Health Committee on June 15th, 2017

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Mr. Chair.

I'll tell you that the more I read about this, I get worried. It seems that humankind may have, what, only 70 or 80 years where these drugs are effective? They have been game-changers.

I want to thank all of you, because it is a huge issue and it's not getting the attention it needs. It's an issue not only here on the ground in Canada, but internationally. It affects everything from livestock to feedstocks. I'm going to try to ask you some uncomfortable questions. I hope you don't mind, but you're the experts and you're here.

Doug mentioned a really good point with our last round of witnesses, which is that sometimes in the practice of medicine or health care on the ground, people get into their prescribing habits and things along those lines.

Dr. Morris, I think you brought up the opioid crisis. Here at the federal level last year we brought up the topic. We got experts in and all that stuff, and what has happened in Canada? This past year, there were more prescriptions instead of fewer. You're here. This is a federal committee, and what we want to hear from you is what the federal government should do. Should the federal government be using more of a heavy stick here? I think it was David Cameron who called “on the governments of the richest countries” of the world “to mandate now that by 2020, all antibiotic prescriptions will need to be informed by up-to-date surveillance information and a rapid diagnostic test wherever one exists.”

You mentioned the dentists, who aren't here to defend their prescribing practice, but we have three organizations here that are hugely important and have a role to play. What would you tell these guys sitting next to you about what they should be doing? Also, what should the government be doing? How far should they be going with the carrot-and-the-stick type of thing?

[Dr. Andrew Morris]

Thank you for the question. I'll try to be as brief as possible.

On the CARSS, Canadian Antimicrobial Resistance Surveillance System, report, I apologize to the people who have done very hard work on it, but it relies on data of very poor quality, and I don't trust it for the paper that it's printed on. We have no current understanding of antimicrobial use in Canada and in most provinces. It's the same problem that we've had with opioids. If you can't properly, reliably, and validly identify the problem, it's very difficult to act on it. A basis has to reside with good data.

Yoshi and I are colleagues, and we've learned over time that leadership is absolutely important in this. I'm going to say that the national leadership around antimicrobial resistance has been largely deafening in its silence. We don't really have a national voice on antimicrobial resistance and stewardship. AMMI Canada likes to see itself as a partner with some of these other organizations here in taking a leadership role, but we need a more centralized role. It hasn't come from the federal organizations. For most provincial organizations as well, we haven't seen that.

Almost certainly what needs to be coupled with leadership and sound data is money that supports an infrastructure to share information across the country, to act on a plan that has been very carefully thought out, and to then be able to provide on a broad level and then at a very granular level the issues around antimicrobial use and antimicrobial resistance. They are intertwined; they are not separate. They are very closely related, and they include both humans and animals and other aspects of our “one health” ecosystem.

When we don't have significant money being put into the pot, we don't have leadership, we don't have reliable data, and we aren't going to go anywhere without those foundations.

[Colin Carrie, Conservative, Oshawa, ON]

I appreciate the answer. I appreciate your trying to be brief, but I think I'm almost over four minutes out of my five minutes with that comment. There are huge challenges in Canada and with the provincial jurisdictions.

You talk about leadership. Have you brought this to the Council of the Federation? I'll give you one word: Quebec. With your national association, when you get provinces and territories together, sometimes there seems to be some protection of who should be doing what. Have you brought this to the Council of the Federation to see if you can get agreement across provinces and territories? That seems to be a block.

[Dr. Andrew Morris]

We have not. I'm not familiar with that council. I apologize.

[Colin Carrie, Conservative, Oshawa, ON]

Okay. I think some of the other organizations are, but I see that my time is up.

Mr. Chair, I know that afterwards we're going to be talking about the potential cannabis bill. I hope we can do that publicly instead of in camera.

[The Chair, Liberal, Bill Casey]

Okay.

Now we go to Dr. Eyolfson.

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

Thank you.

I'm sorry if I'm hard to understand. I had to explain this on Tuesday: I have laryngitis. As I explained to the last panel, I'm not on antibiotics.

[Voices]

Oh, oh!

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

Ms. Dattani, thank you. You made my job very difficult today because I had a number of questions for you and you answered them in your presentation before I got a chance to ask them.

