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Evidence of meeting #31 for Health in the 41st Parliament, 2nd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was disease.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Marc Ouellette  Scientific Director, Institute of Infection and Immunity
Steven Sternthal  Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada
Robbin Lindsay  Research Scientist, National Microbiology Laboratory, Public Health Agency of Canada
Justin Vaive  Procedural Clerk

8:45 a.m.

Conservative

The Chair Conservative Ben Lobb

Good morning, ladies and gentlemen. Welcome back.

We're studying Bill C-442 in our final meeting on it. We're going to get right at it. We have two witnesses here today. We have the Institute of Infection and Immunity. There were a few problems with the connection but we are connected now. So we're going to go right ahead with Mr. Ouellette.

You have 10 minutes for your presentation. We'll just carry on. Can you hear us okay, sir?

8:45 a.m.

Dr. Marc Ouellette Scientific Director, Institute of Infection and Immunity

I can hear you very well. Can you hear me?

8:45 a.m.

Conservative

The Chair Conservative Ben Lobb

We can hear you quite well, yes. So go ahead, sir, and hopefully the connection lasts the entire meeting—but at least for 10 minutes, while you do your presentation.

Okay?

8:45 a.m.

Scientific Director, Institute of Infection and Immunity

Dr. Marc Ouellette

Okay, wonderful. Thank you very much.

I would like to thank the committee for inviting me to speak to you on how the Government of Canada is supporting Lyme-disease-related research across the country.

First of all, I would like to say how impressed I am by the deliberations you have had so far in the committee on this very important bill. As you know, the Canadian Institutes of Health Research, or CIHR, to use the acronym, is the Government of Canada health research funding agency with a mandate to support the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products, and a strengthened Canadian health care system.

Preparing for and responding to existing and emerging global threats to health has been identified as one of the five research priorities in CIHR's 2009-14 strategic plan. This includes the areas of microbial threats and the environment and health, which relates directly to our topic today.

Within CIHR, the Institute of Infection and Immunity for which I'm currently the scientific director supports research and helps build capacity in the areas of infectious disease and the body's immune system. In addition to supporting research, the Institute of Infection and Immunity plays an important role in infectious disease issues in Canada, including helping coordinate Canada's rapid research response to infectious disease outbreaks, especially those caused by new and emerging pathogens.

Since its inception in 2000, CIHR has invested close to $7 million in Lyme disease research. This includes an investment of approximately $600,000 in 2012-13 alone.

These investments have supported research examining the dissemination and replication of the bacteria Borrelia burgdoferi, which is known to be the causative agent of Lyme disease. CIHR's investments also allowed researchers to examine protective practices against ticks and tick-borne diseases.

For example, CIHR is currently supporting the work of Dr. George Chaconas, a Canada Research Chair at the University of Calgary, who is investigating how the genetic information in the bacteria that causes Lyme disease is passed on from generation to generation.

Part of Dr. Chaconas' research focuses on identifying the proteins expressed on the surface of the bacteria that interact with proteins of the human immune system as part of the disease-causing process. This research will help provide a better understanding of the complex processes of this very unusual disease-causing organism, and may well lead to the development of drugs to either block or treat infection associated with Lyme disease.

Over the past decade, Dr. Chaconas' research has been recognized internationally. His CIHR-funded research has resulted in the publication of over 30 peer-reviewed scientific articles and allowed him to collaborate with the best Lyme diseases researchers in the United States. In 2011 Dr. Chaconas received the Canadian Society of Microbiologists' Murray Award for Career Achievement for his microbiology research in the area of Lyme disease.

CIHR is also supporting the work of Dr. Tara Moriarty from the University of Toronto. Dr. Moriarty developed a new microscopic technique for studying the dissemination mechanism of Borrelia burgdorferi in real time. This technique facilitates the work she's currently conducting with engineers at the University of Toronto to design novel devices to screen inhibitors of Lyme bacteria in the bloodstream. This will help further our knowledge of the vascular dissemination of the bacteria, a key step to better understanding the progression of Lyme disease in humans. In 2011 Dr. Moriarty received the Bhagirath Singh Early Career Award in Infection and Immunity, which facilitated the expansion of her research program into new areas related to susceptibility to Lyme disease infection and dissemination.

