Evidence of meeting #60 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was research.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Howard Njoo  Acting Assistant Deputy Minister, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada
Clerk of the Committee  Mr. David Gagnon
Jean-Paul Bédard  Vice-President, Public Affairs, Canadian Blood Services
Margaret Fearon  Medical Director, Medical Microbiology, Canadian Blood Services
Ralph Hawkins  Clinical Associate Professor of Medicine, University of Calgary, Cumming School of Medicine, As an Individual
Elizabeth Zubek  Family Physician, Shepherd's Hill Medical Clinic, As an Individual
Karin Phillips  Analyst

11:45 a.m.

Liberal

Sonia Sidhu Liberal Brampton South, ON

Dr. Njoo, can you explain that?

11:45 a.m.

Acting Assistant Deputy Minister, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada

Dr. Howard Njoo

With respect to the question about transmission through pregnancy, as I said before, one of the things that everyone is looking for is answers to questions such as this.

I go back to the fact that science takes time. There is something called the scientific method that has been well established as a principle for natural science research since the 17th century. The fact is that we need cumulative evidence to answer any one question, and no single research finding is able to do that on its own.

I'm aware there are various types of studies purporting to show potential transmission risk in different types of settings. I think Dr. Hawkins mentioned, for example, congenital transmission. To date, there's been no conclusive, definitive evidence that those modes of transmission actually exist. Therefore, I certainly support that further research needs to be done in these areas to hopefully one day have definitive evidence one way or the other.

11:45 a.m.

Liberal

Sonia Sidhu Liberal Brampton South, ON

Concerning “Lyme Disease in Canada—A Federal Framework”, what research gaps exist, in your opinion, with respect to Lyme disease?

11:45 a.m.

Acting Assistant Deputy Minister, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada

Dr. Howard Njoo

I could go on about a number of research gaps. Certainly I would defer to other experts in the field. We'll be working closely with our colleagues at the Canadian Institutes of Health Research and also with researchers and stakeholders, as mentioned before, to determine what the research agenda should be.

As a starting point, we recognize that there are gaps in knowledge in terms of diagnosis and treatment. All of us in one way or the other have mentioned that, and surely that will be a focus of the research we need and of what we'll do going forward.

11:50 a.m.

Liberal

The Chair Liberal Bill Casey

Ms. Sidhu, Dr. Hawkins wanted to make a comment on your previous question.

Dr. Hawkins.

11:50 a.m.

Clinical Associate Professor of Medicine, University of Calgary, Cumming School of Medicine, As an Individual

Dr. Ralph Hawkins

Thank you for allowing me to interject.

Dr. Njoo just alluded to my name and then mentioned that there was no definitive evidence of transmission of Borrelia.

I know that this committee has been given in evidence a textbook that was published in the late 1990s on neonatal disease. I know that Dr. Njoo is aware of that textbook as well. I would like to point out to this committee that the World Health Organization identifies in sub-Saharan Africa a danger of maternal fetal transmission of another Borrelia species causing epidemic relapsing fever in newborns. This is an active World Health Organization pursuit: looking at Borrelia species transmitted neonatally.

I don't think, then, that Dr. Njoo's statement that there's no definitive evidence of transmission of Borrelia species should be left unchallenged.

11:50 a.m.

Liberal

The Chair Liberal Bill Casey

Thank you.

Ms. Sidhu.

11:50 a.m.

Liberal

Sonia Sidhu Liberal Brampton South, ON

What are some of the barriers to accurate diagnosis of Lyme disease? Can Dr. Hawkins or any of you explain what the barriers are?

11:50 a.m.

Clinical Associate Professor of Medicine, University of Calgary, Cumming School of Medicine, As an Individual

Dr. Ralph Hawkins

The barriers to the accurate diagnosis of Lyme disease start with the patient's presentation for medical assistance. When patients present and give a clear history of a tick bite, they're often greeted with a rebuff, as Liz has already suggested—“Lyme disease doesn't exist here; you don't have a picture; you didn't bring the tick in, etc.”—so that often patients are dismissed at the outset.

Later on, blood testing may be done. The blood testing that is done in Canada, the present gold standard test, is a test called C6 ELISA, which in its best performance carries about a 75% sensitivity for the diagnosis to be established. It's a screening test. That means that 25% of people who have the disease are going to be dismissed on the basis of a screening test that isn't sensitive enough.

The people who pass that phase then go on to have a second test called a Western blot, which in its best performance, particularly in the later stages, has about an 80% sensitivity, which means that overall, 60% of the people who have blood testing are going to be identified, in the best-case scenario, as having a positive test result.

Then we have to embark on treatment. Many doctors are either not educated or are reluctant to prescribe the durations of antibiotics that are required to achieve satisfactory treatment of this disease. It is well established, furthermore, that if treatment is discontinued before symptoms are gone, relapse is almost universal.

The gaps or barriers in treatment, then, have been right from the time that the patient presents for care through the investigation and treatment paradigm. There are financial barriers, because many of the treatments require personal financial expense. Some of the investigations, because they're not offered by our health system, for reasons that have yet to be explained well to me, need to be done internationally at patient expense, so there are expense barriers. Often these patients are mobility challenged, and so they can't come to doctors' visits and can't get to the laboratory as frequently or as easily as they should.

There are myriad barriers to addressing this disease, Ms. Sidhu.

11:50 a.m.

Liberal

Sonia Sidhu Liberal Brampton South, ON

Thank you.

11:50 a.m.

Liberal

The Chair Liberal Bill Casey

Thanks very much.

Mr. Webber.

