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.
Conservative
Rachael Thomas Conservative Lethbridge, AB
Sorry, but is there something that can be done better, though? I understand. I've read the framework and I know the process, but what could be done better to strengthen it going forward?
Acting Assistant Deputy Minister, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada
I think it's fine as it is as a starting point. Moving forward, as you mentioned, I think that if we start looking at the research questions in terms of diagnosis and treatment, I certainly believe there is a role for engagement and involvement of patients and patient advocates in the process as we elaborate the types of research areas we should focus on.
Conservative
Rachael Thomas Conservative Lethbridge, AB
I'm going to turn my attention to you, Dr. Hawkins. How would you answer that question? How could we better make patients equal partners?
Clinical Associate Professor of Medicine, University of Calgary, Cumming School of Medicine, As an Individual
I've answered Mr. Kang's question almost the same way. I think this entire process needs an oversight committee that has equal representation and a little bit of power.
Conservative
Rachael Thomas Conservative Lethbridge, AB
Thank you very much.
My understanding is that there's the potential for developing a vaccine, and I don't see any discussion with regard to that in the framework here. Perhaps, Dr. Hawkins, you can comment on that. Is there potential for developing a vaccine? Should there be further research in that direction?
Clinical Associate Professor of Medicine, University of Calgary, Cumming School of Medicine, As an Individual
Vaccines for Lyme disease are available for my dog.
Vaccines have been developed for humans. A LYMErix vaccine was developed in the late 1990s. When it was applied, the vaccine caused a number of Lyme-related symptoms in recipients and was removed from the market.
The research on Lyme vaccine development is still ongoing. There is a lot of money to be made if a vaccine comes forward, so a lot of the main researchers who feed information into the CDC are actually the people involved in this very lucrative Lyme vaccine discovery effort. At this point, nothing safe has been forthcoming. It remains to be seen if a safe vaccine can actually be developed.
Conservative
Rachael Thomas Conservative Lethbridge, AB
Thank you.
Here's my last question. We have a write-up here from the College of Family Physicians of Canada. One of the things they've said is “the sensitivity of current laboratory testing is insufficient to use it as the primary method of diagnosing Lyme disease in clinical cases.”
We've talked a lot about testing in terms of different tests that are available and their sufficiency. Dr. Hawkins, I believe you've given a really good summary of the problems we're facing and how we could solve those going forward.
Dr. Njoo, I'm wondering if you could comment on this. You seem to be saying that we're fine, that we have the technology, the science, and the tests available that we really need, and that the framework is comprehensive. The College of Family Physicians clearly disagrees with you on that. What would your response be?
Acting Assistant Deputy Minister, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada
I don't think I'm disagreeing with the College of Family Physicians. As I mentioned before, one of the areas that we do recognize needs to be improved is diagnostics. Therefore, with the funding for research, we are focusing and saying that it is one area, along with treatment, that needs to be further dealt with in terms of research.
I also mentioned that in terms of the current testing, it is pretty good in terms of some time, a few weeks, after infection, but certainly, in the early stages after infection, it's not as ideal as it could or should be. Therefore, as I said, that's an area where we need further research.
Conservative
Clinical Associate Professor of Medicine, University of Calgary, Cumming School of Medicine, As an Individual
I disagree with the statement that Dr. Njoo has just given about the testing being pretty good after a few weeks. Clearly, he is not a clinician. Clearly, he doesn't see Lyme disease patients. The testing is not reliable. At its best performance, the test, when it is subjected to external assessment, has about 40% to 50% sensitivity. That's atrocious. In clinical medicine, we want testing that's at least 90% sensitive and at least 90% specific. I've already elaborated on an approach that would provide that.
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
Thank you.
Could I address Dr. Zubek first of all? I'm filling in for Doug Eyolfson, who, I understand—
Family Physician, Shepherd's Hill Medical Clinic, As an Individual
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
So he did actually go to medical school. Is that an affirmation?
Family Physician, Shepherd's Hill Medical Clinic, As an Individual
He did.