As you can see, research conducted in Canada has significantly contributed to global knowledge surrounding the bacteria responsible for Lyme disease. Thanks to researchers' efforts, we have a better understanding of how this bacteria replicates, how it spreads in the bloodstream, how it evades destruction by the immune system, and how gene expression is regulated.

Advances in imaging technology now allow the visualization of the Lyme disease bacterium in the living host. Understanding how this organism survives, functions, and causes disease will help us develop innovative treatments for those who suffer from Lyme disease.

In conclusion, Mr. Chair, let me assure you that CIHR will continue building Lyme disease research capacity in the country, and promoting international research collaborations to address the impact of Lyme disease on the health of Canadians and the global population, and ultimately, find a cure to this disease.

Thank you very much for your attention. I'll be pleased to answer any of your questions after my colleague from the Public Health Agency of Canada has his turn at speaking.

Thank you.

8:50 a.m.

Conservative

The Chair Conservative Ben Lobb

Thank you very much, and a great segue.

Next up, we have the Public Health Agency of Canada.

Go ahead, sir. You have 10 minutes, or thereabouts.

June 3rd, 2014 / 8:50 a.m.

Steven Sternthal Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Good morning.

Thank you, Mr. Chair and members of the committee, for the opportunity to contribute to your deliberations on Bill C-442.

I am pleased to be here today to address the work under way in the Public Health Agency of Canada to reduce Lyme disease across the country.

I'll begin by addressing the agency's role and how it applies to Lyme disease.

The agency aims to promote better overall health of Canadians by preventing and controlling infectious diseases. We undertake primary public health functions, such as health promotion, surveillance, and risk assessment. These inform evidence-based approaches to prevent and control the spread of infectious diseases.

As part of its public health leadership role, the agency coordinates the national surveillance on Lyme disease as one of the most rapidly emerging infectious diseases in North America. I know that was part of your deliberations late last week.

The spread of Lyme disease is driven, in part, by climate change, as the tick vector spreads northwards from endemic areas of the United States. Moving into Canada, it is impacting our most densely populated regions. Based on the lessons learned in the United States, we anticipate the disease will affect over 10,000 Canadians per year by the 2020s.

To date, we have seen cases increase from 128, in 2009, when Lyme disease became a nationally notifiable disease, to an estimate of over 500, in 2013. That's a fourfold increase in just over five years.

However, this national snapshot only reflects a portion of all cases in Canada. This is because some people do not seek treatment for milder symptoms. Others do seek medical help, but may be misdiagnosed because their doctors are not always aware of the range of symptoms, or even that Lyme disease is in Canada. Agency risk models estimate the true number of infections to be at least three times higher than what has been reported today.

To support physicians in diagnosing Lyme disease, laboratory diagnostic testing is available across Canada in various public health laboratories. Like the United States, we use a two-tier test that must be requisitioned by a physician: the ELISA, to screen; and the western blot, to confirm Lyme disease.

The following are just a few facts about the testing in Canada.

Last year, almost 40,000 ELISA tests were administered by provincial and national laboratories. Of this total, approximately 3,000 tested positive or inconclusive, and were sent on to have essentially the second part of the screening and testing, the western blot, for confirmation of Lyme disease, by either our National Microbiology Laboratory in Winnipeg, or by public health laboratories in Ontario and British Columbia.

Following a thorough review of this surveillance information, available domestic and international research, stakeholder views, and existing public health messaging on this important topic, the agency has put in place an action plan to prevent and control Lyme disease in Canada. The action plan identifies three pillars for concrete action: engagement, education, and awareness; surveillance, prevention, and control; and research and diagnosis.

The first pillar includes a comprehensive public awareness plan that focuses on educating health care professionals and the public about Lyme disease.

Raising awareness among health professionals is one of our main goals: informing them that Lyme disease is here, educating them on symptoms, and encouraging them to properly diagnose and report cases.

This year, we have already reached an estimated 200,000 health professionals with awareness posters published in medical journals beginning in March. We have also presented to clinicians at a variety of venues across Canada in recent months.

