Health Committee on June 13th, 2017

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Just to change gears a bit, we were talking about infection control practices in hospitals. I worked in an emergency department for 20 years. I also used to be an EMS medical director.

One of the problems we find is that many people in health care settings use gloves universally, literally every time they touch a patient. I spoke with Dr. Pierre Plourde, an ID, infectious disease, specialist with the Winnipeg Regional Health Authority. Apparently, when health care workers wear gloves, every time they touch a patient they use it as a substitute for handwashing, and you actually get increased infections, yet when I am working with hospital staff in EMS, we cannot get that message through to them, and they're still always wearing gloves.

As part of infection control in hospitals, are there any initiatives to educate health care staff on the proper use of gloves and how not to use them as a substitute for handwashing?

[Dr. Howard Njoo]

I can say there are lots of initiatives going on, too many to even enumerate. They're all happening, I think, in a somewhat ad hoc manner. There are campaigns such as “Do bugs need drugs”, etc.

In the infection prevention and control setting it's certainly the mantra that we've been saying for years across the country, that handwashing is probably the single most effective method in preventing further spread.

Although I think gloves have their place in, let's say, using universal precautions to prevent this, certainly they're not a substitute for good handwashing techniques. Yes, then, we need to double our efforts. We need to work with the health care providers, with committees in health care settings, and with provincial and territorial governments to improve education awareness among front-line practitioners.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Professor Ouellette.

[Dr. Marc Ouellette]

Yes, I support everything that Dr. Njoo has indicated, except that we should not double our efforts, but quadruple them, because handwashing is a recurring theme, probably, when you study medicine, and it is now in the curriculum.

It's about behaviour, really. There is a lot of research being done to try to remind people how important it is. You're absolutely right that simple measures can make a huge difference.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you.

How much time do I have left?

[The Chair, Liberal, Bill Casey]

You have 50 seconds.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Great. It's not going as fast as I thought.

Since many of the questions I had written out beforehand have been answered and there were answers that I liked hearing regarding veterinarians, at this point I have no further questions.

Thank you.

[The Chair, Liberal, Bill Casey]

Okay.

We'll go to Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Mr. Chair.

I want to thank the witnesses for being here today.

Dr. Njoo, when you opened, you said that AMR is one of the most serious global health threats facing the world today. I find that the more I read about it, the more scared I become. It almost seems that we've had a few decades of effectiveness with antibiotics and that if we don't do something, we may be losing that for future generations being brought up. This is extremely important work that you're doing, and I commend Health Canada and the Public Health Agency and CIHR and everyone here.

I wonder whether I could get an idea of a timeline. I'm a little confused on this framework thing. The Government of Canada released a framework in 2014 and then an action plan in 2015, but my understanding is that there is going to be a pan-Canadian framework on AMR and antimicrobial use by 2017.

Dr. Njoo, do you want to take the lead on this? It's a framework, an action plan, and now we have another framework. What's up there?

[Dr. Howard Njoo]

Yes, the first framework you refer to is the federal framework. That's really within the federal family. As you say, that was developed in 2014, and an action plan in terms of what federal departments could or should be doing was released in 2015. As I mentioned in my opening remarks, we recognize that the federal government alone is not the sole solution to the AMR problem. Even besides other levels of government such as provincial and territorial, there are other key players, academia, industry, and so on and so forth.

With that, recognizing that we need to bring other players to the table, we actually engaged in a process to develop what we now call a pan-Canadian framework. We have four structured task groups involving experts from both the animal and human health sectors. The framework has been developed. It's going to be imminently released. It has four pillars. There's the additional pillar of infection prevention control along with stewardship.

Once that plan is made public, I imagine in the coming days or weeks, very shortly, we will get on with the heavy work of then developing a concrete action plan, which will include all the stakeholders beyond the federal family.

[Colin Carrie, Conservative, Oshawa, ON]

It's always fun in Canada developing these things with jurisdictional issues.

Congratulations for moving that forward.

The draft framework, has it been circulated among stakeholders? We're just curious because while you were before us for another framework there was some pushback by stakeholders that they weren't consulted enough or properly.