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
It's heavy sledding for me. Ask me about steam locomotives.
A couple of things caught me in your presentation. You reference the insufficient diagnostic utility of the Canadian two-tier test and compare it with the two-tier test recommended by the Centers for Disease Control. Could you explain the difference?
Family Physician, Shepherd's Hill Medical Clinic, As an Individual
First, it depends on what type of test you're using.
We used to use a different type of ELISA first, followed by the Western blot, and now we have a C6 ELISA first, which is a better tool. However, then we were still following it up with the Western blot, and if the Western blot was negative, we were saying that you didn't have Lyme.
As Ralph was saying, the C6 by itself should be diagnostic of Lyme disease, and in parallel we could do an ELISpot to pick up the people that C6 misses.
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
Okay.
In terms of the lymphocyte transformation test, the CDC is recommending against the use of this test, which, it has now been validated, gives an unacceptably high level of false positives. The reference is as recent as 2014. Why is that?
Family Physician, Shepherd's Hill Medical Clinic, As an Individual
I don't know what references they're using. The references we have and that Ralph has published there show the 84% sensitivity, which is much higher than we're getting from any other test, and we still have good specificity. A 94% specificity means that if we tested 100 people who don't have Lyme disease, six of them might have a positive test, but 94 will be a true negative. That is quite good for the tests that are available now.
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
Could I ask why the Government of Canada does not support the development of a Lyme vaccine? Perhaps I'll put this over to our deputy, Dr. Njoo.
Acting Assistant Deputy Minister, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada
I wouldn't say that we do or don't support the development of any vaccine. As I said, there are a number of players. Certainly, vaccine manufacturers and researchers are in the process of trying to develop vaccines for a wide range of infectious diseases, including Lyme, HIV, and so on.
Certainly in the Canadian context, once there are promising results, our colleagues at Health Canada, who are the regulators, would undertake to review the evidence in terms of the safety and quality of any vaccine. If a vaccine were actually to be shown to be safe, have good quality, and be effective, then it would be licensed for use in Canada.
At this point, as Dr. Hawkins has mentioned, we're still waiting. Nothing has come forward.
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
Let me ask you, Dr. Hawkins, are family physicians being overwhelmed by the evolving knowledge base of medicine? I have a particular interest in the impacts of lead on children. It's not generally.... I've heard public statements from responsible officials saying that lead is something that you do over 50 years and you might get sick from it, and that's really not true. There's so much new evidence in every field. How do we keep physicians up to date on everything, including Lyme disease?
Clinical Associate Professor of Medicine, University of Calgary, Cumming School of Medicine, As an Individual
It's a real tall order. I'm a specialist. I'm not a family physician. Maybe Liz should be talking to this question as well, but from the perspective of being a specialist, I feel the pressure to do the reading of contemporary literature in my little silo area, and I have trouble keeping up. I'm amazed by and in awe of the family physicians who see a cardiovascular patient, move to the next room and see a pediatric case, and then move to the next room and do an obstetrical case.
Clearly, we need to educate in an efficient and effective manner.
Liz, did you want to weigh in?
Family Physician, Shepherd's Hill Medical Clinic, As an Individual
I'd love to weigh in here.
Family physicians are overwhelmed by an abundance of information, but we also have a relationship with the patient. We've known them for years. We've known them before they got sick; we see the changes in them, and we are not willing to accept the guideline that says two weeks of antibiotics should be enough. We want to find solutions. I get family physicians calling me from all across Canada asking for help, asking about different guidelines, wanting better information, and wanting to treat their patients better.
The College of Family Physicians of Canada has put out quite a strong statement in telling AMMI that they are not supporting AMMI's response. AMMI wanted their support to say that their testing is good enough and the diagnosis is good enough. The College of Family Physicians said, “Not for our purposes: we need to look at the holistic care of patients and we need better tests.” Look at the evidence of the College of Family Physicians. They referenced these new guidelines when they talked to AMMI. That represents 52% of the physicians in Canada, who are family physicians and who want these new types of guidelines to help us.