We are also using every means available to get the message out to the general public. From social media, to Google AdWords, to partnering with organizations like The Weather Network, we are telling Canadians that Lyme disease is here, how to recognize it, and how to protect themselves from it. These public messages will continue throughout the summer period, which really is the Lyme disease season in Canada.

The agency has also worked with provincial and territorial public health authorities, as part of the Pan-Canadian Public Health Network, to develop a coordinated, vector-borne disease communications strategy, and public awareness tools targeting Lyme disease.

We hope that by the end of this year's tick season Lyme disease will be a household term.

I would now like to address the second pillar, which focuses on innovative ways to conduct surveillance and encourage preventive behaviour.

Efforts made in Lyme disease surveillance are starting to show some results. This year the majority of provinces are providing detailed case information, which will help identify new areas where Lyme disease is endemic and assist provinces in tailoring their preventive strategies.

The information will also provide a clear picture of the signs and symptoms of Lyme disease, information that is key for clinicians to properly diagnose it.

The final pillar focuses on increasing lab capacity, testing new diagnostic methods and carrying out research to generate new insights into effective diagnosis and treatment.

Under this pillar the agency is increasing testing capacity and quality by using state-of-the-art laboratory equipment. We recognize the challenges with current testing, particularly around detecting early Lyme disease, as the human body takes some time to develop antibodies to the bacteria.

The agency is committed to improving diagnostic testing. New methods are being evaluated and any that outperform current methods, the two-step method, will of course be adopted.

In the meantime we continue to recommend doctors diagnose patients on the basis of a full, wholesome, clinical assessment.

We recognize that laboratory technologies have evolved and will continue to do so in the future. The agency's national microbiology laboratory, in collaboration with the Canadian Public Health Laboratory Network and other stakeholders, will be updating our laboratory diagnostic guidelines in the near future.

However in doing so the agency faces a challenge. We can update the guidelines to reflect the current available evidence, but new evidence is needed to inform new diagnostic and new treatment methods. Therefore the agency is committed to continuing to work with medical professionals, patient advocacy groups such as the Canadian Lyme Disease Foundation and the Canadian Institutes of Health Research, and my colleagues on the video conference today to identify and address research gaps.

In closing, I would like to restate that the goal of the agency is to mitigate the impact of Lyme disease on Canadians. Through our collective efforts, Canadians will become more aware of the disease, how to recognize its symptoms, and the benefits from early treatment.

Together, we can reduce the severity of Lyme disease in Canada.

Thank you for your attention.

9 a.m.

Conservative

The Chair Conservative Ben Lobb

Thank you very much.

That concludes our presentations, and now we're going to the rounds of questions from committee members.

We'll start off with Ms. Davies for seven minutes. Go ahead, please.

9 a.m.

NDP

Libby Davies NDP Vancouver East, BC

Thank you very much, Chairperson, and thank you to both of our witnesses for being here today.

It's very heartening to hear about the research under way through the institute and that PHAC is very engaged with public awareness and getting the message out, because I think what we heard from the witnesses from the foundation last Thursday is that people are suffering from Lyme disease. One of their big concerns is that information is just not out there, so it's very good to hear you say that you hope that by the end of the summer there'll be a much greater awareness in Canada, because it is upon us.

I'd like to focus on a couple of questions. When we heard the witnesses last week, I would say that one of their key points and key frustrations was the lack of access to diagnostic testing. You've spoken about the two tests that are available in Canada, but we also heard stories of people who have gone to the United States to get another test—I forget the name of it—which is apparently not recognized or not available here. Actually, it might be available in one place in Canada.

I'm very interested in your comments at the end of your brief where you say that you're updating your laboratory diagnostic guidelines to reflect current evidence. I don't know if that's your diplomatic way of saying that the testing we have isn't cutting it, is not adequate, and that we're looking for new levels of diagnostic testing. I wonder if you could expand on that and tell us what feedback you've been getting from the Lyme Disease Foundation and whether or not we are looking at other diagnostic tools that will help people who think they've got Lyme disease and could get a test. That's one question.

I'd be interested to hear you talk about the action plan that you're developing and the three pillars. Knowing the bill, I wonder how you see the national strategy in the bill as different from your action plan.

9 a.m.

Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Steven Sternthal

Thank you very much for the questions.

