Evidence of meeting #76 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was amr.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Wendy Levinson  Chair, Choosing Wisely Canada
Andrew Morris  Director, Antimicrobial Stewardship Program, Sinai Health System
Yoav Keynan  Scientific Lead, National Collaborating Centre for Infectious Diseases
Suzanne Rhodenizer Rose  Past President , Infection Prevention and Control Canada
Jennifer Happe  Officer and Director, Infection Prevention and Control Canada

3:30 p.m.

Liberal

The Chair Liberal Bill Casey

I call the meeting to order.

This is our 76th meeting of the Standing Committee on Health. We're going to continue our study on antimicrobial resistance.

We have a very distinguished lineup of guests today.

From Choosing Wisely Canada, we have Dr. Wendy Levinson, chair.

From Sinai Health System, we have Dr. Andrew Morris, director of the antimicrobial stewardship program. Welcome.

From Infection Prevention and Control Canada, we have Suzanne Rhodenizer Rose, past president; and Jennifer Happe, officer and director.

From the National Collaborating Centre for Infectious Diseases, we have Dr. Yoav Keynan, scientific lead.

Thanks very much for coming. We look forward to your testimony.

Dr. Levinson, would you like to start off with a 10-minute opening statement?

3:30 p.m.

Dr. Wendy Levinson Chair, Choosing Wisely Canada

Thank you for the privilege of addressing your committee. I am here in my role as the chair of Choosing Wisely Canada.

We are a national clinician-led campaign that helps clinicians and patients have conversations about unnecessary tests, treatments, and procedures in order to help patients make informed choices. We also organize an international collaboration of Choosing Wisely campaigns that are presently in 20 to 25 countries around the world.

There is evidence from the Canadian Institute for Health Information that up to 30% of all the tests and treatments we do are unnecessary, meaning that they don't add value for the patient, and in some cases they are potentially harmful. Certainly, unnecessary antibiotic use is one such problem, where it doesn't necessarily benefit the patient, can potentially have harm, and has harm potentially to the broader society as a driver of antimicrobial resistance.

As you well know, antimicrobial resistance is a global problem, with causes far beyond human health care, and there needs to be multifactorial solutions, but in health care, antibiotics are overused unnecessarily in hospitals, primary care and outpatient clinics, and long-term care facilities.

I will provide you a bit of the understanding of the drivers of the overuse and some insights into some strategies that might be used to tackle it. It's important to say that overuse of many tests and treatments, such as antibiotics, is complicated. Overuse is baked into our system. It's in our medical culture. There are clinician, patient, and systems factors that relate to this overuse.

Clinicians might prescribe antibiotics unnecessarily for a variety of reasons. They have a perception that patients want a prescription, and they want to please their patients. If you're with a parent and the child has been up all night with an earache and a fever, you want to provide relief. It can actually take longer to explain to a mother why her child has a viral infection, not a bacterial one, and that antibiotics won't help, so we know that it is often easier to just prescribe them.

We also know from research that patients are typically comforted if they feel that a physician has listened and paid attention to their symptoms. They don't necessarily need the prescription. To be frank, in a busy and full clinic, when doctors are rushed, it can be easier to write a prescription than have a conversation that physicians might experience as challenging.

On the broader public side, there are many misconceptions, as you know, about the effectiveness of antibiotics for common colds and viral infections. We live in a society where people might expect medicine to offer quick fixes and a magic pill for every ailment. That's our culture. Patients often come to the doctor's office with an expectation that they'll leave with a prescription in hand. They're also not aware of the potential harms in general of unnecessary tests and treatments, and certainly of antibiotics in particular.

Finally, there are just health system factors that drive unnecessary antibiotic use. For example, we lack in Canada good information systems to give feedback to doctors and other clinicians about their prescribing practices. We work in hospitals and clinics with a real heterogeneity in the types of computer systems that we have that could be harnessed to help prescribers pick the right antibiotic for the situation. We also in hospitals have existing order sets, which are basically pre-written orders for certain situations, and they might encourage overuse.

What does Choosing Wisely Canada have to do with this? In our view, change happens from the inside out. It's our view that health care professionals themselves need to lead the conversation about the problem of overuse in general, and specifically about antibiotics. This is done through national specialty societies. There are about 60 participating organizations right now, including family medicine, physician specialists, nurses, pharmacists, and dentists. These societies work internally to develop a list of Choosing Wisely recommendations that are inside their specialty. They pick, as a minimum, five tests and treatments that are clinically unnecessary or could potentially be harmful to patients. Having that physician, nurse, or clinician buy-in generating the lists ensures that the campaign is grassroots. We think that's the most effective way, rather than top-down.

