I guess we'll start with the Public Health Agency, and then we'll go to Canadian Blood Services. Both presentations should generally go for 10 minutes. Then we'll ask questions.

Is that okay? Great.

[Dr. Gregory Taylor, Chief Public Health Officer, Public Health Agency of Canada]

Thank you very much, Mr. Chair.

Certainly, it's a privilege to be the very first witness, a double privilege. I have a very short deck. I'm going to go through the deck very quickly. I'm going to ask Dr. Matthew Gilmour, who is the head of our laboratory, NML in Winnipeg, to add to that. Those are basically the messages I have.

I'd like to start by conveying three key messages to you. The first key message is that our knowledge is rapidly evolving when it comes to the Zika virus. Many of the recommendations and activities that we're doing currently will likely change as the knowledge increases. The second key message is that the risk to Canadians living in Canada is low at this point in time. The third key message is that based on some of the science we have, we are certainly taking, and I think the globe is taking, a precautionary approach in terms of how we deal with the Zika virus.

Page 2 of the deck talks a bit about the virus, a bit about how it's transmitted. One of the key messages there is that only 20% to 25% of the people who are infected with the virus actually get symptoms. This virus has been around for a long time. It has been around in Africa and Asia since 1947 or 1950, but despite that, we don't know a lot about it, mostly because very few people actually got sick and very few people were hospitalized. It was one of those things that just happened and we didn't even look for it.

The current outbreak of the virus in the Americas is a little bit different, but the vast majority of the genome is the same. It's in a family of viruses, which I'm sure you've heard of, like dengue, yellow fever, and West Nile virus. West Nile virus is the virus that is in Canada, which makes some of the diagnostics a little bit difficult to do.

As I mentioned, there's very limited knowledge. We're learning more and more. You've seen reports of microcephaly and Guillain-Barré syndrome and that knowledge is gradually building. The diagnostics, and Dr. Gilmour will talk to those in a second, are extremely important. A key point here, though, is that there is no treatment. There is no vaccine for this virus and much research is needed.

The next slide is on the risk to Canadians. You've seen in the media that since the huge outbreak in the last several years, over 50 countries worldwide currently have a local circulation or outbreak of this virus and over 30 countries in the Americas at this time.

What's key to us, given that the risk to Canadians, as I mentioned, who live in Canada is very low, is the travelling public. You'll note from the slide that over three million Canadians travel every year to the countries currently affected in the Americas. As of March 7 there have been 20 confirmed cases of Zika in Canada. These are laboratory confirmed and these are all people who have acquired their infection outside the country. The key population that we're worried about is pregnant women and most of the remarks I'll make in the next little while are focused on them.

The next slide is Zika and pregnancy. Brazil, as you're aware, is reporting a serious spike in birth defects known as microcephaly, which is an abnormal head size associated with incomplete brain development. Along with microcephaly, there are other neurodevelopment changes that have been noted as well. This has not been proven yet and that's some of the difficulty.

There is an association of this virus. You've probably seen in the media reports of 5,000 or 6,000 new cases or reported cases of microcephaly. There's some evidence to suggest that those started before the Zika virus was actually in Brazil and there are only a few hundred that have been linked to the Zika virus. I emphasize linked. We will never have proof of this. You can't give a pregnant woman the virus just to see what's going on. They will always be observational studies, but that evidence is gradually building.

We do have evidence of the virus present in fetuses, in placentas. But does it cause the defect or does it just happen to be there? That's what is unknown.

We have special precautions with pregnant women specifically targeted. As you've seen in our travel health notices, we're advising pregnant women who are considering travelling to those countries to reconsider their travel and defer their travel at this time until the outbreak is over. If they must go, they should practice very careful mosquito avoidance techniques.

The other thing that's also new is sexual transmission. Prior to this outbreak, it was exceedingly rare, one or two cases reported globally. You've probably seen in the media a few more cases of sexual transmission. The virus seems to exist in semen. Our knowledge so far is up to about two weeks and there have been a few cases of men who have gone to these countries, become infected with the virus, and given it to women through sexual contact when they come back.