The Public Health Agency recognizes, as I said in my speech, that there are limitations to the current available testing in Canada. Certainly in the early stages of Lyme disease, the tests currently do not necessarily return a positive result.

I think what's very important in the lessons we've learned from other complex diseases such as HIV and others is that often a two-step test, where we initially screen a larger sample size and then continue with a secondary test to do a confirmatory diagnosis, has really been found to be the best way to try to get the best diagnosis and result.

So that's why the concept of the two-step is something that we—

9:05 a.m.

NDP

Libby Davies NDP Vancouver East, BC

Could I just jump in?

9:05 a.m.

Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Steven Sternthal

—to date have felt to be very important.

9:05 a.m.

NDP

Libby Davies NDP Vancouver East, BC

One of the concerns I remember now, that people express, is that the testing that's available only tests for certain strains, so there's a whole bunch that are just left out there undiagnosed. Would you concur that's also part of the problem?

9:05 a.m.

Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Steven Sternthal

That's correct. So the current two-step testing focuses on one strain of the Borrelia, and is not as sensitive to picking up the many other bacteria that, of course, are carried by ticks. There's no question that there are multiple strains of Borrelia and multiple different bacteria that can be carried by a tick in wildlife. So we certainly concur that the association between this particular Borrelia strain with Lyme disease is quite well established, and the two-step testing has so far demonstrated the best way for us to minimize the false positives.

With regard to the tests available in the United States, they have been looked at very closely in the recent past. We'll continue to look at them, of course, because we do want, as I said, to bring the best methodologies forward in terms of the diagnostic testing.

There are really two issues that have been identified. One of them is around the interpretive criteria that the laboratory technical staff apply in interpreting the results. We feel that currently there's the potential for too many false positives in the way in which those criteria are implemented in the United States. So we're very much mindful of the limitations of the current testing. As a result, the agency, through our laboratory in Winnipeg, will in fact be investing in assessing those methodologies, the current ones in the U.S. and other ones that come online in the near future elsewhere, even in Europe. We'd love to cross the globe to find those tests, as we would also, ourselves in-house, help develop testing in the future. So it's very much on our radar. That's why it's one of the three key pillars of the action plan.

If we don't have a good diagnosis, it's very hard to provide early care and treatment. That's why we end up focusing clinicians on really diagnosing the person, and whether or not the person has been in an area of the country where they could have been exposed to ticks. They will look at how they're presenting. Of course, they'll need to rule out other health conditions that may also have some similar symptoms.

So we do appreciate that more work is needed to provide guidance to physicians and laboratories in that area.

9:05 a.m.

NDP

Libby Davies NDP Vancouver East, BC

Can you respond to your action plan versus the contemplated national strategy?

9:05 a.m.

Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Steven Sternthal

Of course.

We very much view the action plan as working on the initial steps required, such as raising public awareness and shoring up our surveillance activities across the country so we can have the core set of data upon which you could build broader approaches, strategies, and frameworks in the country.

So we very much see ourselves working on the early stages and the building blocks upon which this could be built in the future. Absolutely.

9:05 a.m.

Conservative

The Chair Conservative Ben Lobb

Thank you very much.

Ms. Adams, for seven minutes.

9:05 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

Thanks very much for joining us here today.

Just following up on Ms. Davies' comments, the earlier witnesses were not as concerned about false positives and that we were overstating the incidence of Lyme disease. Rather, they were very concerned about all of these false negatives, where people had apparently taken the test and were told, categorically, that they didn't have Lyme disease. They travelled to the United States. They went through exhaustive tests there. They were told categorically there that, yes, they do have Lyme disease. They returned and their physicians continued to say to them that they didn't have Lyme disease. So that was the frustration and the challenge they raised.

Also, this is also what we've really been hearing from constituents over time. I'm certainly not a physician, and I don't mean to put an overabundant weight on these anecdotal representations. However, it's quite clear that these people are in pain. They are suffering. It's person after person coming forward saying he or she is not able to be diagnosed with Lyme disease.

I suppose part of our collaborative approach here, in working with all parties, is to really raise awareness about Lyme disease across the country, so that physicians are aware and are testing for this, and that they too take it into consideration. Some of our witnesses have indicated that no matter how they explained it, their physicians would say, no, you simply don't have Lyme disease.