At present, there are about 270 Choosing Wisely recommendations, and about 20 specifically addressing antibiotics. I'll give you a couple of examples. In family medicine, there's a recommendation that reads, “Don't use antibiotics for upper respiratory tract infections that are likely viral in origin.” For the emergency room, they have a recommendation, “Don't use antibiotics in adults or children with uncomplicated sore throats.”

Another way of engaging the clinicians in this is through the next generation. We are working to teach in medical schools. Two years ago we launched a very interesting program called Choosing Wisely STARS. It was actually started by the students. STARS stands for students and trainees advocating for resource stewardship. It's a grassroots, student-led campaign designed to change the culture in medical education by addressing the behaviours that drive overuse.

At the patient level, we also need to work to change patient and public expectations, but this is clearly a major challenge. We've been working on it through a number of strategies to promote the message that more is not always better. Maybe some of you have seen our hot dog with too much mustard on it, and of course, then, specifically, for antibiotics, it's the same.

The campaign has been aimed broadly at the public through the media. We've worked with news media, and radio and TV outlets, and have written op-eds, but more specifically, we've launched targeted campaigns to educate patients when they are in the physician's office where these issues are top of mind. For example, we've distributed posters to all the family doctors in Ontario where the message is that more antibiotics will not get rid of your cold. We have these posters and additional materials for patients because we're trying to promote patients asking three questions: do I really need antibiotics; what are the risks; and are there simpler or safer options for my condition?

Finally, there's a need to tackle the health system drivers. Physicians practise in a way that is strongly influenced by their local clinical environment. In order to tackle the system factors that drive overuse, we've tried to bring together stakeholders who influence that practice environment and make it easier for physicians to do the right thing, which is to avoid unnecessary prescriptions.

There's growing evidence in Canada through demonstration projects that we can change that practice environment. For example, in Newfoundland and Labrador, the Choosing Wisely group is giving primary care doctors data about their prescribing practices compared to their colleagues, and additionally, they have a big public education campaign about avoiding unnecessary antibiotics.

At Choosing Wisely, we help foster this burgeoning community of early adopters. In fact, just earlier today there were almost 100 sites on a webinar about antibiotics and how to avoid using them. We've seen clinicians really from coast to coast, in a variety of settings, such as hospitals and clinics, try to start using quality improvement measures to promote the recommendation that more is not always better.

Finally, of course, antimicrobial resistance is a global concern. As I mentioned, we have an international collaboration of between 20 and 25 Choosing Wisely countries. We've been working with the OECD, for example, which has measured the rates of antibiotic use in different countries. As you might know, our antibiotic use is quite a bit higher than that of some countries. In fact, it's double that of the Netherlands, so we're trying to learn from our Dutch colleagues why they did better than us on this, especially in their outpatient setting.

In summary, we have a long way to go to tackle the problem, but we're optimistic. We think unnecessary antibiotics, similar to other overused tests and treatments, are just part of the medical culture, but if we can engage physicians and health care professionals to provide leadership in making change, change is very possible.

Physicians are not the only drivers. We have to work in a complex system with a variety of clinicians, patients, and health care system factors. Between clinician leadership and patient education, we can stimulate those conversations one on one between doctors and patients or nurses and patients about whether the patient really needs these antibiotics or not. We're using evidence-based, informed strategies to change and work with the broad network of people in the system—clinicians, patients, the public, and the health care provider organizations—to try to deliver the message that more is not always better in health care, particularly with antibiotics.

I'm very eager to participate in your discussion.

3:40 p.m.

Liberal

The Chair Liberal Bill Casey

Thank you very much, and we're very eager for you to participate in our discussion.

Now we go to the Sinai Health System.

3:40 p.m.

Dr. Andrew Morris Director, Antimicrobial Stewardship Program, Sinai Health System

Thank you, Mr. Chair and honourable committee members. I'm honoured to have the privilege and opportunity to present to you on antimicrobial resistance, or AMR.

I come to you as director of the Sinai Health System-University Health Network antimicrobial stewardship program. Sinai Health System and University Health Network are two academic health care organizations in Toronto that are widely recognized as local, provincial, national, and international leaders in health care.

As a note, without getting into semantics, I'm going to be using “antibiotics” and “antimicrobials” interchangeably for this presentation.

I became an infectious diseases physician so that I could cure people. Antibiotics are used to cure, miraculously. 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.

The heuristic of reliably curing people with any old antibiotic is gone. Frequently now, doctors guess at the infection they're treating, and often guess wrong. Increasingly, even when they know what infection they're treating, doctors find themselves at a loss to choose a curative antibiotic.

As potential patients, you should be scared. As lawmakers, you should be rightly driven to action by this most important global public health crisis of our generation.

