Health Committee on June 3rd, 2014

[David Wilks, Conservative, Kootenay—Columbia, BC]

Please.

[Dr. Robbin Lindsay, Research Scientist, National Microbiology Laboratory, Public Health Agency of Canada]

From a technical standpoint these assays are performed in a standardized fashion, as Steven mentioned. The ELISA is formatted to be used as a screening tool so it can be done as a high throughput test—with multiple tests performed at the same time—and it is really designed to be as sensitive as possible. With that screening assay we want to pull in as many of the positives, or hopefully the full range of positive-infected individuals, as possible. When you use a broad approach like that, often you end up pulling in people who have other infections that could be falsely positive. So you cast a very wide net with the ELISA hoping to get as many of the infected individuals in there, but realizing that you may have pulled in some of these people who are not.

That's why we use the second tier test. To remove those falsely positives we've used the western blot,which is supposed to be more specific. It's supposed to be able to detect primarily the individuals who are infected. We often see that when we do the ELISA; say we get a hundred screened positives. But when we do the western blot a percentage of those will come out because they were falsely positive as a result of infection with other disease processes or just reactive antibodies that were non-specific to Borrelia. So, it's a well-established criterion whereby we use a sensitive test at the front end and then re-evaluate those with a western blot. Again, a combination of the two assays provides better depiction of true positives and true negatives than any of the tests run individually.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thank you for that, Dr. Lindsay.

Dr. Ouellette, can you highlight any of the particularly promising researchers in the area of Lyme disease who are currently being supported by CIHR?

[Dr. Marc Ouellette]

The two main investigators that I've mentioned are Dr. George Chaconas and Dr. Tara Moriarty. They've both won prizes for their work on Lyme disease. Dr. Chaconas is collaborating with a number of Canadian investigators, including Dr. Paul Kubes, also in Calgary, who's a very well-known immunologist and part of the governing council of CIHR. So there are a number of investigators. CIHR functions as an open program, so people apply and if they have ideas they are being judged by their peers and then they can move forward. We are certainly open to having more and more researchers who want to investigate different aspects of Lyme disease.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thank you very much.

[The Chair, Conservative, Ben Lobb]

Thank you.

Mr. Morin is up next.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you, Mr. Chair.

Mr. Ouellette, my questions will be for you.

In your opening remarks, you said that, since its creation in 2000, CIHR had invested close to $7 million in Lyme disease research. How does that investment stack up against that of the United States? I assume the Americans do their own share of Lyme disease research. Canada's research resources are always more limited than those of the U.S. Be that as it may, what can we do to enhance the level of international knowledge?

The research is quite targeted. Could you describe for us the North America-wide effort to better understand Lyme disease and the partnerships or agreements you have with American researchers?

[Dr. Marc Ouellette]

Very well. Thank you for the question.

Obviously, when comparing ourselves with the U.S., right off the bat, we have to multiply any investments by a factor of 10. Consequently, where we have spent $7 million, they have spent at least $70 million. In addition, the U.S. spends twice as much on research per capita than Canada does. Basically, then, after multiplying the amount by 10 and then 2, we are talking about 20 times what we invest in Canada.

We are discussing Lyme disease, but you should know that Lyme is the name of a small town in Connecticut. The disease has been rampant in the U.S. for much longer. A body of research has been built over time. And because of temperature changes, the carrier, meaning the tick, migrated north. So now the disease is endemic in Canada. Right now, the U.S. contributes more per capita to Lyme disease research than Canada does.

As far as international efforts go, there are many, and that applies to a number of areas including vaccines, HIV, Hepatitis C and antibiotic resistance. But, apart from the interaction between the researchers themselves, the level of collaboration between CIHR and the U.S. government is rather low, in terms of Lyme disease efforts.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you.

You said that, in Canada, the main focus of our research was dissemination and replication of the bacteria.

What aspects of Lyme disease does the U.S. focus its research on more?

The idea here is to work in a complementary fashion to avoid the duplication of efforts.

[Dr. Marc Ouellette]

I would say it's important to have a certain degree of duplication because, very often, the strains are not exactly the same. They are just as likely to have unique characteristics in the U.S. as they are in Canada. Even within Canada, ticks out west aren't exactly the same ticks that we have out east. Hence the importance of validating the approach.

Much of the research focus has been on vaccines, but prevention is another important area of research, which I mentioned. And in that connection, the idea is to reduce the number of bites, the number of ticks and even the number of animals that are carriers of the disease. That means prevention mechanisms. And the same is happening on the American side. The research being done covers a rather broad spectrum. As I said, the U.S. has been dealing with Lyme disease longer than we have, and that explains why they have been able to make progress a bit faster than we have. Nevertheless, I can tell you that the calibre of research being done in Canada is world-class.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Very good.

I have one last question for you, Mr. Ouellette.

I'm not sure whether you had a look at the preamble to the bill, but one of the paragraphs reads as follows:

. . . whereas the current guidelines in Canada are based on those in the United States and are so restrictive as to severely limit the diagnosis of acute Lyme disease and deny the existence of continuing infection, thus abandoning sick people with a treatable illness;

Normally, the two countries have guidelines that are in sync with one another.

Do you have a theory as to why Canada adopted guidelines that were so different from the U.S.'s in this case?

