Health Committee on Nov. 2nd, 2017

[Dr. Wendy Levinson]

There's no magic bullet. As you're hearing, this is a complicated problem.

There are some things that need to be done at a policy level and through surveillance and all the things you're hearing about. What we think also is that you have to engage health care professionals in this dialogue with their patients, because in the outpatient setting where a lot of antibiotics are prescribed, it's that one on one.... These higher-level things are needed, but it's also about engaging the profession.

Let me give you an example. If a family doctor is confronted with a patient who wants antibiotics, let's make their job easier for them. Let's give them tools so that the conversation is simpler. One example is prescriptions where you don't get the antibiotics. The prescription would say, “Take Aspirin, fluids, and rest, and in x number of days”—which the doctor fills in—“you can get this prescription if you're not better.” In those studies, it's only 30% of the prescriptions they had filled, because the cold went away in three days. That makes it easier for a doctor.

We have to engage the profession in trying to fix this problem, in addition—not exclusively—to these more policy-related.... Also, educate the public, because if the public thinks there is no harm in it, they'll just take the drugs. They are going to ask for them. If they understood that there might be harm to them or to their child, they would be less likely to ask for them.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Now we go to Mr. Webber.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair.

Thank you to our presenters. Your presentations were very interesting.

Dr. Keynan, you talked about some of these conferences you've held and attended, with AMR at the forefront. You talked about stakeholder meetings, stewardship programs, and case studies in particular.

You mentioned that Alberta is doing well at documenting strategies around case studies. I think I was one of those case studies. About three years ago, I went to hell and back. It started out as an evening of shaking many hands, as a politician, and I ask my colleagues to please listen closely and learn from this, because it is a very dangerous profession, politics, with a lot of handshaking.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Especially in the House.

[Len Webber, Conservative, Calgary Confederation, AB]

Yes.

I had a paper cut, which ended in an infectious bacterial blood infection, later a bone infection, which led to about two months of antibiotic use through a pump, days in the hospital—all from shaking hands.

First of all, I ended up in the infectious disease program at the University of Calgary. The doctor there started out with a small.... There are different potencies with regard to antibiotics. Is that correct, Dr. Morris? I started out with a weak antibiotic, so the doctor knew not to hit me hard because of his knowledge, I guess, of AMR.

It led to increasing the dosage, to the point where they used the most potent antibiotic to alleviate this problem, after two months. Could that not have been alleviated sooner if they had hit me hard right at the start? I would not have had to go through two months of hell.

[Dr. Andrew Morris]

You were addressing that to Dr. Keynan.

[Dr. Yoav Keynan]

With regard to addressing infections, no one in this room is saying that antibiotics should not be used. They should be used when appropriate. You start with the right antibiotics and you try to target. The problem becomes complicated in the presence of antimicrobial resistance.

Part of your work then becomes guessing, and that's part of the problem. The other thing is the absence of guidelines that tell you this is an individual who has this kind of infection and this is an appropriate start of antibiotics, versus this individual doesn't need antibiotics because this is a viral infection.

That would address the previous questions on how you explain to the patient and the family why you're avoiding the antibiotic in this case versus using the heavy guns in another case.

It's a combination, and there's no simple answer. I don't know enough details about your particular case. There are ways where guidelines can help us in making sure that patients who need the antibiotics get them immediately, without delay. However, the others who do not are avoiding the antimicrobial use that is unnecessary.

The problem is that there is significant collateral damage. Using broad spectrum antibiotics is not only acting on the patient who is receiving the antibiotic, but it's acting on the hospital environment. These organisms travel between patients and that's why we need to hit them early and hard, but we need to know when to narrow it down.

There are very good case studies of programs that you alluded to in Alberta, and in Mount Sinai. There is expertise, but that is available in patches and does not cover the entire country.

[Len Webber, Conservative, Calgary Confederation, AB]

Do you see any progress in what you're doing with respect to all these stakeholder meetings and such? Do you see doctors coming around in Canada, knowing more about AMR?

[Dr. Yoav Keynan]

For me personally, and for the NCCID, the biggest revelation was the fact that public health physicians, the public officers of health of different jurisdictions, did not see antimicrobial stewardship or resistance as part.... They have millions of problems on their desks that are related to multiple health concerns. Antimicrobial resistance was a threat that looked like something that is removed and not present.

Engaging them in the conversation has been very gratifying, because I think we now have champions. We have people who are interested. It's a matter of making the information available and finding more champions in additional jurisdictions. For that, a national centre that coordinates those efforts and copies those success stories.... We don't need to recreate the wheel for every region. We need to use the expertise available in centres of excellence.

In order for that to happen, we need sustainable funding, so those activities will be—

[Len Webber, Conservative, Calgary Confederation, AB]

Not only for doctors, but I think that Canadians need to know more about AMR as well. I think a lot of us here had no idea of this issue until the committee brought it up to study it.

How knowledgeable are Canadians?

Dr. Levinson.

[Dr. Wendy Levinson]

First of all, I think most people are more worried about their own infection, and this might seem theoretical to them, bugs that are resistant somewhere in the hospital. The research shows that you have to actually have people understand the risks to themselves. If people understand that antibiotics can cause bad skin reactions or allergies.... They're not benign. You don't want it when you don't need it. You want it when you need it.