I'll be describing four things for you. What are antibiotics? What is AMR? Why should the House of Commons Standing Committee on Health and the Canadian public care about AMR? What can you and Canada learn about tackling AMR from the Sinai Health System-University Health Network antimicrobial stewardship program?

What are antibiotics? Organisms in the environment, especially bacteria and fungi, fight each other for survival. By and large, antibiotics are the weapons used by fungi to ward off bacteria. Alexander Fleming taught us to exploit these weapons to kill bacteria, so that now, not only environmental bacteria, but also animal, fish, bird, and human bacteria, known as the microbiomes, are also exposed to antibiotics intentionally.

What is AMR? Antimicrobial resistance, or AMR, is basic Darwinian selection. Most bacteria exposed to antibiotics die off, but bacteria that have randomly developed a mutation rendering them resistant to the antibiotic end up thriving. These new emerged strains of bacteria are therefore antibiotic resistant. There really are only two things required for AMR to develop: bacteria and antimicrobials. AMR occurs naturally in the environment, but when the drug-resistant genes in bacteria take hold in a community, a farm, or a household, the ability to reverse the growth of drug resistance is uncertain.

Human bacteria shouldn't really have natural antimicrobial resistance. We don't usually interact closely with fungi and their antibiotics, so neither should our bacteria, unless we are exposed to antibiotics. The more we use and abuse antibiotics, the more we risk our microbiome developing resistance. We are where we are today because of rampant global antimicrobial use of little or no value.

Why should you and the Canadian public care about AMR? Canadians pride themselves on their health care. Canadians have come to expect safe pregnancy and delivery in neonatal care, management of common infections such as pneumonia or urinary tract infections, routine surgeries, and even organ and stem cell transplantation. These are threatened by antimicrobial resistance. For some of these conditions, this is a present-day threat rather than a future one.

Up to half of pathogens causing infections in cancer and surgery are already resistant to first line antibiotics in the U.S. I'd love to quote Canadian data, but we really don't have it, although it's 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 use 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 medical lexicon was MRSA, or methicillin-resistant staphylococcus aureus. Today, that list includes KPC, ESBL, NMDA1, VRE, CDI, and the list goes on.

The fact that we have antibiotics supply insecurity—and I can't recall the last time we didn't have a shortage of one antimicrobial or another—exacerbates the problem. These drug-resistant organisms cost the health care system billions of dollars. This is juxtaposed with the over $1 billion we spend on prescription antibiotics in Canada, of which about half of the use is unnecessary.

Estimates by the World Bank are that the future AMR risk is greater than the global financial crisis of a decade prior. More importantly, it's a threat to national security and public safety and threatens Canadians in a manner greater than violence and accidents. However, AMR doesn't have headlines. There are no walks, runs, bike rides, golf tournaments, or galas for antimicrobial resistance. There's no ribbon, and the pharmaceutical industry has largely distanced itself from antimicrobial development.

Governments have been seduced into investing in industrial approaches to AMR, which are necessary, by the way, but it's at the expense of investment in the proven domains of public, animal, agricultural, and environmental health, which explore social determinants. I'd be remiss if I didn't point out the acuity of this need in our indigenous populations.

What can you and Canada learn about tackling AMR from my antimicrobial stewardship program at Sinai Health System and University Health Network? It's the first and largest of its kind in Canada. It reflects all that is right in tackling AMR in Canada, but it also shines a light on all that prevents further advances in AMR. In 2009, leaders with purse strings at my hospitals recognized the need to spend money to improve patient care and safety. They mandated a program with accountability and allowed the experts, people such as me, to run the show. Eventually the two organizations realized that collaborating and having a joint program with shared oversight would improve the efficiency of the two programs. Agreements were needed and policies implemented, but it got done.

The backbone of our program is a substantial and continued investment and obsessive focus on high-quality surveillance and epidemiologic studies of antimicrobial resistance and use in our hospitals. Over time we gradually built an interprofessional team that includes nurses, pharmacists, physicians, data and computer professionals, and management and project implementation experts.

Starting locally, we demonstrated improvement in antibiotic use coupled with financial savings. Bolstered by these successes, the Council of Academic Hospitals of Ontario, and subsequently, Health Quality Ontario, funded exporting our program and approach out of the province. The ecosystem we developed has spilled over to Public Health Ontario and national and international research projects and has helped train AMR leaders in other provinces.

Our pharmacists have taken leads in educating other pharmacists nationally, as well as running an innovative and groundbreaking course dedicated to the topic of antimicrobial stewardship. Our nurse steward, the first position of its kind in Canada, is poised to make knowledge of infections and antibiotics the core competency for nurses.

We have also enlightened health care leaders that these programs need project and program management professionals. Our manager is a major reason for our ongoing growth and success.