On slide 5 I'm going to talk a bit about our domestic response. Key to us is surveillance. We're monitoring the outbreak, compiling a national picture to find out what's going on, and we're certainly meeting our obligations under international health regulations.

We're a signatory to the International Health Regulations with the WHO. We're not obligated to the IHR to report on all cases of Zika that are acquired outside the country, but we are obligated if anyone acquires Zika inside Canada, or if it's associated with a birth defect.

We've been producing a lot of guidance, such as travel health notices, which I've alluded to. We have a public health notice going to the general public. We have CATMAT, the Committee to Advise on Tropical Medicine and Travel, a group of experts we've put together. They've been in existence for many years. They have produced a series of travel guides and put them on our website.

We also have laboratory testing and recommendations for Zika virus, which Dr. Gilmour will talk about in a second. You're probably aware that there's a 21-day deferral period in place for blood, cell tissue, and organ donations. My colleagues from Canadian Blood Services will speak to that in a minute.

Slide 6 talks about the diagnostic testing support, and I wanted to let you know that we have had the virus in Canada since 2013. It was isolated from a traveller who acquired it in Thailand in 2013. We kept a sample of it in our laboratory, which gave us a jump-start on the diagnostic tests for the virus. The virus was 99% identical.

Matt, do you want to add a few comments about our diagnostic support?

[Matthew Gilmour, Scientific Director General, National Microbiology Laboratory, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada]

Yes, I'd be glad to, Dr. Taylor.

First, thank you for having me in from Winnipeg. It is certainly a busy time at the National Microbiology Lab right now, because we're offering first and foremost all the diagnostic testing services for Zika virus within the country.

We're offering two different types of tests. One is a molecular test. It's a rapid test. As Canadians return from endemic areas or areas where Zika is transmitting, if they've recently come back and they're recently symptomatic, we have a test that very quickly and definitively confirms if they do have the virus. It's detecting if they still have the virus circulating within their blood or within other tissues. It's an easy test.

The other test we have is called serology, and that's a test to see if someone has been exposed to the virus in the past. It's testing someone's own immune system to see if they have produced antibodies to the virus. Unfortunately, that test is not as rapid as the molecular suites, because we're trying to detect a past infection. It could take weeks to confirm a case.

Right now, we're lucky to have both of those within our menu of testing. It's coming through collaboration with our colleagues in the States at the CDC, through having had this 2013 isolate that came through a traveller who went to Thailand.

As you expect for the NML, one of the reasons we're there is that cases of infectious disease occur in Canada and there's not a chance to diagnose them locally within a hospital or provincial public health lab, as was the case with this return traveller from Thailand who had returned with symptoms of dengue. It wasn't dengue. It was something else, so they called on the NML. The specimens came to us in 2013, and we confirmed that this was the first travel-associated case of Zika. As Dr. Taylor said, it gave us that leg-up to start doing the work and to start offering and developing some of those diagnostics.

Right now, we're offering the diagnostic testing for all the provincial public health labs. In the background we've started to do research. Some is applied research on developing new tests. Some is evaluating commercial assays. If we can get those put into place, then we can disseminate the testing capacity into provincial labs so it's not all coming into Winnipeg.

We're also beginning other research studies, such as small animal models, because if one wanted to test antivirals or candidate vaccines, you'd want to start in small animals. Other models...such as in mosquitoes. We have an entomology lab where we can start doing testing to see if the mosquitoes that are in Canada can carry this virus. We have math modellers, tele-epidemiologists, and mathematical geographers who can model if the mosquitoes that are present in Brazil and Central America have a possibility of coming to Canada and also bringing the disease to Canada.

Again, we have a variety of research means to interrogate the likelihood, which is low, of this coming to Canada and sustaining in Canada. We have research on the go to develop these animal models, which will lead to possible therapeutics, whether an antiviral or a vaccine.

That's some of the work at the NML right now.

