Health Committee on June 8th, 2017

[Len Webber, Conservative, Calgary Confederation, AB]

Dr. Hawkins, when you treat your patients you're only allowed to prescribe so much by way of antibiotics. Once they achieve the maximum, you cannot treat them anymore, even though they may still have these conditions. You are suggesting, then, that obviously the guidelines should change and that you should be able to prescribe more antibiotics for these patients so that they can, hopefully, be cured of this horrible disease.

[Dr. Ralph Hawkins]

Mr. Webber, my practice in prescribing to my patients is not constrained by the guidelines and is not constrained by any arbitrary time limit. The guidelines actually contain a very small disclaimer at the outset identifying that they are voluntary and that they are not meant to supersede the judgment of an expert physician.

The protocols I follow are published protocols from the literature that employ much longer durations of antibiotics, so I follow those protocols rather than the arbitrary guidelines.

[Len Webber, Conservative, Calgary Confederation, AB]

It certainly seems obvious to me that they need to change these guidelines and allow more antibiotic prescriptions to these patients. Would you agree?

[The Chair, Liberal, Bill Casey]

Your time is up.

[Dr. Ralph Hawkins]

Yes.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you.

[The Chair, Liberal, Bill Casey]

Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair, and thank you to all the witnesses for being here today.

I want to focus a bit on the framework, if I could, because I think that's the subject of this study right now.

Dr. Njoo, last meeting we heard testimony from a witness about the funding priorities, indicating her view that the funding priorities in the framework did not come from patients and “did not come from the conference”, referring, of course, to the conference that was set up and required under legislation.

Where did the funding priorities in the framework come from?

[Dr. Howard Njoo]

The funding priority, as I think is mentioned in the framework, is going to be directed toward research, and I think that patients, other stakeholders, physicians, professionals, public health authorities, and others who attended all agreed that further research needs to be done. Therefore, the minister announced $4 million in additional funding for research.

I think that kind of funding is significant, and I think the next step is for the partners, including the Canadian Institutes of Health Research, us, and others, to determine what the priorities should be. I think the minister mentioned at the beginning, and also based on the input from patients, that initial priorities in research should be on diagnosis and treatment.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay. Thank you.

Dr. Njoo, witnesses, I think, gave some pretty trenchant first-hand testimony and informed testimony from other Lyme patients. They complain about the lack of effective diagnosis in Canada versus what they claimed was better diagnosis in the U.S.

What is your response to that complaint?

[Dr. Howard Njoo]

I will say that it's true, as many have said, that laboratory tests currently in use could be improved. Certainly the current tests are more valid in diagnosing infection some time after the infection occurs and sometimes not in the early stages.

However, having said that, the diagnostic methods we use in Canada are the same as those developed and used by the U.S. Centers for Disease Control and Prevention and also endorsed by other public health organizations around the world, such as in the U.K. Also, it has been validated and accepted by experts within our Canadian Public Health Laboratory Network and the public health laboratories throughout the country.

The other laboratories referred to, for the most part in the U.S., are private laboratories that offer tests that—certainly I'll defer to my laboratory and other experts—are using assays that have not been adequately validated and established for use generally. Therefore, we go with what the U.S. CDC and other public health authorities indicate are there.

[The Chair, Liberal, Bill Casey]

Mr. Davies, Dr. Zubek wanted to make a comment.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'll come back to Dr. Zubek in just a moment.

[The Chair, Liberal, Bill Casey]

She wanted to make a comment on your last question.

[Don Davies, NDP, Vancouver Kingsway, BC]

I know, but I'm not finished with Dr. Njoo on this question first.

I'm not clear about your answer. Is it the view of the government or your department that there is not a differential in diagnosis in the U.S. versus Canada? I'm unclear from your answer, because you seem to suggest we adopt the same standards.

[Dr. Howard Njoo]

Yes, the U.S. Centers for Disease Control and Prevention is at the national level, in a sense our counterpart in the U.S, as are such other similar public organizations as the Health Protection Agency in the U.K. We use the same laboratory diagnostic standards.

The other types of testing you're referring to are offered, as I mentioned, by private laboratories in the U.S. The types of testing they offer sometimes use methodologies that have not been validated and established as being accurate.

[Don Davies, NDP, Vancouver Kingsway, BC]

Dr. Zubek, I have another question for you, but on this question, is it your view that there are significantly better standards or results in the U.S. than in Canada?

[Dr. Elizabeth Zubek]

In the U.S., there are a number of different private laboratories. I choose to go to Germany, myself, and the ELISpot test I use from a few different labs in Germany is available in a certain lab in the United States as well.

Diagnosis is very difficult. The standard in the U.S. is looking at a certain number of bands, whereas other countries have said that this makes no sense: either you have five bands or you have nothing. What about somebody who's very suggestive and has four bands? We need to report that out, because if the picture is really suggestive, how can you set such a hard and fast limit, which the infectious disease people set 20 years ago as their criteria?

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay.

Dr. Njoo, I'll come back to you. I want to put one last comment to you, which I think we got from testimony last week, to get your view on it. The witnesses complained very clearly about their lack of access to sufficient, in their view, appropriate antibiotic treatment in Canada as compared with the U.S.

What would be the department's response to that? Is there superior antibiotic treatment in the U.S. as compared with Canada?

[Dr. Howard Njoo]

No, I wouldn't say that.

First of all, I'll make a couple of points. Health care, as we know and as I mentioned in my opening remarks, is the responsibility of the individual provinces and territories. It's their jurisdiction, and therefore it's difficult for the federal government to intervene in what is a provincial and territorial responsibility.

When it gets to the point of clinical diagnosis and treatment, as I mentioned before, that is also in a sense the purview of the experts on the front line, the clinicians who are represented by various professional organizations and are in the best position to look at the evidence around the world and make a.... They're taking the best available evidence into account to develop guidance for their members. In that sense, I would defer to those experts who are on those committees in those professional organizations to develop the guidance.

In terms of various guidance out there, we certainly respect the fact that IDSA, which has been referred to, has developed guidance. In a sense, our counterpart here in Canada, known by the acronym AMMI, the Association of Medical Microbiology and Infectious Disease Canada, also concurs with the guidance put out by IDSA.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'm probably running out of time, but Dr. Hawkins, I see you itching to get in. What are your comments on any of the subjects I've raised?

[Dr. Ralph Hawkins]

I am itching to get in.

Dr. Njoo has not been completely open about the differences in testing between the United States and Canada. The national medical laboratory authored a paper, which is in the medical literature, in February 2017, on the diversity of test results in Canada. Within that article, there's a specific sentence that I'll read: “The proportion of C6-positive/equivocal tests that tested positive by WB [Western blot] was much lower than in reports from the U.S.” The two-tier system is performing less well in Canadian populations than the same testing applied in American populations.

It is not being forthcoming to this committee to suggest that the performance of the testing is the same, when the national medical lab is reporting exactly the opposite.

[The Chair, Liberal, Bill Casey]

The time is up.

Mr. Oliver.

[John Oliver, Liberal, Oakville, ON]

Thank you very much for your testimony and for sharing some of the concerns.

We certainly heard some very powerful and emotional testimony from some of the victims of Lyme disease. I have to say that I think some of their concerns were still expressing the environment that exists today, because the framework is just being released, and the work that needs to be done around the three pillars has yet to fully take weight. I'm very much looking forward to it.

One of the key pillars is guidelines and best practices. Dr. Zubek, were your concerns around the 2006 guidelines about diagnosis? Was there a concern around treatment?

[Dr. Elizabeth Zubek]

They were about both diagnosis and treatment.