We have subsequently established best practices and made it easy for providers to access them. We have transparent reporting of our successes and failures, and yes, we have failed repeatedly. They can be seen on antimicrobialstewardship.ca. We also have a substantial and growing research enterprise refining how we can improve antibiotic use.

Although I'm proud of our program, what you really need to know are the things Canada needs. Mirrored on that, we need leadership with purse strings, expert leadership with a built-in accountability structure, and a substantial dedicated commitment to standardized, reliable surveillance of antimicrobial resistance and use across Canada, accompanied by epidemiologic inquiry.

We need to look at AMR interprofessionally, and ideally, with a one health view. That means involving the environment, animals, and humans.

We need to evaluate and scale up excellence across the country. We need to invest in tomorrow's AMR leaders. We need to definitively identify and make accessible what is accepted antibiotic practice. In Canada, we have no national standards of appropriate antibiotic use.

We need scientific investment. In Canada, antimicrobial stewardship and resistance research funding is less than $10 million per annum. Embarrassingly, my institutions' investments add up to upwards of 10% of this overall national investment.

The Canadian antimicrobial resistance surveillance system, the term “system” being a euphemism, doesn't have dedicated funding. It piggybacks on a benevolently unrelated envelope of infectious disease funding, and it is a patchwork of information that frustrates the many users it aims to satisfy.

That funding pales in comparison with the Canadian Institutes of Health Research's funding of $273 million for cancer or oncology, with another $95 million from the Ontario Institute for Cancer Research, $91 million from the Fonds de recherche Santé Québec, and numerous other research sources, including charitable foundations and industry.

Honourable committee members and Mr. Chair, on behalf of Sinai Health System and University Health Network, I am here to tell you that Canada needs federal leadership, with accompanying funding to move past the pan-Canadian framework on AMR to pan-Canadian action on AMR.

Expert health and scientific leadership needs to be put in place with an accountability structure involving provinces, territories, and the federal government, bringing together various disciplines in a one health approach that would be implemented with surveillance systems to gather, collate, and study antibiotic resistance and use.

Canada has the capacity to lead the world on this effort. We need to develop the next generation of experts, lure them into this mission critical field with an exponential increase in dedicated funding, independent of the important and, I fear, disregarded Naylor report, which I support. These new experts will research, innovate, and disseminate the necessary solutions to tackle AMR.

Thank you for your attention.

3:50 p.m.

Liberal

The Chair Liberal Bill Casey

Thank you for your presentation.

Now we'll go to Dr. Keynan.

3:50 p.m.

Dr. Yoav Keynan Scientific Lead, National Collaborating Centre for Infectious Diseases

Thank you, Chair and honourable members of the committee, for the opportunity to present here.

My name is Yoav Keynan and I'm the scientific director of the National Collaborating Centre for Infectious Diseases, or NCCID. The six national collaborating centres for public health were set up after the SARS epidemic. At that time they were fed by the experiences of perceived weaknesses in the public health system in Canada. Compared to that epidemic, AMR is a far deeper and more serious problem.

The NCCID is currently hosted by the University of Manitoba in Winnipeg under a contribution agreement with the Public Health Agency of Canada. Our mandate at NCCID is for knowledge translation and brokering to provide evidence and other information to inform public health practice and policy across Canada at all levels of authority. The centre fosters connections among public health practitioners, decision-makers, researchers, and clinicians, with a shared goal of improving control of infectious diseases in Canada.

Since its inception in 2005 under the early leadership of Dr. Ronald and Dr. Plummer, as well as others, the NCCID has played a role in bringing attention to antimicrobial resistance and the importance of appropriate antimicrobial surveillance, use, and stewardship. For example, the NCCID has been involved with hosting antimicrobial awareness week in Canada since 2010.

Since then, NCCID's involvement has grown, and the centre plays a role in AMR in public health, particularly supporting collaborative efforts to improve coordination and equitable delivery of stewardship initiatives across sectors, disciplines, and settings. Here I emphasize what Dr. Morris already mentioned, the area of inequity with the distribution of antimicrobial stewardship resources. There are fantastic centres of excellence within Canada, but it is not broadly available across all jurisdictions.

Working closely with the Public Health Agency and other partners and colleagues, the NCCID is able to convene and host in-person meetings across federal, provincial, and territorial jurisdictions and ensures the involvement of other agencies within the health portfolio.

Last year, in June 2016, NCCID co-hosted a national round table of antimicrobial stewardship leading to the development of a national action plan, “Putting the Pieces Together”, and to the establishment of AMS Canada, a national network of key stewardship experts and stakeholders co-chaired by NCCID.