[Dr. Gregory Taylor]

Thanks, Matt. That's great. Also within the federal family we're coordinating across several departments, we're working with the provinces and territories, and we're also engaging with the international community.

We're communicating—and this is engaging the provinces—regularly with all of our colleagues across the country, consulting experts, providing the latest information, and assembling the guidance, as I mentioned. I'm talking to the chief medical officers of health almost daily. There's a lot of angst across the land in terms of how best to report, what happens, etc. We're going on an ongoing basis. We've connected with front-line practitioners, specifically the Society of Obstetricians and Gynaecologists, the college of family practice, the pediatric society, etc.

As you can imagine, pregnant women who may be infected or are concerned they're infected have a very difficult decision to make. The CEO of the Society of Obstetricians and Gynaecologists of Canada—I've talked to her several times—says she thinks that lot of women will be deciding to terminate their pregnancies, and whether they have a positive lab or not, a lot of women are having a very difficult decision. If they aren't symptomatic and it is based on serology or antibodies, it's a very difficult test to interpret, so we're working very closely with front-line practitioners to assist them with that.

I've mentioned several federal departments. We're also connecting with Sport Canada; the Canadian Olympic Committee, specifically Dr. Bob McCormack, who is the chief medical officer of the Olympic Committee; and the Canadian Paralympic Committee to assist them in terms of making their decisions for their athletes.

Internationally, we're working with WHO, and also PAHO. Since this is in the Americas, PAHO is our main contact. We've been working very closely with them. As I mentioned earlier we're reporting cases to the International Health Regulations, to WHO, so they're aware of what's going on in Canada. The WHO has been looking for $56 million across the federal departments. We're looking at how we can best meet some of those needs.

In terms of how we can assist, some of the work the laboratory is doing.... We're considering assisting CARPHA, the Caribbean Public Health Agency. We've worked closely with CARPHA for many years now. In essence, it's several Caribbean countries that have come together to form one overarching organization to support them. We're looking at how best to support them.

I will stop there and pass it on to my colleagues.

[The Chair, Liberal, Bill Casey]

Thank you very much, and thanks for the deck. It's very clear and it gives us a lot of information.

Dr. Sher.

[Dr. Graham Sher, Chief Executive Officer, Canadian Blood Services]

Thank you very much to committee members. At Canadian Blood Services we welcome this opportunity.

I'll very briefly tell you about Canadian Blood Services to give you some context on the issue of the Zika virus. As members of the committee know, we're an arm’s-length organization within the larger health care system, supporting transfusion and transplantation medicine across the country. We are regulated by Health Canada under the Food and Drugs Act, but we are funded by the provinces and territories and the ministers of health across the country, who serve as the corporate members of Canadian Blood Services.

Our mandate is to manage the national supply of blood, blood products, stem cells, and related services for all the provinces and territories except Quebec, which has its own agency, Héma-Québec. We also manage for Canadians the national public umbilical cord blood bank. We're involved in the procurement of a variety of plasma-derived drugs for the country. We also lead an integrated interprovincial and national system for organ donation and transplantation. We look forward to talking to the committee about that at another opportunity.

We are dedicated as an organization to providing value to Canadians by improving the health outcomes of patients who depend on transfusion and transplantation by enhancing health system performance and by optimizing costs of the health system. We are an integrated pan-Canadian service delivery model, national in scope, with an infrastructure and governance model that makes us a unique part of the health fabric in this country.

I won't go into any detail with respect to Zika virus—for background, you've heard from colleagues at the Public Health Agency—other than to say that we do have a responsibility for mitigating risks to the blood supply for all viruses. Certainly Dr. Taylor referred to West Nile virus as a similar virus that emerged quite a number of years ago. At that time, we took very rapid and proactive steps to protect the blood supply against West Nile virus. Here we now face the same situation with respect to Zika virus.

What do we know about Zika virus and risks to the blood supply globally, and in particular in Canada? The transmission of Zika virus through blood transfusion was not entirely clear in the early evolution of this. More recently, there have been a couple of cases in Brazil that have strongly suggested that transfusion of blood products is indeed a route through which the virus can be spread.