On this one here, how are we doing with industry consultation, things along those lines, discussion with the physicians? Doug talked about the animal food chain, stuff like that. How are you doing on that feedback?

[Dr. Howard Njoo]

I think it's been very comprehensive and it's been very encouraging, as I mentioned before. We've had great collaboration on both the animal health side and the human health side. As we speak, I note that it's gone through various approval levels in terms of provinces and territories as well as the federal level for both agriculture and the human health side. It's also gone to ministers for their concurrence.

[Colin Carrie, Conservative, Oshawa, ON]

That I'd be really interested—

[The Chair, Liberal, Bill Casey]

Dr. Ouellette.

[Dr. Marc Ouellette]

If I may, I would just add a little on this because I did participate in the 2014 framework and action plan. On the pan-Canadian framework, just to give you an idea, there were four pillars. For each pillar, there were two co-chairs, one on the human side and one on the animal side. Industry representatives were present. Provincial representatives were present. The four pillars then came together in one document and this is the framework. All the provinces looked at this. This was a very serious in-depth consultation on the AMR scene.

[Colin Carrie, Conservative, Oshawa, ON]

It would be very interesting to see what the ministers have come up with as far as the decision-making to move it forward is concerned.

I'm curious, Dr. Ouellette, about moving this forward. We talked a bit about habit. Doug talked about wearing gloves. With doctors being the gatekeepers for antibiotics for human use anyway, over the years there was a practice that sometimes patients would get antibiotics “just in case”, if it was a virus or a bacterial infection.

I was wondering about the medical doctors and the schools. Are they resistant? Are they slow to respond? These are prescribing habits that may have taken years and years and to change them it's important to get that message out. What are you guys doing to get the message out to the educational institutions?

[Dr. Marc Ouellette]

Thank you for your question.

We're talking about prescribers, and often they're medical doctors but often they're prescribing nurses or other specialists. Actually in the new curriculum, because of the importance of AMR, this is more and more discussed. Now they are young students who are asking for a curriculum on how to be better prepared in not providing antibiotics to somebody who is asking for them when it's not clear yet whether they're required or not. Antibiotics are mostly used in the community, not in hospitals.

It's only 30% of the antibiotics that are for human use, and out of this 95% is in the community. That's really where it will have a lot of impact. Of course, the pressure is big in hospitals, but it's in the community practice also that we have to.... A sore throat may not require antibiotics. This is part of the curriculum now in education and because the problem is getting more and more serious.... Here in Canada, I think we're still doing fairly well, but there are regions of the world where there are no more antibiotics that are capable of treating some very bad bugs, the superbugs that we're talking about.

[Colin Carrie, Conservative, Oshawa, ON]

You mentioned, too, some of the innovation that you're looking at. Just out of curiosity, have you looked back at some of the older ways that we were treating infections years and years ago? They weren't as good as the antibiotics, but for some things, maybe they would have been appropriate. Out of curiosity—I know we were doing some work with different communities, like traditional Chinese medicine—are we learning anything?

Madam Ireland, I believe, talked about vitamins and minerals and how to take preventive wellness approaches. Are we learning anything in that regard, too?

[Dr. Marc Ouellette]

This is a fantastic question.

Yes, actually Canada has strengths in those alternatives to antibiotics, to antimicrobials. Phage therapy was developed by Félix d'Herelle, a French Canadian researcher. He developed it in Paris, but he was from Canada. That was the first therapy in the pre-antibiotic era, where they were using phages, which are viruses against bacteria. Then when antibiotics came along, this was less popular, but now it's coming back. Actually, we have some major strengths in Canada on phages.

It's the same thing for the microbiome. This is all the bacteria that we have in our body. Most of the bacteria that we have are good bacteria and they're helping us. How do we make this equilibrium between the good bacteria and the potential bad bacteria?

There are many approaches, both in veterinary medicine and in human medicines, to use a more ecological approach. I think the best example, and everybody has heard about it, is a stool transplant for recurrent Clostridium difficile infection. It's not antibiotics. The reason for a stool transplant function is that you provide a lot of good bacteria and now there can be this equilibrium and then people can get rid of Clostridium difficile.

