Health Committee on June 13th, 2017

[Aline Dimitri]

I'm going to defer to my colleague Mary-Jane, because they're responsible for the policy work and the regulatory work behind it.

[Don Davies, NDP, Vancouver Kingsway, BC]

I wasn't sure which of you would answer.

[Dr. Mary-Jane Ireland]

I'd be happy to answer that. You're correct that, in his report, the Auditor General did say that Canada should finalize its plans to address own-use importation of veterinary antimicrobial drugs and strengthen its control over the importation of veterinary antimicrobial active pharmaceutical ingredients. With the Canada Gazette, part II publication and the new laws published on May 17, we are addressing the own-use importation of veterinary drugs. As I described, moving forward, producers will not be able to import veterinary drugs for personal use on their own animals, unless Health Canada has determined that those specific drugs do not pose a risk to public health or food safety. For example, we would not allow medically imported antimicrobials to be imported for personal use or a prescription drug. By those regulatory—

[Don Davies, NDP, Vancouver Kingsway, BC]

Is that as of today or is that in progress?

[Dr. Mary-Jane Ireland]

That will come into force in November. There's a six-month coming into force period to allow for everybody to prepare.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you. How am I doing for time, Mr. Chair?

[The Chair, Liberal, Bill Casey]

You're out.

[Don Davies, NDP, Vancouver Kingsway, BC]

That was a good question, then.

[The Chair, Liberal, Bill Casey]

That was an excellent question.

Mr. Ayoub, you have seven minutes.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you, Mr. Chair.

I want to thank the witnesses for being here.

The topic is very broad. If we aren't scientists or if we're not very familiar with the research in the field, it's easy to be confused. However, as consumers and representatives of Canadian consumers, we're listening to what's being said about the war on antimicrobials. We're talking about 10 million deaths by 2050. This is more than the number of deaths resulting from cancer, a disease we're currently fighting.

In the case of HIV/AIDS, for example, the good news is that we've finally found drugs and some form of treatment. Here, it seems that we're talking about a wheel that will never stop turning. How do we stop it or slow it down while maintaining quality of life? We're looking for quality of life when we use antimicrobials or other drugs.

I want you, the experts, to tell us what we don't know. For example, what would a journalist in the field reveal about drugs that aren't prescribed, but that can be obtained through the Internet; about farmers who use certain substances to produce faster growth; or about citizens who say they don't use pesticides, but whose grass is as green as a golf course?

Can you talk about things happening in the field that we aren't aware of?

[Aline Dimitri]

Thank you for the question.

The fact is that we know these things. However, it's difficult to know whether the chicken or the egg came first. In other words, it's hard to determine who contributes the most to the issue.

Our current measures are very broad. In particular, they relate to surveillance in the field, whether it concerns animals or health, and to the change in culture in terms of how we administer antibiotics. All this reflects what we already know about the things happening in the field. Nothing is truly hidden. That said, the fact that a person violates the law by engaging in unlawful conduct is serious. However, we've established systems to monitor this.

Regarding food safety, we conduct carcass surveillance tests to make sure the carcasses don't contain antimicrobials, which shouldn't be found in food. We have a surveillance and traceability system in place to limit and minimize the risk of this type of conduct occurring within the system. In that sense, we work very hard. We want to make sure the items that reach consumers are healthy and safe, whether we're talking about public health or food. We know what's happening.

However, it's important to always keep our eyes and ears open, given that people are still looking for new methods or pathways. We must find out from our foreign colleagues whether new practices in the field require us to take measures or should be taken into account when planning our surveillance system.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you for the answer. We could talk about these issues for much longer, but I have only seven minutes.

Along with the microbiological war, we have an economic war. It's not really a battle, but a confrontation between various pharmaceutical companies and chemical manufacturers. There's one we won't name, but I think we all know which one it is. We're still looking for a balance. There are some positive aspects, but there's also the fact that drugs in Canada are among the most expensive. We conducted a study on the matter. At the same time, it would probably be worthwhile to develop new drugs. These drugs would be expensive, but the costs would be covered for Canadians.

How can we balance this other aspect, which isn't scientific but economic?

[Aline Dimitri]

The economic aspect is obviously an important part of the equation. That said, it doesn't concern only Canada in relation to other countries. We're all in the same boat. Many of these major companies are multinational corporations. For these companies, the issue must be addressed from an international perspective.

I'll now leave the floor to Mr. Ouellette, then to Mr. Njoo, if they want to add something.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Yes. I would be pleased to hear from them.

[Dr. Marc Ouellette]

Thank you for the question.

You're right. There's an economic aspect. However, we must also take into account that antibiotics are still saving lives. This is the case for people suffering from an infection.

Unfortunately, our collective unconscious leads us to believe that antibiotics are effective, that it isn't necessary to take them for a long time and that they're inexpensive. We have this equation in mind. That said, cancer drugs can cost from $20,000 to $25,000, and add only four months to a person's life expectancy. Everyone knows it's the price to pay. However, this isn't the case for an antibiotic, which will probably save the life of the person who takes it.

There are what we call

“push and pull incentives”.

If the market is small, the development of the drug costs billions of dollars and the period is short, this incentive can't be applied. Regarding antibiotics, major pharmaceutical companies no longer invest in innovation. However, they invest in innovation when it comes to diseases such as diabetes and cancer. Many organizations are concerned about this issue, which was raised at the Davos forum and on a number of other occasions.

