Thank you.
Mr. Chair and honourable members, I am honoured to have the privilege and opportunity to present to you on antimicrobial resistance.
I come to you as chair of the antimicrobial stewardship and resistance committee of the Association of Medical Microbiology and Infectious Disease Canada. We represent the medical specialists in Canada with expertise in antimicrobial resistance: how it develops, how to prevent it, and how to manage it.
I am also a practising academic infectious diseases physician, running the country's oldest and largest antimicrobial stewardship program at Sinai Health System and University Health Network in Toronto.
I want you to know that I became an infectious diseases physician so that I could cure people. Antibiotics are used to cure, miraculously. This book, titled The Clinical Application of Antibiotics: Penicillin, is from 1952. As you can see, it is 700 pages long, and it describes the miracle of penicillin. If we were to revise it today, it would be about 100 pages long, as most of penicillin's utility in medicine has been lost because of resistance. In fact, most doctors today don't even know how to prescribe penicillin.
Antibiotics, to infectious diseases physicians, are like scalpels to surgeons. The only difference is that infectious diseases physicians don't really get the glory; the antibiotics do. That heuristic of reliably curing people with antibiotics ended for me relatively early in my career, about 14 years ago, when I was taking care of a young man—a husband and a father—in Hamilton, Ontario, where I was working at the time. He had a brain infection due to a drug-resistant bacterium. It became resistant because it was repeatedly exposed to the antibiotics he was receiving. I had to use what at the time was relatively experimental therapy. He died, either despite me or because of me.
That event, which was the critical event of what I had seen emerging over the years prior, due to overuse of antimicrobials, has shaped what I do today, and it leads me to what I want to cover with you in the next few minutes.
First, what is antimicrobial resistance? Antimicrobial resistance, or AMR, is basic Darwinian selection. Bacteria in the environment—in humans, animals, birds, or aquaculture—are exposed to antibiotics, and as many of the drug-susceptible bacteria die off, bacteria that have randomly developed a mutation rendering them resistant to the antimicrobials thrive. There are only two things required for antimicrobial resistance to develop: bacteria and antimicrobial use. When the drug-resistant genes in bacteria take hold in a community or a population, the ability to reverse the growth of drug resistance ends up being rather uncertain.
Why should the House Standing Committee on Health and the Canadian public care about AMR? Canadians pride themselves on their health care. They have come to expect safe pregnancy and delivery, including C-sections; neonatal care; management of common infections such as pneumonia and urinary tract infections; routine surgeries such as appendectomy, cardiac surgery, and joint replacement; cancer care; and even organ and stem cell transplantation. These are all threatened by antimicrobial resistance.
For some of these conditions, it is actually a present-day threat, rather than a future one. Up to half of the pathogens causing infections in cancer and surgery are already resistant to first-line antibiotics in the U.S. I would like to quote Canadian data, but we don't really have reliable ones. It is likely comparable.
Whereas untreatable infections were unheard of when I first started practising medicine, physicians like me are already routinely seeing patients for whom we are using novel therapy to treat routine infections. Many antibiotics are rendered so obsolete by drug resistance that manufacturers have stopped producing them and clinicians have stopped learning about them.
When I started practising medicine, the only common AMR acronym in our lexicon was MRSA, methicillin-resistant Staph aureus. Today, that list also includes KPC, ESBL, NDM-1, VRE, and CDI, and the list goes on.
These all cost the health care system billions of dollars. This is juxtaposed with the over $1 billion we spend on prescription antibiotics in Canada, about half of the use of which is unnecessary. More important, it is an overall threat to national security. It threatens Canadians in a manner greater than violence and accidents combined.
AMR doesn't have headlines. When a woman needing a lung transplant recently ran out of effective antibiotic options to keep her alive, the story in the media was on the heroic removal of the infected lungs and keeping her alive, rather than the fact that she had a tipping point of completely drug-resistant infection.