Yes, we are funding and we are interested in going to alternatives. We recognize the importance of developing new molecules because we will need them, but we also have to look at alternatives to antibiotics.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Mr. Davies, you have seven minutes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair.

Thanks to all the witnesses for being here today.

Dr. Ouellette, I want to begin with you. In the 2015 spring report of the Auditor General of Canada, the organisms of greatest concern for antimicrobial resistance were identified. Six of the seven identified are common in Canada and those are E. coli, klebsiella pneumoniae, staphylococcus aureus, streptococcus pneumoniae, non-typhoidal salmonella, neisseria gonorrhoeae, and shigella organisms. Pardon my pronunciation. It reported resistance rates from Canada ranging from 0% to 31% for the first six organisms.

I'm wondering if you could help situate the problem here, because in that same report, it said that, according to data from the Public Health Agency of Canada, the number of drug-resistant infections in Canada was increasing.

Can you give us a bit of a flavour for how serious the problem is that we're facing and how urgent the need is to take action?

[Dr. Marc Ouellette]

I'll start, and maybe my colleagues would like to complement what I'm saying.

The problem is rising. Twenty years ago we were talking about this, but the rates of resistance that we are encountering now are frightening, and I'm talking worldwide, especially in the outer regions of Asia, in India for instance. There are cases of resistance that are very high in human populations. Some of the bacteria that you just named are problematic.

In Canada you've talked about staphylococcus aureus or MRSA. This is a serious problem. It's not going down. I think we should put more effort into this. This is a serious infection and the drug of choice is methicillin, and then infections are MRSA, methicillin resistant, so it does not function. In Canada this is an issue that we have to look at.

For streptococcus pneumoniae, now we have a vaccine. We were talking about alternatives. I think the development of a vaccine has been very helpful in decreasing the rates of streptococcus pneumoniae infections, but unfortunately, the vaccine is effective against the subgroups that were the most frequent, and now there's a deplacement. When you remove something, something else is coming. Unfortunately, these are becoming resistant, and so we will have to look at this.

With the E. coli and the shigella, I mean the problem is more acute in other places of the world. For instance, if you look in agriculture, four or five years ago they were still using some of the class 1 drugs that were helpful also for human medicine. Some of the percentage that you're highlighting were from this equilibrium between the use of those antibiotics that are used both in human medicine and agriculture. Now they've banned those antibiotics and now the resistance rates are going down. It's showing that good stewardship can make a difference.

In a nutshell, I think it's very important that we work on it because—and I'm not sure how to translate that in English. I'll say it in French and hopefully it will be translated:

“Prevention is better than cure.”

I think we have to be aware of this. We are aware and it's politically quite clear. It's also scientifically quite clear and we have to take action.

[Don Davies, NDP, Vancouver Kingsway, BC]

What are the major contributors to the antimicrobial resistance? Is it over-prescription for humans? Is it the use of antibiotics in animals? How would you prioritize or rank the contributors to this problem?

[Dr. Marc Ouellette]

That's a fantastic question. If we had the answer, we would already know where to focus. This is why it makes it complicated, but interesting, from an academic point of view. This is why Canada and all the other countries also have used this multi-sectoral approach, because if you only focus on prescribing in hospital, it won't work. If you're only taking an agricultural stand, it won't work. There's also the environmental dimension. I don't want to frighten anybody, but they took 10 samples of soil close to sewers in the region of Toronto and out of those 10 samples, seven had some of the bacteria that were highly resistant to the best antibiotics. That doesn't mean it will transfer from the environment to humans, but we have to be aware that they exist already in Canada.

I realize that I'm not really answering your question here, but on the other hand, I think it's really a multi-sector approach that is needed. Maybe some of my colleagues would like to complement this answer.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you very much.

Ms. Dimitri, in that same Auditor General report in 2015, the Auditor General found that Health Canada had not stopped the importation of unlicensed veterinary antimicrobials, at that point. We know that 13 years earlier, in 2002, the department's advisory committee on animal uses of antimicrobials had recommended that it do so and the AG recommended that Health Canada stop that own-use importation of unlicensed veterinary antimicrobials. The department agreed with that recommendation. Has that importation been stopped?