Evidence of meeting #62 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was antibiotics.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Andrew Morris  Chair, Antimicrobial Stewardship and Resistance Committee, Association of Medical Microbiology and Infectious Disease Canada
Karey Shuhendler  Policy Advisor, Policy, Advocacy and Strategy, Canadian Nurses Association
Shelita Dattani  Director, Practice Development and Knowledge Translation, Canadian Pharmacists Association
Michael Routledge  Medical Officer of Health, Southern Health, Regional Health Authority, Royal College of Physicians and Surgeons of Canada
Yoshiko Nakamachi  Antimicrobial Resistance Nursing Expert, Canadian Nurses Association

11:45 a.m.

Conservative

Rachael Harder Conservative Lethbridge, AB

Thank you.

June 15th, 2017 / 11:45 a.m.

Policy Advisor, Policy, Advocacy and Strategy, Canadian Nurses Association

Karey Shuhendler

Yoshi sat on the committee, and so did a colleague of mine. Josette Roussel was a member of the CNA. We did have additional representation from CNA on that committee as well. We did provide input on the infection prevention and control draft framework, as well, which was merged into the complete report.

11:45 a.m.

Conservative

Rachael Harder Conservative Lethbridge, AB

Mr. Routledge, were you involved at all?

11:45 a.m.

Medical Officer of Health, Southern Health, Regional Health Authority, Royal College of Physicians and Surgeons of Canada

Dr. Michael Routledge

I don't think we were involved at all.

11:45 a.m.

Conservative

Rachael Harder Conservative Lethbridge, AB

Ms. Dattani.

11:45 a.m.

Director, Practice Development and Knowledge Translation, Canadian Pharmacists Association

Shelita Dattani

We were not involved on this particular committee. We are a part of the AMS national steering committee.

11:45 a.m.

Conservative

Rachael Harder Conservative Lethbridge, AB

Mr. Morris.

11:45 a.m.

Chair, Antimicrobial Stewardship and Resistance Committee, Association of Medical Microbiology and Infectious Disease Canada

Dr. Andrew Morris

AMMI Canada has had some involvement with it, as I, personally, have. I wear several hats. One of those hats is obviously representing AMMI Canada, but I also represent the Sinai Health System and University Health Network program. In my capacity of wearing all those hats, I've been involved. AMMI has also been involved with the other task forces.

11:45 a.m.

Liberal

The Chair Liberal Bill Casey

Time is up.

Mr. Davies.

11:45 a.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

Thank you, Mr. Chair.

Thank you to all the witnesses for being here.

Dr. Morris, you've given us, I think, a very trenchant description of the seriousness of the problem. On a scale of one to ten, ten being very serious and one being that we don't need to care about it at all, how serious is the issue of antimicrobial and antibacterial resistance in Canada today?

11:45 a.m.

Chair, Antimicrobial Stewardship and Resistance Committee, Association of Medical Microbiology and Infectious Disease Canada

Dr. Andrew Morris

Thank you for the question.

I'm not sure how to put a number on it. I'm not somebody who really wants to scare. It's very important. If we're talking about how much it will affect Canadians' lives in the next five to 10 years, I'm going to say it's going to substantially and almost certainly affect Canadians' lives if we don't do anything. In fact, it may involve Canadians' lives despite us doing something about it, because the world is small. We have to deal with antimicrobial resistance to not only those bacteria that we breed in Canada, but also to those that we import here through travel, immigration, agriculture, trade, etc.

11:45 a.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

Would you agree with me that the problem is serious and requires urgent attention?

11:45 a.m.

Chair, Antimicrobial Stewardship and Resistance Committee, Association of Medical Microbiology and Infectious Disease Canada

Dr. Andrew Morris

It requires urgent attention.

11:45 a.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

Thank you.

Now I want to try to get a handle on the causes.

Can anybody on the panel tell me what the contributors to antimicrobial resistance are, and list them in the order of priority for me?

11:45 a.m.

Chair, Antimicrobial Stewardship and Resistance Committee, Association of Medical Microbiology and Infectious Disease Canada

Dr. Andrew Morris

I'll start.

The number one cause of antimicrobial resistance is antimicrobial use. Antimicrobials are the “A” in AMR. One could argue that the only cause of antimicrobial resistance is antimicrobial use.

Without trying to be too pedagogical about it, I will just say that as I was teaching students yesterday, I said that if we went just outside and went to the lawn, there was a war being waged between bacteria and fungi. The fungi are defending themselves against the bacteria with antibiotics that they produce. The bacteria are defending themselves from the fungi by developing resistance mechanisms. That war rages on in many places.