[Dr. Marc Ouellette]

I really can't answer that. Guidelines aren't within my area of expertise. The people from the Public Health Agency of Canada may be in a better position to answer that.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is Mr. Lunney for five minutes.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thank you very much.

Thanks, Dr. Ouellette.

Is it Dr. Sternthal or Mr. Sternthal?

[Steven Sternthal]

It's “Mister”.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thank you, Mr. Sternthal.

As well, it's great to have Dr. Lindsay here with us.

I want to follow up on the state of knowledge. We heard from the people who were here the other day from the Lyme Disease Foundation that multiple strains of Borrelia seem to be involved.

There was a comment earlier that burgdorferi was the causative agent, but they felt there was a range of other strains of Borrelia that seemed to be causing symptoms as well, and maybe that's why our diagnostic tests were not so accurate.

Can you comment on the state of knowledge regarding which strains or multiple strains might be involved in the infection?

[Robbin Lindsay]

That's a very good question.

We have been doing research looking at the different strains of Borrelia burgdorferi, or genotypes, as they're called. There are minor differences in either the DNA of the organism or the amino acid. We know that there's a range of these different genotypes. We know from work done in the U.S. that there are differences in the rate of whether the strains will disseminate or not and maybe just cause a localized infection, depending on those genotypes.

The easiest source to find those isolates, to look at these genotypes, is to look at the ticks. When we do active surveillance for ticks or we go out in the field and collect ticks, either actively ourselves or through our passive system, we have these ticks that we can look at, the different strains, and we realize when we're looking at an analysis of those genotypes that we have many of the same genotypes that are present in the U.S. It's not surprising, because we feel that these ticks that we see in Canada come through the U.S. and establish populations here. I guess they are transplanted American ticks, in a way. So it's not surprising.

But we are finding that looking at those genotypes in populations that actually do establish, we are seeing some unique differences. We do realize that yes, we have differences in genotypes that come here, and those genotypes may present a disease in a different way, and we're starting to get a better understanding of that. But what we lack at the present time is an understanding of which strains are infecting individuals. So we can look at the ticks, but we don't know how the strains that are present in the ticks are going to present. We need to doing further research looking at the actual strains that are infecting individuals to get a better handle on here's what comes into Canada on an annual basis, here's what is infecting individuals, and here's the clinical presentation to put that whole piece together. Also, we need to look at how our diagnostic tests perform when these individuals are infected with a particular genotype. That's one of the missing elements that we need to do further research on.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

With animal studies, they were talking about a deer tick here, but they say that in fact the white-footed mouse and rodents can be a vector reservoir as well.

Is there benefit in studying the micro-organism at the vector level in animals to get a better handle on how this thing is hiding itself in the immune system and how it spreads to so many tissues before it's diagnosed, in many cases, when it's hard to eradicate?

[Robbin Lindsay]

Absolutely. It's useful to try to understand the breadth of that.

The way that the bacteria might respond in the tick is going to be different than in a mammal and perhaps in a bird. We have developed the research proposals to look at that in more detail. Understanding that whole breadth of the sort of core science Dr. Ouellette talked about, gaining the basic understanding of how the bacteria operates and how it evades those systems, will be useful, and we are looking potential studies to do that.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

On treatment options, I'm not sure whether I should go to Dr. Ouellette or Dr. Lindsay. In terms of treatment options, apparently it responds well to treatment early—it's a spirochaete, after all. What are the treatment options for early as opposed to late treatment? Also, what are the complications from long-term use of antibiotics?

Dr. Ouellette, could you comment on that?

[Dr. Marc Ouellette]

Yes, certainly. I can briefly discuss this.

I'm not a clinician myself, but I prepared for this as a witness, and I read quite a bit on the treatments. Basically, you're right. It responds very well when you take it early with doxycyclines or amoxicillin, which are very standard antibiotics that are being used by our kids when they have otitis, for instance. Actually, the bacteria will respond very well. So far, there have not been examples of bacteria that were resistant to those antibiotics. For more-difficult-to-treat cases—so when you don't take it early—again it's the same type of antibiotics but usually for a longer period.

I have to say that when I was reading the literature, it was not that clear that very-long-term antibiotic use is as effective as people are thinking. So there will be a need, again, for more clinical research on the length of antibiotic treatment. The term is up to nine months of antibiotics. I think there needs to be more research in that direction to see whether this is indeed as effective as we think because you're right, long-term antibiotics can have other consequences on your gastrointestinal tract bacteria, which are very important for a number of other things. We have to be cautious of not having very-long-term antibiotics.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Thank you, Mr. Lunney.

We have a few minutes left. If the NDP has a few questions, we could do that. We'll have to be mindful of the time, so maybe take about two or three minutes.

[Libby Davies, NDP, Vancouver East, BC]

Actually, we were going to turn it over to Ms. May, but she's not here. Her stuff is still here, so she must have just stepped out.

In her absence, I think Mr. Morin did have one more question just to clarify something.

[The Chair, Conservative, Ben Lobb]

One more question? Okay.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Mr. Sternthal, I am going to ask you the same question I asked Mr. Ouellette, as I think it falls more within your scope of responsibility.

Why are Canada's current guidelines, which are based on the U.S.'s, more restrictive than theirs? I am referring to one of the paragraphs in the preamble of the bill.