Within two months of the round table and before AMS Canada formally released the action plan, we embarked on new work to bring evidence and other knowledge about stewardship to public health. The work is predicated on the critical role that public health has to play in controlling the emergence and spread of AMR. Public health partners with health care providers and facilities to promote education, surveillance, and prevention strategies. Public health has a strong role in planning infection prevention programs and strategies and is positioned to promote AMS across health care settings, particularly addressing known gaps in the deployment of community antimicrobial stewardship programs, rural settings, and in redressing inequities for structurally disadvantaged populations inadequately served by health systems.

I will highlight some examples of NCCID activities to inform and engage public health in addressing AMR. We have contributed to advancing public health professional knowledge of the burdens and drivers of AMR and to articulating the role in contributing to efforts to control AMR. In 2016 we commissioned two new reviews. One examines the role of animal and human health care in growing resistance globally and in Canada. The other provides a glossary to encourage shared understanding of the terminology.

Earlier this year we hosted a series of presentations at Public Health 2017 and brought antimicrobial resistance and stewardship to the forefront of this annual conference. The two documents will be circulated for those who are interested.

The NCCID models the public health sector's role in convening interdisciplinary knowledge exchange on sound and evidence-based AMS programs by providing opportunities for practitioners, researchers, and program planners to inform one another on successes and challenges in the regions or institutions specific to antimicrobial stewardship programs. For example, during the meeting in 2017, we hosted an Atlantic region stakeholder meeting, including a live webinar broadcast to exchange knowledge. Later this month we will be co-hosting accredited continuing education and training sessions for physicians, pharmacists, and nurses to open a dialogue on ways forward to improve the appropriate use of prescribing antimicrobials.

As another knowledge strategy, we have documented strategies that have been useful and have worked in Alberta to develop a provincial stewardship program, in an easy to read case study that is shared with other jurisdictions. The projects have helped to document challenges, gaps, and capacities for stewardship at national, provincial, and regional levels. These have included helping to convene exchanges in the Atlantic region, and we have worked with a proof of concept in a regional health authority in Manitoba, trying to use tools developed in other jurisdictions to implement an antimicrobial stewardship program.

As already mentioned, similar themes and challenges are emerging. There's a need for IT infrastructure, and there's inadequate capacity for developing metrics and analytics for antimicrobial use and resistance. There's an interest in obtaining readily available materials for practitioners and for patients...appropriate leadership to allow physicians and pharmacy partnerships. The lack of guidelines and access to existing guidelines was already mentioned.

We intend to analyze the distribution of stewardship programs, including how well stewardship is understood and implemented in rural and first nation communities, as well as the availability of materials and resources for francophone users.

Part of our role for the AMS stewardship program is fostering development in a community setting, including long-term care and continuing care, leveraging existing strengths and expertise from acute care settings such the Sinai Health System and University Health Network in Toronto, as was described.

We engage senior leaders and public health professionals to help situate information for use in a public health setting. An example is a webinar planned for later this month to feature the business case model for a stewardship program in acute care developed by the Association of Medical Microbiology and Infectious Disease Canada. This webinar will clarify the essential elements of a quality program with resources that are needed for effective stewardship. A senior public health physician will discuss helping public health physicians and trainees to understand the public health role, and applications for planning similar programs in the community.

In the past year, in partnership with Do Bugs Need Drugs? and Alberta Health Services, we are fostering a growing community of practice, or a network of practitioners and decision-makers who are keenly interested in understanding how to develop and implement AMS programs tailored to distinct contexts of long-term care and nursing homes—a huge gap. A series of webinars provides a platform to build relationships and foster dialogue. The first webinar was a testament to the acuity of the need, with an overwhelming response and 350 registrants.

NCCID has supported the development and dissemination of public education tools, particularly to primary care physicians, educating patients about necessary antibiotic use. We've revised and actively promoted our popular non-prescribing prescription pads, adding one that is for parents of young children. Working with regional health in Manitoba, we've helped adapt their own viral prescription pad and entered it into their electronic medical system.

Other collaborative efforts for awareness building include a national social media campaign and efforts for public health prescribers to coordinate and share consistent messaging. These efforts can lead to a more systematic, coordinated effort of awareness building, leveraging partners' positions to reach the various audiences.

This requires alignment through a proactive Canada-led plan. We see a need to get beyond Antibiotic Awareness Week to arrive at a more integrated strategy to build knowledge for changing prescribing habits.

Currently NCCID is assessing how well public health personnel can obtain and understand data of antimicrobial resistance surveillance in Canada. It is our intention to work with partners and to connect public health to data managers, perhaps ultimately leading to versions that public health can use for planning responses. Currently the surveillance data, as mentioned by Dr. Morris, is siloed and barely comprehensible.

Last, as a result of the activities across Canada fostering public health involvement and stewardship and reducing resistance, we're working with colleagues on applications for a national centre of excellence that can continue to sustain the efforts to combat antimicrobial resistance.