Dr. Routledge, as we discussed at the door, I'm an emergency physician. I trained in the Royal College program about 20 years ago. Through the program, we went through pretty much every specialty in medicine: general surgery, intensive care, internal medicine, and orthopaedics, which is where we learned that the heart is the muscle that pumps the Ancef to the bones. Given that every specialty I was in, with the exception of psychiatry, prescribed antibiotics, would it be a reasonable thing to make sure that units on antibiotic resistance be included in the guidance of the curriculum of all the different residency programs?

[Dr. Michael Routledge]

The quick answer is yes, but I'm going to divert your question if that's okay, because we've talked a lot about education. There are all kinds of things we've talked about in terms of analogies to the opioid crisis. Climate change is actually another interesting analogy.

What's missing right now is that while providers have heard this for a long time, and I think all physicians—and I'm going to say other health care professionals too—know about antimicrobial resistance and know they should be following guidelines, I personally think the challenge is that our health care organizations in this country haven't taken this on. In terms of national leadership, Accreditation Canada has really moved that forward by introducing this ROP, which means that health care CEOs across this country have to care about this now, whereas before they didn't.

Until we actually create structures whereby the health care organizations in which health care workers work are seeing this as a priority and developing it, it's tough to get providers to say that they should care about this. If you just put it on education, it's not going to happen. Andrew used the word “environment”, I think, at some point in his comments. You have to create the environment. You must have the health care organizations making it easy for providers to follow the appropriate guidelines. We need to have the education, but until the health care organizations take this on...and that needs to come from the bottom up and top down.

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

Thank you.

Dr. Morris, I was very interested in what you said about the lack of a role in failure to complete a course of antibiotics, because that was one of the things I was taught in residency: you should use antibiotics like azithromycin, which have a shorter course, because they're more likely to complete, and less resistance, and how we find out.... As I say, that's news to me that it's not actually an issue. That was very interesting.

My challenge is that my whole career was in the emergency department. The last eight years were in an inner-city emergency department. There was a lot of poverty. A large proportion of my patients did not have a primary care physician. All their primary care was through the emergency department, so we saw things that we had to prescribe antibiotics for, and follow-up was a tremendous challenge.

How would you advise the emergency medicine community? They're doing a greater share of primary care. What advice would you give to that field in follow-up and their antimicrobial stewardship?

[Dr. Andrew Morris]

Thank you for the question.

I do a fair amount of work with emergency physicians in my LHIN in Ontario, my local health integration network. It's really an issue of knowledge translation. Emergency physicians are front-line physicians. As you mentioned, increasingly they play a role in primary care. It's not so much preventative care, but primary care. I don't see it as much different from any other aspect of the health care system in terms of wise use of antimicrobials. We need to put systems in place. We need to have tools available to the prescribers so they make the right decisions, and so it's easy to make the right decisions and very difficult to make the wrong decisions.

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

That's true. We were taught that “emergency medicine is the art of making correct decisions with insufficient information”, so that's good to know.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now we go to Mr. Webber.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you.

The first thing I want to talk about is climate change. Something I read in an article a while back was in regard to the recession of our glacial waters and our pack ice and such. What's coming up, apparently, are ancient organisms that are getting into our lakes, organisms that we're not familiar with.

I don't know whether to ask you about this, Dr. Morris, or you, Dr. Routledge, as to whether or not you have the college studying or researching this. Have you heard of any research going on with respect to preparing for these ancient organisms that will perhaps one day hit us as a population?

[Dr. Andrew Morris]

I haven't. I'm sorry.

[Len Webber, Conservative, Calgary Confederation, AB]

All right. I was hoping to ask that in the last session, but of course I didn't have enough time. I just thought I'd throw that out there.

I want to share the story of an experience I had. Most politicians meet people and shake hands daily. About three years ago, after shaking hands with about 200 people at an event, I went home with a sore wrist. I woke up at three in the morning with a hand that was about two times as large. I went to emergency, where they basically cut my hand open. They took blood samples, and of course I had an infection, through a tiny little cut I had in my finger, that apparently I got from shaking hands. This led to many levels of antibiotics. I spent a week in the hospital. They were talking about perhaps amputation, which scared the heck out of me as well. I went through two months of carrying an antibiotic pump on my side.