One important point—certainly Dr. Devine can expand on this should committee members have questions—is that there is no licenced screening test we can put into the blood system today for Zika virus. Unlike the tests we have for West Nile, HIV, hepatitis B, and hepatitis C, there is no screening test that we can routinely do on blood donors. Blood system operators like Canadian Blood Services, in countries where Zika virus is not widely present, have had to resort to the policy of deferring as blood donors the people who have travelled to areas where Zika virus is present.

As the situation emerged, we began to see cases in Brazil in the middle of 2015; subsequently in Colombia, Mexico, Guatemala, El Salvador, Venezuela, and Paraguay by November; and in Puerto Rico by December. By January it was emerging in other parts of the Carribean.

At Canadian Blood Services, we immediately determined, given the frequency of travel of Canadians to this part of the world, that we needed to take some rapid and precautionary measures to protect the blood supply. We consulted with our international scientific and research advisory committee, a group of experts in the field of transfusion-transmitted diseases. We consulted with colleagues at Héma-Québec. We've been in regular conversation with both the Public Health Agency and Health Canada.

I echo what Dr. Taylor said, that we all recognized that the risk was small. Even if we didn't put anything in the way of a deferral policy in place, the likelihood of a transmission through blood transfusion in Canada was very low.

Nonetheless, and in keeping with the precautionary principle that underscores decision-making at Canadian Blood Services, on January 28 of this year we announced our intention to implement a formal risk-based decision-making policy with respect to Zika virus for the blood supply no later than one week after that announcement on February 5. At the time, on January 28, we publicly asked Canadians who had recently travelled to Zika-risk areas to postpone donating blood for a month until we had time to complete a comprehensive risk assessment and determine an appropriate deferral policy for the country.

Dr. Devine and her team of experts immediately began a rigorous risk-based decision-making process. It was primarily focused on ensuring the safety of the blood supply balanced with the security of the blood supply—meaning ensuring that we had enough blood to meet the needs of patients across the country.

We used all available scientific information to understand the nature of the risk and the data on travel behaviour of our donors. We developed a sophisticated risk model based on assumptions, predictions, and experience both with Zika virus as a known pathogen and similar viruses such as dengue virus.

On February 5 of this year we implemented a deferral policy of 21 days following exposure to Zika-risk areas. Héma-Québec introduced the same deferral policy. That 21-day deferral policy is based on several important criteria: an estimated risk of infection through a unit of blood in the Canadian blood system; available information on the duration of illness and residency of time of virus in the blood stream; the need for a deferral time period that aligned with our computer system so that we could implement it rapidly and effectively; the need for a simple approach that did not require changing every time another country reported Zika virus presence; a calculated impact on sufficiency of supply so we wouldn't lose more donors than could meet the needs of Canadian patients; and most importantly, the introduction of proportionate risk so as to have the right balance of safety and security of supply.

It was known to us at the time that the U.S. Food and Drug Administration was contemplating a 28-day deferral policy, as were several other countries where Zika virus may have been of concern. This concept of a 28-day deferral policy was based on calculations done by an organization in the United States known as the AABB, or the American Association of Blood Banks. Dr. Devine and I have served on the board of that organization. Their committee did two risk assessments: one for 14 days and one for 28 days. They did not do a risk calculation for 21 days. Those two time frames, 14 days and 28 days, were selected because they had been used for deferral policies for other viruses.

Their data showed that a 14-day deferral policy is likely too short from a risk mitigation point of view, so they ended up recommending a 28-day deferral policy. FDA followed this advice from the AABB, and that has become the policy in the United States.