So is there an approach for all these false negatives, or what is the best understanding at this point?

9:05 a.m.

Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Steven Sternthal

It's a very difficult issue, of course. I'm not a clinician myself either. I think what we have identified in our action plan is the starting point for that discussion: raising awareness among health professionals and raising their understanding of where Lyme disease is in Canada. Of course, we understand that there are areas with well-established tick populations in the country. We also know that through impacts of climate change and temperature change in the country, the part of the country where ticks are living is growing each year.

I think perhaps debunking the myth regarding whether or not the ticks are here and the idea that if there are no ticks you can't get Lyme disease have certainly been among the primary focuses of our action plan. I think once you address that question—which will be an ongoing area of interest, not only for us but also for our partners in provinces as well as for organizations such as CanLyme—the dialogue with health professionals regarding how best to guide situations in which patients are presenting with these complex challenges and symptoms for which there could be multiple diagnoses will have to continue. We would like to see as thorough as possible an examination to allow that to be ruled out.

I appreciate the challenge, certainly, of going to another part of North America and receiving a positive test, when you may have a negative test in Canada. We appreciate the challenges. I spoke a moment ago about the nature of the tests currently available in some of the private laboratories in the U.S. But I think it's something that we need to work on over a period of time. It doesn't provide short-term relief, which is very difficult, and that's why we're also trying to engage with the Canadian Medical Association, the Canadian Nurses Association, and the College of Family Physicians of Canada to really talk about how best to equip the front-line health care professionals, recognizing that all of the evidence, all of the diagnostic testing, is not complete and that we're not in a position to have those perfect tools in the hands of our practitioners. In the meantime we are really trying to work on interim solutions with them.

9:10 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

Thank you.

Are there other stakeholders? I know from my time as a regional councillor and from working with the public health authorities, for instance, on West Nile virus, that it really came down to the region, where we would actively go out and monitor and test for West Nile and where we would actually put the insecticides into the sewers. We also undertook quite a bit of public-awareness advertising at our own expense. Could you perhaps speak a little bit to the stakeholders you're hoping to engage as part of this national framework, and how we might actually implement the action plan?

9:10 a.m.

Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Steven Sternthal

Thank you.

I mentioned a few of the professional associations already. As an illustrative example, in the last six months, we worked with, among others, federal, provincial, and territorial officials involved in the surveillance of Lyme disease. They are involved in public communications and in raising awareness, and they are trying to develop ways in which we could leverage each other's opportunities and each other's messages. One of the things we now have in place is a joint FPT communications approach, whereby in different regions across the country there will be similar messages used to raise awareness of Lyme disease, and there will be sharing, across jurisdictions, of lessons learned and tools.

9:10 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

Thank you so much.

I have one final question for you. Could you comment on what sharing best practices means in terms of the federal health system versus developing national standards of care? Would one or the other more naturally fit with the federal role in health care?

9:10 a.m.

Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Steven Sternthal

Certainly at the Public Health Agency we recognize that the delivery of care is the responsibility of the provinces and territories, of course, under our constitution. With regard to the development of best practices, the agency has, through the development of guidelines over a number of years, identified, articulated, and shared best practices and tools to help practitioners in the field adopt those practices. Encouraging that assessment of the evidence and sharing those practices across the land are very much parts of our role within the federal framework and federal action.

9:10 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

Thank you.

Can you provide some details on the surveillance process currently used by the agency to track the spread of Lyme disease?

9:10 a.m.

Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada

Steven Sternthal

Since 2009, as I indicated, Lyme disease has been a nationally notifiable disease. That means that clinicians, when they do receive and make a diagnosis, report through their public health officials, through the provincial and territorial health authorities, and straight up to Ottawa, so we can compile the numbers and the statistics. As well, we have now added special surveys and additional surveillance tools so the majority of jurisdictions can actually go and get more case information so we can find out more about how patients are presenting in doctors' offices, what they look like, and what the profile is in Canada. Then we can essentially tailor our guidance and our practices to better understand how in fact this is playing out in Canada.

9:15 a.m.

Conservative

The Chair Conservative Ben Lobb

Thanks very much.

The next round is seven minutes each.

Ms. Bennett, go ahead, please.