11:50 a.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Thank you, Mr. Chair.

Dr. Fearon, you talked about the screening procedures at Canadian Blood Services and the fact that you don't ask about tick bites. Why not, especially when we see in the report a detailed map of the areas that are infested with ticks? They're growing and, of course, you're collecting blood from these areas. Why would you not ask if people have had tick bites?

11:55 a.m.

Medical Director, Medical Microbiology, Canadian Blood Services

Dr. Margaret Fearon

Many people who have been bitten by ticks don't recall it. If we did ask about tick bites, we might get a few people saying yes, but the majority of people—maybe even folks who have or have had Lyme disease—may not remember that tick bite, so it's not been found to be a reliable question.

11:55 a.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

I just think it would take a matter of one or two seconds to ask that question, and you would get that one or two who would then admit that they had been bitten. I think it's something you should put into your questioning, your screening.

Dr. Hawkins, may I ask you about what I think is a strain of Borrelia called Babesia? I know from studies done in the United States that it has been confirmed that Babesia can be transmitted through transfusions. Can you talk a bit about Babesia, Dr. Hawkins? Is it a threat?

11:55 a.m.

Clinical Associate Professor of Medicine, University of Calgary, Cumming School of Medicine, As an Individual

Dr. Ralph Hawkins

Sure. Thank you, Mr. Webber.

The Babesia duncani and Babesia microti are both intraerythrocytic parasites that are similar in some ways to the malaria parasite. They are not Lyme disease, but they are tick-borne infections. They're transmitted by the same ticks that carry Lyme disease, and the areas that Babesia is showing up in are the same areas of risk where Lyme-disease-carrying Ixode ticks are showing up.

Babesia is transmitted through blood transfusion. I am aware that there are jurisdictions in at least certain counties in the United States that are now actively screening for Babesia in donated blood. There has been a reported case of Babesia domestically acquired in Manitoba, so there is no question that this is a concern and a potential risk within the jurisdiction of Canada.

11:55 a.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Thank you.

I'll go back to Canadian Blood Services.

You say you test donated blood. How do you test in the laboratory? Do you test all blood donations in the laboratory? Do you test for particular diseases: HIV—

11:55 a.m.

Medical Director, Medical Microbiology, Canadian Blood Services

Dr. Margaret Fearon

We test for HIV, hepatitis C and B, etc.

11:55 a.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

But you test nothing to do with any of the strains here of Lyme disease?

11:55 a.m.

Medical Director, Medical Microbiology, Canadian Blood Services

11:55 a.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

What would it take to put these tests in place? Of course, there would be a cost involved, but it can be done, correct?

11:55 a.m.

Medical Director, Medical Microbiology, Canadian Blood Services

Dr. Margaret Fearon

Well, there would have to be a Health Canada approved test before we would be allowed to implement it.

Let's get back to the Babesia question because that is of concern to Canadian Blood Services and to Héma-Québec.

A couple of years ago we carried out a large donor prevalence study because we were well aware there were cases of transfusion transmission of Babesia, particularly in the northeastern U.S. where it's, as you know, transmitted by the same tick as Lyme disease. This does cause illness in transfusion recipients.

Because Babesia is not a reportable disease in Canada, we really don't have much data on babesiosis in this country. In this prevalence study, we looked at donors for antibodies to Babesia to see whether donors had recently been infected or had ever been infected. Out of the approximately 14,000 donors that we tested, zero were positive, so we did not see any Babesia in the blood donors that we tested.

However, we are well aware there was a case of transfusion transmission of babesiosis in Canada in 1998. This was a case where a donor had travelled to Cape Cod. Then there is the recent endemic case that you described in Manitoba. We are repeating that prevalence study next year. We're in the planning phase for that, and we will increase the number of donors that we survey.

11:55 a.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Great, thank you. I don't mean to cut you off. I just have some questions here, and I'm limited by time.

Dr. Zubek, I have a couple of quotes here from you—and you mentioned this in your presentations—about the outdated guidelines. You also urged the Minister of Health to reject the framework and insist on a real Canadian action plan for Lyme disease. This needs to be created in partnership with people who are affected by Lyme.

With respect to the guidelines, obviously the guidelines are insufficient because you can only prescribe so much antibiotic before you're not allowed to anymore. Is that why doctors are saying to these chronic Lyme sufferers that their hands are tied, that they cannot do any more treatment for them, and that these sufferers must go down to the United States or somewhere else in the world to seek treatment? Can you talk about that, please?

Noon

Family Physician, Shepherd's Hill Medical Clinic, As an Individual

Dr. Elizabeth Zubek

Doctors are quite afraid to go outside the box of published guidelines. If they look on the PHAC website and it links them to 2006 protocols that say you have a central nervous system infection with Lyme disease, and they then give one antibiotic for two to four weeks, they're wondering whether they're going to get into trouble if they prescribe more. I've seen so many doctors caught in that dilemma in which they've seen massive improvements and they know they want to go further but wonder whether they will get into trouble with their licence.

Noon

Conservative

Len Webber Conservative Calgary Confederation, AB

Exactly. These guidelines have not been changed, even after the conference that.... Has the new framework not changed those guidelines at all?

June 8th, 2017 / noon

Family Physician, Shepherd's Hill Medical Clinic, As an Individual

Dr. Elizabeth Zubek

It has not changed what PHAC posts on their website. They post a link to these 2006 guidelines and do not say that there are other much more evidence-based and current guidelines available. If a physician could look on the website and find those other guidelines, they would then be able to use their clinical judgment, with a bit more relief that there will not be any governing bodies out after them.