Our risk modelling included a detailed calculation, including the 21-day deferral policy. Our data will show, as does Héma-Québec's, that the risk of a unit of blood being infected with Zika virus and entering the blood supply in Canada with our 21-day deferral policy in place is one in 38 million. The risk using a 28-day deferral policy would be one in 380 million. As context for committee members, the combined risk of HIV, or hepatitis B, or hepatitis C entering the blood supply in Canada today in the face of sophisticated screening tests is about one in 3.8 million. We're confident that our 21-day deferral policy significantly reduces the risk of Zika virus proportionate to other risks we manage.

The region of travel that we have chosen is intentionally very wide. In other words donors who have travelled outside of North America and Europe will be deferred for their 21-day period.

As was mentioned, there are also considerations with respect to donors for cells, tissues, and organs. As I mentioned in my opening remarks, in addition to managing the blood system we are also responsible for managing the stem cell network for Canada and the public umbilical cord blood bank. We are also involved in supporting organ donation and transplantation across the country. We are confident that the risk calculations applied to blood donors will be equally applicable to adult stem cell donors.

Health Canada has indeed provided guidance for cells, tissues, and organ organizations that aligns with our 21-day deferral policy that Canadian Blood Services and Héma-Québec now have in place. While we don't screen organ donors directly—that is done by other provincial organizations—we do believe the advice related to organ donor management provided by Health Canada and the Canadian Transplant Society is appropriate.

Like the Public Health Agency of Canada, we're involved in active monitoring of this evolving situation. We remain in contact with numerous partner organizations, including blood system operators around the globe, provincial and federal public health agencies, and many other organizations managing this entity.

As a closing point, I would like to leave committee members with an understanding of one other technology that, while not available imminently in Canada, is a technology that we at Canadian Blood Services believe is incredibly important from a risk management and risk mitigation point of view. It is a technology known as pathogen inactivation technology. Sitting beside me is one of the world's leading experts in that. She will be happy to answer committee questions.

It is a technology whereby we don't rely on testing for agents in the blood supply but actually depend on technologies to kill or inactivate the pathogens prior to transmission. That technology is not yet licensed and available in Canada, but Canadian Blood Services is on record and working with a clinical trial and the regulator to get licensing of the technology to further enhance the safety of the blood system.

In closing, Mr. Chair, Canadian Blood Services can assure Canadians that we have taken swift and decisive action to mitigate the risk of Zika virus from entering the blood supply in Canada. Canadian patients can continue to depend on us to manage a safe and secure system. We are confident that our rigorous, risk-based decision-making processes have resulted in an appropriate policy for Canada, given what we know about Zika virus today.

Thank you very much.

[The Chair, Liberal, Bill Casey]

Thank you very much. You've certainly raised a lot of thoughts and a lot of questions.

We're going to start with questions from Mr. Kang for seven minutes. Then we'll go back and forth.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, Mr. Chair.

Good afternoon. I'd like to thank everybody. I'd like to thank the Public Health Agency and Canadian Blood Services for appearing before the committee. I think a lot of light has been shed on the Zika virus.

My question is about the risk. Are there any demographic groups or residents of the country in particular that are at risk in Canada?

[Dr. Gregory Taylor]

Do you mean people living in Canada? Is that what you're asking?

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Yes. Is there any particular group or any particular region of the country—

[Dr. Gregory Taylor]

Right.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

—that may be infected with the virus?

[Dr. Gregory Taylor]

Currently, the virus is not transmitted in Canada. The mosquitoes that transmit the virus can't live in our cold weather. As Matt said, there's research going on to see if Canadian mosquitoes could transmit the virus. Currently, there's a very low risk of that happening in Canada.

The risk is for Canadians who travel outside the country to countries where it's being circulated. Currently, we're not aware of any risk for anyone specifically, other than pregnant women. The association or the risk for a pregnant woman who gets infected with the Zika virus is the neurodevelopmental problems in the fetus, be it microcephaly, small brain, or other developmental disorders. There's even some new evidence suggesting that it can affect outside the neurological system, but those are all just associations so far.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

That may lead to a further question. We are now in winter. Are we prepared for the spring and the summer when the mosquito season is here? Do we have any plans in place to deal with it if that is the case?

