Health Committee on Nov. 2nd, 2017

[Suzanne Rhodenizer Rose]

I think it's important to have one central repository, with everyone collecting data using the same methodology and the same case definitions. You'll find different epidemiological patterns based on where you are in the country. We know, for example, in the west there were higher incidents of antimicrobial resistance way back when with MRSA, for example. Moving across to the east, those rates were lower. There are differences across the country in rates.

By having a standardized set of case definitions, where it's funnelled up to one central repository where that information can be distilled down so that it is usable by clinicians and shared broadly across the country, we're able to benchmark our own individual locations much better.

[Dr. Andrew Morris]

I would just add that I totally agree with everything that was said. I think one of the dangers of having it just centrally, though, without having a true network—to disclose, I'm at the moment working on developing a network across the country to do this very thing—is that you lack some of the elements that Dr. Levinson was talking about in terms of having local engagement. I think it's really important to have engagement throughout the country so that it's locally relevant. It has to also address various marginalized populations. The indigenous community needs a stake in this as well.

Those things I think are all really important, but certainly someone has to have responsibility for coordinating that. So I would agree with that.

[Dr. Wendy Levinson]

I would just add another point, though. All of this is true. There are also certain research issues where we might want to have our experts around the country. For example, we might want social scientists to help us figure out, based on behavioural economics and social science, the best way to motivate doctors to make these changes, or the best way to present evidence. We might have these centres managing the epidemiology and the surveillance, but we might want to have researchers help to answer questions that would help us make the change better.

Those might be some of the kinds of grants we would still want.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

Thank you.

My next question is about immune systems and general wellness. I was an older high-mileage marathon runner, and I ran with a lot of medical people. One of the things we all did was keep running diaries, which also ended up being health diaries. For marathon runners, typically 30% of a marathon field will have a respiratory infection within two days after a marathon. We were told to be careful about taking too many remedies, because if you get a respiratory issue, it will go away. Sure enough, the diary shows that.

In terms of medical delivery, should we be spending more time on bolstering the immune system and general wellness in addition to working with the antibiotic problem?

[Dr. Yoav Keynan]

That's a complex question. I don't know that I have an answer to it. Part of a healthy and balanced immune system is maintaining the normal microbiome, whatever the normal microbiome is, and exposure to antimicrobials has an effect on that. The disappearance of the natural protection provided by the microbiome causes immune dysfunction and potentially more susceptibility to other infections. Actually, by prescribing antimicrobials only when they are needed, it has the effect of boosting that.

There are additional methods as well that I....

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

Okay. I have another question.

I led a medical delegation to the city of Qingdao in China in January of this year. We were looking at a very large complex that they're building in that city. It was interesting to discover the extent to which traditional medicines have been integrated into the medical system in China. Is there anything to be learned from that in terms of the way they treat infections, often with herbal remedies that have existed from time immemorial?

[Dr. Andrew Morris]

Is there a potential benefit? I think the answer most people would say is “yes”. I think all of us have already alluded to the fact, though, that we don't have enough investment in the basic elements of public health infrastructure, the things that will prevent infections—hand hygiene, good environment, not overcrowding, sanitation, and those elements—as well as surveillance and understanding of what our problems are.

I think in the interest of drug development and cures, there absolutely are benefits. I think most investigators looking into cures, whether they be in industry or academia, have also started looking at alternative and traditional medicines. I think that's just a different avenue. That's part of the research and innovation aspect of our pan-Canadian framework.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

Do you have any comments on the proliferation of disinfectants—you know, the little hand things that are all over the place—and how they relate to the general issue?

[Dr. Andrew Morris]

I will let our IPAC Canada colleagues answer.

[Jennifer Happe]

To date, there's no evidence that bacteria become resistant from the alcohol, so at the moment, it really does benefit more than harm. There's really sound evidence to show that the practice of good hand hygiene can have a significant impact on the spread of micro-organisms, so at the moment, it's a very cheap, but very powerful, solution.

[The Chair, Liberal, Bill Casey]

Be really quick, please. You're running out of time.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

It's interesting to me that the real problem seems to be communication and, in the age of communication, that doctors and patients don't have enough information.

Thank you.

[The Chair, Liberal, Bill Casey]

Ms. Gladu, and I owe you an extra minute from the very first round.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Oh, very good.

As I understand it, the World Health Organization has this plan that involves these pillars: surveillance, infection prevention, stewardship, and research. Have they agreed on an antibiotic protocol, that is, which ones will be used first to attack, or do we have situations where one country is overusing a certain antibiotic and developing resistant bacteria there, and then, of course, those people are getting on planes and flying over here where a different antibiotic is being used?

[Dr. Andrew Morris]

First of all, it's not a feasible thing to have a universal protocol because bacteria and their resistance differ internationally. There's certainly a hope that eventually we'll have an acceptable standard policy for what settings they can be used in so that they should only be used for humans or animals that have documented infection, or where the use of antibiotics for prevention is of benefit, and that they should be prescribed by a health care professional. I think, as a starting point, we need to get to that stage because you can go to the market in some developing countries and just choose by colour, shape, and size which antibiotics you want.

It's important to Canadians that we advocate for wise use across the country. For most of the drug-resistant infections that we have in Canada, the strains originated elsewhere, but some did not. We even have some strains that we're proud to call Canadian, but many have come from elsewhere as well.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

In terms of Canada, is it just an issue of educating physicians and the public, or is there any incentive for doctors to prescribe one antibiotic or another?

[Dr. Andrew Morris]

I'll start that at least.

Education is really important, but we know in health care that education alone doesn't work. In terms of what we refer to as implementation science, it is probably one of the weakest interventions we can have. We need governance and policy. We need best practices. We need to have force functions. We need to understand, as Dr. Levinson mentioned, what behavioural economists and other people who know how to change behaviour know already. We need to put systems in place to make it very easy to do the right thing. Education alone is not going to make much of a difference.

[Dr. Wendy Levinson]

I'll just add to that.

There is a variety of things that we do know work that are pretty simple to do, like audit and feedback. If you show me that I'm prescribing twice as much as my colleague for similar patients, I'll think, “Wow, I'd better change that.” There are some very simple things, but we do lack the infrastructure to do those things.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

That's the next question. How much money do we need for the infrastructure and research that's needed? Do we know that?

[Dr. Andrew Morris]

A hundred million dollars.

[A voice]

Are you serious?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

A hundred million dollars. Okay.

Ms. Rose.

[Suzanne Rhodenizer Rose]

I don't actually know the amount, but I do know there are pre-existing platforms in infrastructure that we can build upon and leverage so that we're not going out and spending $25 million on a database or a national repository. We can pull and leverage what's already pre-existing.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Excellent.

[Dr. Andrew Morris]

If I could just add.... There was a comment about whether I'm serious. I'm dead serious. We use well over a billion dollars of antimicrobials. We spend billions of dollars isolating patients and doing things to prevent spread. With $100 million, we'll reap that reward in spades.