AMR has no walks, runs, bike rides, golf tournaments, or galas. It has no ribbon, and the pharmaceutical industry has either distanced itself from antimicrobial development or fought to prioritize drug innovation over antimicrobial stewardship, or the wise use of antimicrobials.
What is needed to tackle AMR? Almost a year ago today, on June 16 and 17, I co-chaired the national action round table on antimicrobial stewardship, co-hosted by HealthCareCAN and NCCID. That event included 50 thought leaders and stakeholders from across all sectors, some of whom you will hear from today. We came up with a menu of what needs to get done.
For starters, convene and fund a national network to coordinate stewardship, herein known as AMS Canada; nominate executive leads on AMS at the federal, provincial, and territorial levels for strategic planning and implementation; enhance accreditation for AMS; support and scale up core operations in hospital-based AMS; enhance awareness of AMR and AMS among prescribers and public; establish an AMS or antimicrobial stewardship research and development fund; develop and support core datasets in AMU or antimicrobial utilization surveillance; incent community prescribers, using audit and feedback mechanisms; develop national guidelines for antimicrobial prescribing and mechanisms to promote adoption; and finally, develop a network of centres of excellence in knowledge mobilization for AMS.
As I mentioned, that was one year ago, almost to the day, and what has happened? Its the same thing that happened with the 2004 report, “National Action Plan to Address Antibiotic Resistance”, and the 2009 report following pan-Canadian consultation by the since-defunded Canadian Committee for Antibiotic Resistance.
In 13 years, we have had three national reports on antimicrobial resistance, and the collective response from the federal government remains a tacit one. In fact, the Public Health Agency has all but eliminated any anticipated funding towards antimicrobial stewardship and surveillance for the upcoming year. “Suspended” is the term we have been given. This pales in comparison to the United States, which spends over $1 billion annually to combat antimicrobial resistance, with an effort that includes the Departments of Defense, Justice, and Homeland Security, amongst other departments. The United Kingdom has equally provided strong leadership and effort, with their chief medical officer of health, Dame Sally Davies, perhaps the strongest world advocate on the subject.
In Canada, antimicrobial stewardship and resistance research funding is less than $10 million per annum. More has been announced recently, but this compares with CIHR funding of $273 million for cancer or oncology, which has another $95 million from the Ontario cancer institute, $91 million from the Fonds de recherche du Québec—Santé, and numerous other research sources.
I could go on, but suffice it to say that, in Canada, antimicrobial resistance is not being sufficiently addressed. This is reinforced by our own Auditor General who two years ago concluded that the Public Health Agency of Canada and Health Canada “have not fulfilled key responsibilities to mitigate the public health risks posed by the emergence and spread of antimicrobial resistance in Canada.”
The Auditor General also stated that the Public Health Agency of Canada:
has not determined how it will address the weaknesses it has identified in its collection, analysis, and dissemination of surveillance information on antimicrobial resistance and antimicrobial use. The Agency has taken some steps to promote prudent antimicrobial use in humans, such as developing and disseminating guidelines for health professionals, but has identified the need for more guidelines.
Honourable committee members and Mr. Chair, on behalf of AMMI Canada, I stand here to tell you that Canada has been lucky to avoid an antimicrobial resistance catastrophe. I am not a boy crying wolf. There were warning signs around opiates for decades and they only became front of mind when the deaths escalated, researchers started identifying the public health crisis, and civil society took notice. Governments have had to play catch-up ever since.
Today, I represent the voices of Canada's experts on infectious diseases and antimicrobial resistance telling you that the current situation and the crisis that we will be facing will be like it is with opioids, only worse. The victims will span all ages. Our health care system will be paralyzed. The costs of ignoring AMR today will be paid many times over in lives lost. When the post-mortem will be done, as it was for the Naylor report following SARS, the country will look to missed opportunities and ignored warning signs. You have an opportunity to heed those warning signs.
Thank you for your attention.