In summary, we see a continued need for strong leadership at the federal level. As mentioned earlier, this leadership needs to come with funding to adequately resource development implementation and the scaling up of programs. We need support for the national coordination of stewardship, to make sure that the endeavours that have already begun are continued, and public health leadership in planning, to improve the breadth of the initiatives, including ongoing recognition of the importance of public health and population health interests beyond the involvement with just their clinical and acute care settings.

Thank you.

4:05 p.m.

Liberal

The Chair Liberal Bill Casey

Thank you very much.

Now we will go to Infection Prevention and Control Canada, for 10 minutes. I'm not sure if you're going to divide your time.

Ms. Rose.

4:05 p.m.

Suzanne Rhodenizer Rose Past President , Infection Prevention and Control Canada

Thank you, Mr. Chair.

Good afternoon, everyone. My name is Suzanne Rhodenizer Rose, and I serve as past president of Infection Prevention and Control Canada. I am very pleased to be with you this afternoon to address the pressing issue of antimicrobial resistance, or AMR, in Canada. I am joined by my colleague, Jennifer Happe, who is an infection control professional and an officer of IPAC Canada.

IPAC Canada is a multidisciplinary association with over 1,600 members nationwide. It is committed to public wellness and safety by advocating for best practices in infection prevention and control across the continuum of care.

I want to begin by commending this committee for taking the time to study this issue, which deserves attention from elected officials and from the public they serve, though it's often reduced to a few short sound bites in the news. People who have heard of superbugs or pandemic influenza, for example, may be inclined to think that these issues are far removed from them, whether in the past or many continents away. However, that assertion is deeply flawed. AMR has been identified as a fundamental threat to the modern health care system. It creates challenges not just for the patients who endure its effects but also for the health care system as a whole. When the best medicines we have to combat illness cannot defeat the micro-organisms that infect people, illnesses become more easily spread and much harder to treat.

Additionally, the World Health Organization, which has shown exceptional leadership on this issue, has noted that antimicrobial resistance increases the cost of health care, with lengthier stays in hospital and more intensive care required. These are the facts of AMR, and they are the issues that our providers can find every day in Canada's hospitals, clinics, dental offices, and other care settings across the continuum. It is important to provide more detail on the pressure placed on hospitals and the health care system as antimicrobials become increasingly ineffective at treating certain pathogens.

In testimony to the U.S. House of Representatives in 2013, Dr. Tom Frieden, a CDC director, put the consequences very plainly. He said, “Patients with resistant infections are often much more likely to die, and survivors have significantly longer hospital stays, delayed recuperation, and long-term disability.” It should come as no surprise, then, that the overall capacity of our health care system declines daily as care providers find themselves using additional rounds of antibiotics and resorting to less commonly used, more toxic pharmaceuticals to treat the most prevalent antibiotic-resistant organisms such as MRSA or C. difficile, and the recent and concerning emergence of carbapenemase-producing organisms. At the same time, investments in new and improved treatments by pharmaceutical companies have declined, and professionals are not being equipped with the resources they need to effectively stem the tide.

Taken together, these facts make it more important than ever to ensure that appropriate infection prevention control measures are in place to limit the spread of antimicrobial-resistant organisms and to improve treatment when they are encountered in patients. Infection control professionals in Canada's hospitals, in public health roles, and in other care settings are working hard to ensure that this is the case. However, we have been fighting an uphill battle.

We believe Canada is well positioned to become a leader in the fight against antimicrobial resistance, but to get there for the good of our population, we will have to make significant investments that support national systems and provide funding for the adequate human resources to implement and encourage infection prevention and control practices across the care continuum.

Antimicrobial resistance is a very complex issue that cannot be addressed by a single policy change or advancement in medical practice and technology. Rather, the federal and provincial governments, health care professionals and administrators, the agricultural community, our international partners, and the public at large need to be aware of the pressing and global concern that has been echoed widely.

Steps have been taken by the federal and provincial governments and regional health authorities to address AMR challenges, including limiting the spread and occurrence of infections that are caused by antimicrobial-resistant organisms, and encouraging the responsible use of antimicrobials. However, there is one key area in which Canada remains behind other countries, and where the federal government needs to be a leader, and that is in tracking incidents of resistant bacteria and analyzing the success of our collective interventions.

The Government of Canada has published a document entitled “Antimicrobial Resistance and Use in Canada: A Federal Framework for Action”. There are four pillars of this framework that are strongly supported by IPAC Canada.

In order to effectively implement change, it's necessary to have the ability to measure whether steps taken are having the intended outcome. Through surveillance, which is one of the best measures of AMR, we have the number and the rate of antibiotic-resistant organisms in the health care setting.

