Health Committee on June 13th, 2017

[Dr. Marc Ouellette]

I'll give a first try at that question, and then hopefully my colleagues from the Public Health Agency can complement that.

Basically, providing health is a provincial jurisdiction. Each province has its own guidelines to move forward on how it will deal with that type of infection. This is also why we have this federal framework. However, we understand that if we don't have a partnership with provinces, it will be complicated to try to integrate all the knowledge that we have to have better practice at the end. It's really to try to embed and integrate all the provinces together so that there's more uniformity, so that we'll have maybe one or two guidelines that we could follow—and I'm not talking about universal protocols. In my opinion, we have 13 different health systems, and it's a question of trying to integrate when possible.

I don't know whether Howard has something to add to this.

[Dr. Howard Njoo]

Thank you, Dr. Ouellette. Sure, I can add to that.

Certainly, the surveillance we do across the country for AMR is good, but it could be a lot better. For example, most of the surveillance we have for human illness is based in hospital settings in terms of what kinds of infections are prevalent. To be honest, we don't have very good data on what happens in the community setting, as I said in my opening remarks. For example, for sexually transmitted infections like neisseria gonorrhoeae, there's certainly a lot of resistance out there, but we don't really have a good, complete picture.

I think your question about the antimicrobial use links in part to having a better understanding of which diseases and infections are prevalent in different parts of the country. We need to link that up with antimicrobial use and prescription practices to see if they actually match up in terms of appropriate prescription based on what actual diseases and infections are occurring. Those are areas that we certainly intend to move forward on with our partners to strengthen, both on the disease outcomes in terms of the community and hospital settings, but also in terms of antimicrobial use and prescription practices.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

Marc said earlier that 95% of antibiotics are used in the community. With regard to community education, Dr. Njoo, are there any awareness programs out there?

[Dr. Howard Njoo]

There are a lot of programs out there. Just in reference to a previous question, it's interesting that among health care practitioners—I'll focus on physicians—as Dr. Ouellette pointed out, the young future practitioners in medical schools now are well aware of the issue of AMR. They're getting all the right education on how to appropriately prescribe and so on. That's good, but we can't forget about the practitioners who are already out there. I think there's a greater focus, as well, in various professional organizations. We've supported various types of campaigns, as well, in terms of continuing medical education to make sure that physicians already out there in the community are better equipped to appropriately prescribe antibiotics. There are some things like little educational campaigns, even something as simple as a notepad. It's almost like a prescription pad, except it has little notes in terms of criteria that help guide physicians on how they can properly prescribe antibiotics.

The other part, which I think is sometimes not emphasized enough, is that it shouldn't be all, in a way, on the front-line practitioners, the physicians. A lot of it is also driven by the demands and expectations of patients. A lot of education also needs to be focused on the patients. If they're better aware and educated about the difference between viruses and bacteria, and so on, they will also be in a better position to have good dialogue with their health care practitioners about what would be appropriate treatment for any type of infection they have. What happens now.... I understand how physicians may feel; there's a lot of pressure. A patient may easily go into a doctor's office and demand an antibiotic. The doctor will do the best he or she can to explain, “No, this is a viral infection from what I see. You don't need an antibiotic.” The patient will get really upset and say, “You're not a good doctor. I'm leaving.” The patient will go to see another doctor, and that same scenario will be repeated.

I think, as with many issues in AMR, it's complicated. There are a lot of things we could and should be doing, but hopefully as we move forward, we'll integrate the response so that everyone who has a role to play, including the general public and patients, will do their part.

[The Chair, Liberal, Bill Casey]

Your time is up.

Dr. Ouellette, you looked as though you wanted to make a comment.

[Dr. Marc Ouellette]

No, I just support what Howard is saying. Often when we are having meetings or workshops, we bring patients also to share their views and to see how we can move forward to try to improve on this.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Ms. Harder.

[Rachael Thomas, Conservative, Lethbridge, AB]

Thank you.

I'm going to hone in on the pan-Canadian framework that has been created or is in the midst of being created. Do we know when we will see that?

[Dr. Howard Njoo]

Yes, imminently.

[Rachael Thomas, Conservative, Lethbridge, AB]

Imminently. Good.

[Dr. Howard Njoo]

I would venture to say it will be this year, in the next few weeks or so. It's more about the appropriate approvals in terms of sign-offs, but in terms of the actual document and all the hard work that has gone into it, the actual framework is there.

[Rachael Thomas, Conservative, Lethbridge, AB]

Mr. Njoo, maybe you could comment on some of the challenges faced as that pan-Canadian framework has come together. Has it been a streamlined process? Has it been difficult? What has that process been like?