[Dr. Gregory Taylor]

For the mosquitoes in Canada, the closest one that they transmit is West Nile virus. That is in Canada. It's typically a very mild infection. We recommend the typical routines to avoid mosquito bites: tuck your clothes in, wear Off!, etc. But that does not apply to Zika, because Zika is not able to live in.... The mosquitoes can't transmit it. I'm not an entomologist, but it has something to do with the salivary glands in our mosquitoes versus the two mosquitoes that it is transmitted in, and they can't reproduce.

That's some of the research we're doing with other folks to see if it's possible. At this point in time, there's no evidence of that. When the season comes to protect yourself from mosquito bites, it's the typical things, but it's more worrisome about things like West Nile virus, not Zika.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Do you have any public education plan to put in place to educate people on this?

[Dr. Gregory Taylor]

We educate people with our travel health notices for people leaving the country. We've been doing that for several weeks now and we will continue to do that. We're tweeting. It's on Facebook, etc.

Every spring we educate people about mosquito bites in general, so those messages will reinforce and support each other.

For the people who are travelling, such as the pregnant women I alluded to, and who must travel, we have very—rigid is a bad word—different sorts of things. We advise a bed net, for example—and we don't advise that for anybody else—where at night, be it at a resort or not and whether or not they have screens on their window, they sleep under a bed net. Those are only for people who have to go.

We have those messages and our messages typically will support each other.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, sir.

Considering Brazil as the epicentre of the current outbreak, do you foresee any potential travel ban in the future, or at any time did you consider a travel ban to Brazil?

[Dr. Gregory Taylor]

At this point in time, no.

This is different from Ebola, for example, where with Ebola there was a person-to-person transmission. With this particular disease it's transmitted through a vector and that is the virus. The vast majority, 80% of people who are infected, have no symptoms whatsoever. For most of the other 20% who are infected, there are very mild symptoms and a very small number are hospitalized with serious infections.

For the vast majority of people it's a very mild infection. We always recommend...for people who travel to countries with mosquitoes, because there are other diseases like malaria and dengue that are carried by the same sorts of mosquitoes, so that will continue. But we see no need for a travel ban, other than advising women who are pregnant that they should reconsider their travel until the outbreak has decreased.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Is there a possibility that the virus may go dormant after maybe a month? How are we sure that after three or four weeks the person is clear of the virus? Is there any chance that after a month's time the virus may go dormant in the body and later on it may trigger again?

[Dr. Gregory Taylor]

That's a very good question. I alluded to this earlier, that the presence in semen, for example, is new knowledge. Prior to this outbreak there were only very rare cases of sexual transmission.

I think the U.S. now has identified six, if not more, potential cases of sexual transmission, where men have gone to a Zika-infected country and brought it back and infected a woman through sexual transmission. The knowledge base so far is that it stays in semen about two weeks, as far as we know. That science will change, and as I said in the opening, our recommendations will change if the science changes.

We're not aware of any other evidence of it staying anyplace else in the body at this time. There's no evidence of that, but we're watching very carefully and watching the science and would change, as I mentioned, recommendations if it does.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, sir.

You shed a little bit of light here on how the Public Health Agency of Canada is going to reach out and coordinate with the provinces and health care providers. On a scale of one to 10 what work has been done on trying to reach out to the provinces and the territories?

[Dr. Gregory Taylor]

When you work for the federal government it always feel like a 10 when moving with the provinces.

We've had very good relations. It's becoming almost routine, if I may say, so we had the pandemic and then we had Ebola, and then we've had disease after disease, which is really quite interesting.

We have standing committees. There's the public health network, which I co-chair with Nova Scotia, which is a formal committee. We have the chief medical officers as well. We do that on a regular basis and an ongoing basis, so it has been routine business.

With the front-line practitioners it has been the same. We connected with them for the same issues as well. For the Syrian refugees, we connected with them as well, and that would be the nurses and the doctors and some of the other front-line practitioners. We're doing that on a routine basis. It is really becoming business as normal with this.