That was all because of shaking hands and getting infected. I warn everyone to continually wash their hands. I know that's been part of the education program.

By the way, Mr. Chair, I don't even know if we have any of that handwash stuff in here. We need to get it. Can we work on that?

[The Chair, Liberal, Bill Casey]

Absolutely.

[A voice]

It's out in the hall.

[Len Webber, Conservative, Calgary Confederation, AB]

Okay.

I've become very paranoid. I don't touch doorknobs anymore. When I do shake a hand, I think about wanting to quickly go to the washroom to.... No, I'm just kidding.

Ms. Sidhu brought up awareness in Canada about such things, and about how we can easily become infected. I hope that is very much a part of the Nurses Association.... I have to say that the nurses were incredibly wonderful at the Foothills hospital in Calgary. I can't say enough about them in treating my episode. I do believe it is incredibly important that we teach kids at a young age to wash their hands, to be aware not to put their hands in their mouths and their eyes. I just wanted to share that, and I hope that is part of your mandate for the future as well.

Do you have any comments on that at all, about where you are with education?

No, it doesn't look like it. Okay.

Boy, this is difficult, trying to get—

[Karey Shuhendler]

Thank you for sharing that story. It highlights some of the challenges that people experience first-hand with resistant organisms or infections.

In our brief we recommended, as an example, the scaling up of community-based antimicrobial stewardship programs. We used the example of Do Bugs Need Drugs? I'm not sure if the committee is familiar with the program, but as Yoshi mentioned, it targets across the lifespan. It does teaching in schools about washing your hands, about when you need vaccinations or not, or when you don't need medicine if you're sick. There are those programs that are available that CNA absolutely believes in.

Much of Do Bugs Need Drugs? is a collaborative effort. A colleague of ours who presented last week, Kim Dreher, is a nurse, and she said that at the outset of delivering those programs they were nurse-delivered in communities. Now they're also delivered by med students and pharmacy students. It's a very collaborative effort.

Really, the shift to public education has to start with health care providers. Of course, being from the Nurses Association, I'll just highlight that sometimes nurses are the only health care providers in a community or in a setting. We appreciate the opportunity to respond to that, because we are sometimes people's first point of contact with the health care system. We have a role here in making sure that people are aware in terms of preventing infections but also judiciously using antibiotics.

[The Chair, Liberal, Bill Casey]

Thank you, Mr. Webber, for the excellent questions. Your time is up.

Mr. Oliver.

[John Oliver, Liberal, Oakville, ON]

Thank you.

Thanks very much for being here today and for your testimony.

I got a bit confused listening to this. I had always thought that AMR was about a pathogen that for various reasons had become resistant, and about the difficulty of treating at-risk people. I kind of heard in the testimony, particularly from Mr. Morris, that AMR is about ongoing exposure to antibiotics. Are there situations where individuals become resistant? Is it more about a pathogen that's resistant that then becomes transmitted, or is it about individuals becoming more AMR because of their antibiotic use?

[Dr. Andrew Morris]

Thank you for that question and allowing me to clarify. People in and of themselves don't become resistant. It's somewhat of a metaphysical kind of question, because to some degree we're not only what we traditionally think of as ourselves but also the organisms that are in and on us. We each have our own bacterial fingerprint.

The person doesn't become resistant. It's the pathogens, that for many people don't cause any problems, that develop resistance and may be passed on from person to person, or animal to person, or the other way around. When those take hold and cause disease, that's when we have a clinical problem. People in and of themselves don't characteristically develop resistance; it's the bacteria, the pathogen, that can be transferred onward.

[John Oliver, Liberal, Oakville, ON]

Okay. Thanks for that.

There were two recommendations, I think, from the Canadian Nurses Association, and I heard a number of strategies from the pharmacists group.

The committee will be issuing a report. Do you have any other recommendations? We know that a new national pan-Canadian framework is coming out. There are the 10 recommendations in the action plan. Is there anything else that you recommend we flag to the minister and to the government to expedite or improve our response to AMR?