[Dr. Howard Njoo]

It has been very good. Obviously, it's challenging in some ways, as others have alluded to, with the fact that the federal government can't do it alone. Just between governments, having to work with provincial and territorial governments that obviously have the responsibility for the delivery of health care services, we recognized going in that this might have an impact in terms of how the services are rolled out, maybe even budget impacts. To everyone's credit, it has been very good in terms of the final result. They've all signed on and are willing to do their part.

The other part that is also important is dealing with the other stakeholders: industry, the animal health side as well, academics, and so on. As I mentioned earlier, it has been remarkable how all the stakeholders, universally, to everyone's credit, recognize the seriousness of this global threat and they've all come to the table in a good spirit to help do their part.

[Rachael Thomas, Conservative, Lethbridge, AB]

Mr. Njoo, we're told that this will come out imminently, which is excellent, and then it will really be up to the provinces and territories to implement. Then we will do some assessments in terms of where we are.

Let's say we fast forward to one year from now. What does success look like?

[Dr. Howard Njoo]

Before we get to that part, the framework itself won't actually have something to be implemented, because it's, in a sense, a high-level policy document. It sets out the parameters in terms of the four pillars and what we want to work on. Once the framework is released, we will get to the heavy lifting, as they say, working through our task groups and with all the partners to develop the concrete action plan.

[Rachael Thomas, Conservative, Lethbridge, AB]

Will provinces and territories not have a role to play, then, on the framework?

[Dr. Howard Njoo]

Yes, they will. They will also be part of the development of the concrete action plan in each of the pillars.

[Rachael Thomas, Conservative, Lethbridge, AB]

Okay, so my question still stands. In one year from now, what does success look like? What will we have accomplished based on this framework?

[Dr. Howard Njoo]

The framework sets the foundation, and with the concrete action plans, once we actually develop the specific actions in each of those pillars, there will be targets or objectives set out. That's how we will be able to measure one year, five years, or 10 years moving forward.

[Rachael Thomas, Conservative, Lethbridge, AB]

Okay.

[Aline Dimitri]

Perhaps I could add to my colleague's comments.

Given the complexity of the issue we're dealing with, for the first time in a very long time, we're bringing together two sectors that don't always work hand in hand. Success is really having an action plan where we can see everybody bringing to the table what they're going to do in a concrete way. That is what success would look like in a year, because it will take time for us all to sit down and agree on what we can do, by when, and how we're going to measure it.

I know it might not sound like a big milestone, but it is a huge milestone when we're thinking of the massive number of people we're bringing together in a coordinated conversation. They all have to change something in the way they do their business. This is not just about “I'll give you this and you'll give me that.” We're talking about, for instance, on the agricultural side, hard questions such as, do we need to change our husbandry behaviours? How are we going to change the curriculum? When we've already changed the curriculum for vets, do we need to go even further?

Really it is about having a concrete plan where we can see everybody reflected in a concerted effort to address the issue, with a way of actually tracking and measuring that.

[Rachael Thomas, Conservative, Lethbridge, AB]

Sure, and I think that's exactly my point. It's one thing to put pen to paper, but it's another thing to actually have measurable goals or objectives that are going to be attained and there's actually going to be a reporting mechanism or a measurable way to know that we've achieved something.

It would be a shame if we found ourselves at this table in another five years having this same conversation. We certainly need to make sure those goals are put in place.

I think that's my time.

[The Chair, Liberal, Bill Casey]

You had one second left.

Mr. Oliver.

[John Oliver, Liberal, Oakville, ON]

Thank you very much for the presentations.

I'm reminded a bit of a story I heard about algae growing in a pond. In 20 days, if it doubles in size every day, it would cover the entire pond. You begin on day one with what looks like a very small problem, and on day 17 a quarter of the pond is filled. On the 19th day it's half filled, and on the 20th day it's filled. That's the logarithmic growth you can get in some of these spreads.

In our case, we're looking at 10 million people worldwide, or 50,000 Canadians, if we don't manage it.

I listened to your testimony and read through it. All of you are pretty much saying the same thing: in collaboration, Mr. Chair, CIHR will continue building research capacity, and we're going to work to fight this global threat; from CFIA: we're making progress through collaboration, and there's still work to be done, but we're working on it; at PHAC, we'll continue to develop the federal contribution in global efforts to make sure that AMR will be addressed.

The message you're giving to the health committee, then, is that you're on it, that it's being managed, that there's still work to be done, but you have the capacity, frameworks, and collective efforts to address this problem.

I wish we had the pan-Canadian framework done, so that we could see what's in and what's not in it. I'll ask each one of you, however, is there anything you would like this committee to say in the House and to the minister to further prevent this potential crisis from emerging? Is there anything more that any one of you feels we should be doing?

I'll start with Dr. Njoo.

[Dr. Howard Njoo]

The one thing I would say that would be important to re-emphasize is that collaboration, which my colleagues have said has happened across sectors, between different levels of government, and so on, just needs to continue. We need to maintain the momentum.