In order to carry out surveillance effectively, measurement needs to occur in the same way, so that apples are compared to apples and oranges to oranges. When carried out in a uniform manner, surveillance provides a measure of the burden of illness, establishes benchmark rates for internal and external comparison, identifies potential risk factors, and allows for the assessment of specific interventions. As such, IPAC Canada urges the implementation of a national surveillance strategy for antimicrobial-resistant organisms.

Currently in Canada we largely measure the number and rate of resistant micro-organisms in different ways across the country. As such, the process is fragmented. AMR does not understand political and territorial boundaries. A fragmented approach defeats the goal of protecting the health of Canadians and does not align with the one health strategy or with the federal action plan.

We absolutely acknowledge that there are some measures in place to do this now, but we believe these piecemeal approaches are not suitable to address the growth threat of antimicrobial resistance that we face.

The Canadian nosocomial infection surveillance program, or CNISP, gathers data that is considered highly reliable yet covers only a very small fraction of the many health care facilities in Canada. Most hospitals and long-term care facilities are not currently able to participate in CNISP surveillance. CNISP also lacks the human resources support and technical infrastructure it needs to reach its full potential.

The existing Canadian Network for Public Health Intelligence, or CNPHI, is also gathering data, but could be better leveraged to support collection and integration with other data sources.

The Canadian Institute for Health Information, or CIHI, has recently explored the use of information and administrative data contained within individual patient medical records as a source of data on AMR and health care associated infections. While this electronic method of data collection is efficient and allows for global reach across the country, it cannot provide the level of reliability we need to accurately define the level of AMR in Canada.

The establishment of the Canadian antimicrobial resistance surveillance system, or CARSS, is a federal commitment to support the federal action plan on AMR and use in Canada and it has made an important first step in defining priority resistant organisms to conduct surveillance on; however, this is but one piece, and the potential data from this system can complement the data from a national repository for health care associated infections.

Strong integrated surveillance systems are needed to provide a comprehensive picture of AMR in Canada. We are not starting from scratch. Through a collaborative effort with other organizations, IPAC Canada has established standardized surveillance case definitions for long-term care and has participated in the advancement of the establishment of standardized surveillance definitions for acute care and a commitment to continue to seek options for a pan-Canadian adoption of these definitions.

There is also a groundswell of interest and commitment from partner organizations to explore options using infrastructure that's currently available to support a pan-Canadian approach. These goals align and support the achievement of the goals defined in the government's federal framework.

Canada has been recognized as a world leader in many aspects of health, yet we lag behind many international jurisdictions in the development and implementation of a national approach to address AMR. Federal engagement with provincial and territorial partners at the ministerial and deputy ministerial levels is needed to establish a consistent national surveillance system, with nationally approved case definitions, that is adequately funded. We need support to make the data being collected better integrated and more useful for the people and professionals working to fight AMR on a daily basis.

Thank you.

4:10 p.m.

Liberal

The Chair Liberal Bill Casey

Thanks very much.

The picture you've all painted about this situation is amazing, and so little is heard about it.

Now we're going to our question period with seven-minute sessions, starting with Mr. Ayoub.

November 2nd, 2017 / 4:10 p.m.

Liberal

Ramez Ayoub Liberal Thérèse-De Blainville, QC

Thank you, Mr. Chair.

I'm going to ask my questions in French.

I liked the presentations very much, as they really covered the entire situation.

I'm a neophyte in the medical field, but I am a Canadian who is concerned about the health of Canadians. As you talked about communication and education, I told myself that resistance to antimicrobials is a slow killer. It is a latent and invisible occurrence that still leads to suffering. Research shows that. You were saying that you had difficulty obtaining information. You have scientific data, but there is a lot of data to interpret.

Even though the Canadian Antimicrobial Resistance Surveillance System exists, how can we validate the improvements made over time to address the antibiotic resistance epidemic?

I don't know who can answer my question. I have seven minutes, but I would like to ask some other questions afterwards.

Madam Rose, you can start.

4:15 p.m.

Past President , Infection Prevention and Control Canada

Suzanne Rhodenizer Rose

I think your question is a good one. We have a number of surveillance systems in place. I think there's an opportunity for Canada to use what already exists. There's good infrastructure that can be scalable and integrated, so that we are comparing the same thing across the board. With the right analytics, assessment, monitoring, and trending of the data that's coming in, you can actually see, at a regional, local, or pan-Canadian level, how we are doing, based on the rates of AMR and health care associated infections.

4:15 p.m.

Liberal

Ramez Ayoub Liberal Thérèse-De Blainville, QC

Where is the trigger? Where do we need to improve ourselves? Where do we need to improve the teamwork?

4:15 p.m.

Jennifer Happe Officer and Director, Infection Prevention and Control Canada

Thank you for the question.