We, as humans, don't tend to have many fungi in or on us, but we have many bacteria. When we do get exposed to fungi or the antibiotics that they produce, we use them to kill bacteria that cause us problems. Some of the resistance occurs out in the environment and comes to us, but there really is no major cause of antimicrobial resistance other than bacteria being exposed to antibiotics.

11:50 a.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

If I can focus you, Dr. Morris, I'm going to zero in on the human causes of antimicrobial resistance. Can you give me an idea as to the relative contribution to antimicrobial resistance of, perhaps, over-prescription to patients versus the contribution of antimicrobial use in veterinary medicine and agriculture?

11:50 a.m.

Chair, Antimicrobial Stewardship and Resistance Committee, Association of Medical Microbiology and Infectious Disease Canada

Dr. Andrew Morris

I'm not sure we know that. I think there have been several smoking guns over time related to certain strains of drug-resistant bacteria, but there is a lot of overlap.

In Canada, for medically significant antimicrobial resistance in humans, almost certainly more than half of that resistance is related to human use. It can be very difficult, because there's so much interface between, for example, the food we ingest and resistance that we may acquire from the food that it makes it very difficult to pinpoint it to one. This is why, again, I think all of us believe that taking a one health approach is really important, because there isn't just one problem that needs to be fixed.

11:50 a.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

I see.

Dr. Routledge, could you explain how the prescribing practices of physicians and the prescribing practices regarding antimicrobials are regulated, reported, or enforced?

11:50 a.m.

Medical Officer of Health, Southern Health, Regional Health Authority, Royal College of Physicians and Surgeons of Canada

Dr. Michael Routledge

I'll take a stab at that, and maybe Andrew can add something as well.

I would say that the prescribing per se isn't regulated. Overall practice is what would be regulated. Certain types of prescriptions would be more regulated. For example, narcotic prescriptions have a regulation to them. Antibiotics don't have those, generally speaking. I think probably where you're going is that the prescribing of antibiotics generally speaking isn't specifically regulated.

11:50 a.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

Do you think there's a need to have stricter antimicrobial prescribing practices? I'm curious about the prevalence of this issue, say, in the training of physicians. After all, it's physicians who are prescribing the antimicrobials. Should it be stricter? Is there enough education of physicians on the subject?

11:50 a.m.

Medical Officer of Health, Southern Health, Regional Health Authority, Royal College of Physicians and Surgeons of Canada

Dr. Michael Routledge

On that last question, I think the answer is no, and it's not just physicians. As we've talked about, this is really all health care providers, because not only is the prescribing expanding to go beyond physicians to include nurses and pharmacists, but also we work as teams. All the health care professionals involved in the teams need to have that education.

Should there be more regulation? I would say no. I think there are other ways you can get at this without regulating it. It's an option, but I would say there are other ways we can do it that are probably more effective.

If I could just add something, you asked the question about agricultural versus human use. I would basically echo what Andrew said, but I think both really are important. Depending on what you read, some sources will say that it's agricultural use predominantly; others will say human use is the major cause. The reality is that both are significantly important, so it really is important and critical to address both spheres.

11:50 a.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

Ms. Dattani and Ms. Nakamachi, is there enough education among the nursing profession and pharmacists about antimicrobial resistance?

11:50 a.m.

Director, Practice Development and Knowledge Translation, Canadian Pharmacists Association

Shelita Dattani

Maybe I'll answer first. I think there's always need for education, both intra-professional and interprofessional. Education in and of itself can be a relatively passive strategy. It's important, but it needs to be coupled with other things. What's worked really well—and Andrew can speak to this, I know—in the hospital care environment is direct audit and feedback, and physicians' prescribing practices being compared with those of their peers.

I've lived and worked in that scenario as well, and I feel that it has met with quite a bit of success. I think the way we educate and how we actively provide feedback becomes a little bit more salient than sort of more passive group education, but it's important.

11:55 a.m.

Antimicrobial Resistance Nursing Expert, Canadian Nurses Association

Yoshiko Nakamachi

Thank you for the question. I would have to agree that education alone is possibly not enough. It has to be coupled with other types of interventions or knowledge translation.

To answer your question with regard to whether there is enough education for these health care professionals, I agree that it's a team sport, but up until now, nurses have been largely ignored and underutilized and have not received the same type of training. Again, I think there definitely needs to be more training for both pharmacists and physicians, but for nurses there is almost no training available when they're doing their nursing degrees.

Also in the hospital setting and the community setting, there aren't educational programs for nursing or targeted at nursing, because the triggers for antimicrobial use or monitoring are very different for nursing than they are for pharmacists and physicians. The educational programs need to be specific to the profession. It's a team sport, and we all play different positions on the team.

11:55 a.m.

Liberal

The Chair Liberal Bill Casey

Time's up.

Mr. Kang.