How can these pharmaceutical companies develop antibiotics while making a profit? This involves an economic aspect. The discussions currently concern topics such as the possibility of extending the duration of the patent or granting a bit more protection to a pharmaceutical company for research on an anti-diabetes drug, for example, if the company agrees to develop an antibiotic that won't be economically profitable. Therefore, we're trying to establish push and pull incentives. It's very economically innovative. We're trying to encourage the development of new antibiotics.

[The Chair, Liberal, Bill Casey]

Your time is up.

Now we're going to go to five-minute periods for questions, beginning with Mr. Webber.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair.

Just to let you know, I am an urbanite. I am not a farmer. I don't raise cattle. I am pretty much a layperson here.

I have a question.

Dr. Ireland, you brought up the prudent prescribing of antibiotics by physicians for cattle, for example. Let's say I'm a cattle rancher, and I have some sick cows. I call up the veterinarian, who prescribes some antibiotics for my herd. It improves their health, but they're still needing more antibiotics in order to alleviate or to take away whatever is left there.

With the prudent prescribing that's in place now, you reach a limit with regard to the amount of antibiotics a veterinarian can prescribe to cattle, so here I am now with cows that are still sick, and I've reached my limit with antibiotics. What are my options?

[Dr. Mary-Jane Ireland]

Thank you for the question.

I'm a large-animal veterinarian, although I come from the city, so I can relate to your position.

First of all, there are many types of antimicrobials that are available or at the disposal of veterinarians and producers. If the first line of treatment does not work, there are options for second line and third line treatments. There are times where, due to the nature of the disease or the severity of the outbreak, some animals will be lost. Access to the antimicrobials, for both the veterinarian and the producers, is what we are trying to ensure. We're also trying to ensure that the first line, second line, and third line antimicrobials remain effective now and into the future. With misuse and overuse, they're going to find themselves with fewer options. We'd like to keep all of those options open for their animal welfare and their production systems. These are the family farms, and they need those treatment options.

[Len Webber, Conservative, Calgary Confederation, AB]

Absolutely.

Now I'm going to move into the human use—you brought that up as well—and the same scenario. You have a sick individual, perhaps infected by a vector-borne disease. They go to the doctor. They are prescribed antibiotics to alleviate or get rid of the bacteria in their system, yet they've reached a peak in their prescription, and they can no longer get the rest of that antibiotic to take away that bacteria. The doctor's hands are tied. They cannot prescribe further antibiotics. What's the option for this patient?

[Dr. Howard Njoo]

Maybe I can answer that.

My understanding is that there is a patient who obviously has a serious bacterial infection that requires antibiotics. Sometimes, based on what they understand the prevalence of bacteria to be within a community, physicians might give a broad-spectrum antibiotic, thinking that will most likely be able to deal with the infection. If it doesn't deal with the infection, and the patient continues to be sick, there's really, in a sense, no limit as to what antibiotics they can prescribe, or the amount. It would be prudent, if it's possible, to actually get a culture or a sample from the patient and test it in a laboratory to see what drugs it is sensitive to. By and large, for most infections that doctors see in a community setting in Canada, there will be an antibiotic that can effectively deal with it.

What Dr. Ouellette and all of us, and many others outside of this room, are worried about is that, with the overuse or the inappropriate use of antibiotics, it's just natural selection. Over time, the bacteria in the community and so on will become resistant if we keep using antibiotics. Then, when you actually need that antibiotic for a particular infection, that particular bacteria that's circulating in the community will be resistant.

[Len Webber, Conservative, Calgary Confederation, AB]

I guess, then—and we studied this just last week with regard to chronic Lyme disease sufferers, for example, who have reached their peak when it comes to the use of antibiotics—there is no option for them now. Is that correct, Dr. Njoo?

[Dr. Howard Njoo]

Not to get into last week's discussion, but there are obviously differing views in the medical community regarding Lyme disease. In terms of acute Lyme disease and what the treatment is—antibiotics and so on—that's pretty well established. However, for these individuals—some of whom have chronic symptoms that could be consistent with Lyme disease but there's not an actual laboratory confirmation—it is, to be quite honest, a controversy. Many physicians will say that there really is nothing to treat, and that inappropriately giving antibiotics when there isn't an established infection that you can actually diagnose would do more harm in the long term, both for the patient and also for the community at large. That is the ongoing issue. That's how Lyme disease, in terms of some physicians giving long-term antibiotics, affects this issue we're discussing today, AMR.

[Len Webber, Conservative, Calgary Confederation, AB]

Exactly. I feel that a lot of these patients, these chronic sufferers, are put out to pasture and just left on their own.

[The Chair, Liberal, Bill Casey]

I'm going to have to put you out to pasture now.

Ms. Sidhu, you're up.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Thank you to all the presenters.

My question is for CIHR. The rate of prescription and dispensing of antimicrobials varies across the country. In the north and in Quebec, we have seen that rates are fairly steady: five to six daily doses per person. In Ontario, Manitoba, and British Columbia, it's six to seven. Other provinces continue to increase. Saskatchewan shows eight to eight and a half, and Newfoundland and Labrador shows 10 or more daily doses. What is the reason for the higher prescription rates or daily doses in Saskatchewan and in Newfoundland and Labrador?