The Government of Canada has put together a pan-Canadian framework of action that addressed four core competencies. Beyond surveillance, it also includes infection prevention and control, stewardship and.... I've drawn a blank on the fourth one all of a sudden.

4:15 p.m.

Past President , Infection Prevention and Control Canada

Suzanne Rhodenizer Rose

Research and innovation.

4:15 p.m.

Officer and Director, Infection Prevention and Control Canada

Jennifer Happe

Thank you. Research and innovation. How could I forget that?

4:15 p.m.

Liberal

Ramez Ayoub Liberal Thérèse-De Blainville, QC

Funding.

4:15 p.m.

Officer and Director, Infection Prevention and Control Canada

Jennifer Happe

Yes. It's really through those four core competencies that you're going to address the core of the problem.

4:15 p.m.

Director, Antimicrobial Stewardship Program, Sinai Health System

Dr. Andrew Morris

Your question is a good one, but I'll point out that the Montreal Canadiens, the Ottawa Senators, and the Toronto Maple Leafs have more analytics in their organizations and more reliable data than we have in our whole country on AMR. If we can figure out how much puck time each player has, and their analysts can figure out how to optimize that, then surely we can identify and learn how to optimize antimicrobial resistance in Canada.

4:15 p.m.

Liberal

Ramez Ayoub Liberal Thérèse-De Blainville, QC

What you are saying is interesting. I was just wondering whether too many organizations were conducting research at the same time without sharing the gathered information.

You have a lot of requests for information on care and funding, but I feel that stakeholders are working in silos and have difficulty communicating.

How could the discussions and information sharing be improved and progress be monitored?

4:15 p.m.

Director, Antimicrobial Stewardship Program, Sinai Health System

Dr. Andrew Morris

That's very true.

You are exactly correct. It needs to be coordinated. There is so little money available for this topic. I pointed out to you how it is a fraction of what some other areas of health care are afforded, and there's no coordination. We need national coordination that's participated in by the various sectors on a national and federal level, as well as on provincial and territorial levels. It needs to be coordinated. There needs to be an infrastructure to coordinate it.

4:15 p.m.

Liberal

Ramez Ayoub Liberal Thérèse-De Blainville, QC

Thank you.

Ms. Rhodenizer Rose, go ahead.

4:15 p.m.

Past President , Infection Prevention and Control Canada

Suzanne Rhodenizer Rose

Recently, IPAC Canada has partnered with a number of other national organizations, such as the Public Health Agency of Canada, the Canadian Institute for Health Information, and CPSI, which is the Canadian Patient Safety Institute. We started out with one day of information sharing around how we currently collect data on health care associated infections and antimicrobial-resistant organisms, and there was a bunch of back and forth over a period of months about whose data was more accurate, because everybody is collecting it differently and using different definitions and different data collection methodologies.

At the end of it, just as recently as last week, we all agreed that we all have pieces of the puzzle that are strengths. If we can collaborate more and use the infrastructure and the resources that currently exist—that's not to say they will be adequate, and an infusion of funding would be required—we do have a lot of good work going on. It's just a matter of bringing those disparate pieces together.

4:20 p.m.

Liberal

Ramez Ayoub Liberal Thérèse-De Blainville, QC

Thank you for the answer.

I have one more question, maybe for Madam Levinson.

You told us that 30% of tests are “superflu”, as we say in French. They are not accurate.

A lot of money could be saved by the government, although more funding is being requested. I am thinking of pharmacare, for example. It seems that more money would be saved if there was a Canada-wide action plan.

I was surprised—and not surprised, at the same time, as this is the reality—to hear that physicians prescribed medication just to reassure people. I am wondering if people are looking for a temporary placebo effect or just want things to be easier. Doctors know what the situation is, but they still do these things. They need to be educated.

How can we address this issue? What is the solution?

4:20 p.m.

Chair, Choosing Wisely Canada

Dr. Wendy Levinson

If we just step back in the broader context, there are many reasons why doctors over-order both prescriptions and tests. Sometimes patients want them, and that is particularly true on the antibiotic side in the outpatient sector.

Sometimes it's just that it takes longer to explain. If you come in distressed, you want an antibiotic because you want to get back to work, and you say to the doctor, “Dr. Morris, I just want a script and then I'll get out of your office”, he thinks to himself, “Am I going to spend the time explaining to the patient why he doesn't need it or is it just quicker, and am I going to make him happier?” It's easier to do it.

Also, sometimes doctors over-prescribe because they're worried about being sued, so they're trying to cover everything and be thorough. In—

4:20 p.m.

Liberal

Ramez Ayoub Liberal Thérèse-De Blainville, QC

What is the answer? I know that, but what would be the solution?