I think there are a lot of misconceptions because people think treatment is better than no treatment, and we don't really explain risk to patients very well. It's just sort of not talked about in the doctor-patient conversation. It's sometimes hard to explain risk because risk isn't just black and white. It's a relative risk. It's a marginal benefit or a marginal risk. These are statistical concepts that are better explained with decision aids and visuals, and we lack a lot of that, so people don't really understand risk very well.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Ms. Sansoucy, welcome.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Thank you, Mr. Chair.

I want to thank the witnesses for contributing to the committee's work.

My first question is for you, Dr. Levinson. In a Huffington Post article published in 2016, you said the following:

We need to change doctors' practices to align with best practice by getting them to stop using various interventions that are not supported by evidence. And we need patients to consider that tests and treatments may sometimes not be necessary and may have potential risks and side-effects.

You said the same thing today.

In your opinion, if we had a national directive and an evidence-based form accompanied by decision-making tools for prescribers, would it help us reach your objectives?

[Dr. Wendy Levinson]

There are a lot of guidelines in many specialties. You've seen how doctors and societies produce guidelines, but they often address what we should do and not what we shouldn't do. They very rarely tell you what to stop. Think of all the older patients you know who are on a zillion drugs. What happens is that they go into their doctor's office, and the next specialist adds another drug, but people rarely say, “Let's look at whether you're on too many drugs.” Stopping things is not embedded as well in our guidelines.

We think if specialists themselves look at their practices and ask themselves about the common things they do where evidence shows they might do more harm than good and start to articulate that...because we haven't really as a profession articulated what we overuse. Twenty of our societies of the 60 that are engaged—and infectious disease is definitely one of them that's been working with us—have lists that include antibiotics. A lot of them have things around opioids, the other public health issue that you're certainly worried about. There are many reasons that overusing test and treatment gets baked in, so we need to engage the profession, I think, in trying to correct that problem because it's been around for a really long time without being addressed.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

You said that your approach was used in a number of countries. The World Health Organization has a global action plan to address antimicrobial resistance. As a member state, what kind of a responsibility does Canada have in terms of that global action plan? Do you know?

[Dr. Wendy Levinson]

I think probably some of the other people know the World Health Organization work better than I do.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Okay.

[Dr. Andrew Morris]

I can start. Our commitments are similar to what was outlined in the pan-Canadian framework, so we have responsibilities for surveillance, and we have responsibilities for antimicrobial stewardship and infection prevention and control. We equally have responsibilities to develop policies that support public awareness and change, and the pan-Canadian framework supports research and innovation along with that.

Because there are low-income and middle-income countries in addition to high-income countries in the United Nations and WHO agreements, the bar is actually relatively low. I can tell you that there are many countries, including the U.S., the United Kingdom, Australia, Germany, the Netherlands, Scandinavian countries, etc., that are putting in substantially more relative investment than Canada is, and have already started significant work and put in significant investments. In the U.S. alone, there's a presidential advisory committee on AMR with important national leaders getting together and advising on where investments should go. We don't have the investments to advise our leaders on where it should go.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Thank you. I will continue with a few questions.

Mr. Morris, in a CBC News article published in July, 2017, you said that, for quite some time, doctors have been telling patients to take antibiotics over a long period without scientific data to support their recommendation.

Here is what you said:

In general, we've always thought that a little bit longer is a little bit better. I would say that the conventional thinking—certainly what's been spread around for a long time—is that if you stop your [antibiotics] course too short you're going to help breed resistance. Resistance primarily emerges when bacteria are exposed to antibiotics. So the longer bacteria are exposed to antibiotics, the greater the risk of resistance developing.

Do you think that traditional thinking, which has been propagated on antimicrobial resistance, exacerbates the problem it is trying to solve?

[Dr. Andrew Morris]

Absolutely. That conventional wisdom is born out of misunderstanding, even of statements originally made by Alexander Fleming when he received his Nobel Prize, and from experiences with management of tuberculosis. They are not grounded in fact. Treating longer for most infections only exposes the patients to more harm, increases the likelihood of drug-resistant infections, and almost certainly doesn't give any benefit.

The reality is that, as I said in my presentation, the main two elements that you need for antibiotic resistance are bacteria and antibiotics. The more antibiotics, the more antibiotic resistance you get.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

You made various recommendations in your presentation.

How can we ensure that doctors who prescribe antibiotics have quick access to the most up-to-date evidence on antimicrobial resistance?

[Dr. Andrew Morris]

I think it's important that we have a system in place to allow that to happen. We need a centralized database, a centralized repository of the information. We need to make it readily understandable, so it has to be easy to digest. Things like infographics are very helpful. Much like when I alluded to the sports teams with their analytics, those analytics are easily understood by people who don't have training in statistics. We need to have complex data that is then analyzed and then churned out for prescribers—and the public, to be honest—and policy-makers so that it's easily understood. Really, the only way to do that is to have centralized data and to have investments in that data.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Thank you.

[The Chair, Liberal, Bill Casey]

Mr. Bratina, go ahead.

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

Thank you.

I'm from Hamilton. McMaster University has put a lot of research into this field. I was pleased that we have received research grants, but when I was participating in the awarding of the grants, I found out that there were two of 16 going to McMaster. I just looked up the release. They work closely with the researchers from the University of British Columbia, Simon Fraser, Dalhousie, developing software and database systems, etc. They weren't really large amounts of money.

Would it be better to find one or two centres rather than trying to distribute the money among 15 or 16? Would anyone comment on that?