Health Committee on Nov. 7th, 2017

[Dr. Yvonne Shevchuk]

Sorry; I might have gotten a bit off track.

I think pharmacists can certainly help in that way to make sure that use is appropriate.

I think your other question was around general approaches to improving prescribing. I think the electronic medical records with cues embedded in there could go a great way to assisting in prescribing. They could put up red flags when things don't match up, when things don't look right. I'm not a technical person, but I've seen examples of some amazing things that can happen.

There are examples of good tools out there to put in the hands of prescribers, which might help them to do a better job.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Mr. Ayoub, you have seven minutes.

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

Thank you, Mr. Chair.

I would like to thank the witnesses for their interesting testimonies.

We have been listening to the witnesses and colleagues talk about prescriptions, accuracy and education. For newbies like me, it is surprising, even alarming, to learn that doctors prescribe drugs that are not appropriate. I'll put it that way, quite simply. Having to educate patients is one thing. But I'm hearing some people say that individuals who go to the doctor want to receive professional care and prescriptions without too many questions.

In the world we live in, people are becoming more informed. So, they ask more questions. For instance, parents ask many more questions when it comes to their children.

What I have realized from the beginning of our study on antimicrobial resistance is that there are no clear statistics. There is difficulty in establishing the point of contact and determining whether or not there is a crisis. At the global level, there are action plans, but it is not as striking. Ms. Kossey has given us some completely shocking numbers today.

As for the opioid crisis that we are experiencing, we are at the heart of this crisis, we are responding to it now, and we are taking action. However, the problem of antimicrobial resistance is like a silent killer that sneaks up quietly, but may end up striking with a hockey stick.

Dr. Rau, what is the equilibrium curve? What plan of action will allow us to tackle this problem head-on?

[Dr. Neil Rau]

First of all, we need a good monitoring system. It all starts with that. Right now, we don't have the numbers that would indicate where we're at.

The second challenge is the fact that we are a litigious society. Many of those who consult a doctor don't want to argue with the doctor about what to do. They want treatment. That's why they waited for half an hour or an hour before seeing the doctor: they want to receive something. So, one of the doctor's reflexes is to prescribe something, instead of starting an argument or a discussion. We would like doctors to give more explanation to patients. However, some people will be dissatisfied if the doctor doesn't prescribe something after they have waited for several hours in the emergency room, for example. This is another aspect of the problem.

As for when to press the panic button, having a very good monitoring system will allow us to say when, given the resistance rate, we will need to use a new available antibiotic. We don't currently have the numbers that would justify this reaction. I don't think we're there yet. In my experience, I know for sure that situations where this could happen are still rare. However, we need a good monitoring system to react accordingly.

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

I'm still concerned when I hear you talk about this reflex doctors have.

How can we help them to resist the pressure from patients who want an easy solution, such as a prescription for antibiotics? It's an endless cycle. Under this pressure, doctors agree to prescribe antibiotics, and the problem gets worse. It may not be a short-term problem, but it gets worse in the long term.

[Dr. Neil Rau]

I'll give you the example of children with an ear infection in the Netherlands and the Nordic countries.

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

An ear infection, quite simply.

[Dr. Neil Rau]

They are observed for 48 hours before giving them antibiotics. In Canada, however, the reflex is to give them antibiotics because an ear infection can sometimes cause meningitis, and the infection, if undiagnosed, can lead to many long-term complications. To avoid a single possible case of harmful complications, a hundred people are treated with antibiotics. Given the possibility of litigation, this is how the medical practice is done. I don't want to excuse everyone's behaviour, but what I'm saying is that some doctors may be encouraged to do so for fear of possible prosecution. Having said that, I have a little compassion for the people on the front line who have to respond to this problem.

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

There is another aspect that we haven't touched much. We're talking about vaccines and prescription antibiotics, but what about agriculture, particularly with respect to meat? Agricultural methods must be efficient, economical and profitable. These methods aim to ensure that there is as little disease as possible in farm animals. We now have the choice to move towards organic farming, but there are other breeders who give antibiotics to their animals. Does this have an effect on health?

[Dr. Neil Rau]

It could have an effect.

I read the record of the testimonies of people from the veterinarian society who appeared before the committee. They said that it wasn't common here and that veterinarians avoided using antibiotics without a good reason. According to these testimonies, they aren't used for growth, but only to prevent or treat infections. So this practice is preferable to using them solely for growth purposes.

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

It's always a question of balance. It's the same for vaccinations. We can vaccinate excessively all the time, but we must find a balance at a given point.

You said that it was the state of health of the patients that determined whether they needed a vaccine or not. In a long-term perspective, a frail person will need a vaccine more than a healthy person.

[Dr. Neil Rau]

Sometimes there is no vaccination against a given infection. I'm thinking of bacterial infections in hospitalized patients. We don't yet have a vaccination against the harmful pathogens I've described.

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

Okay. Thank you.

[The Chair, Liberal, Bill Casey]

Thanks very much.

That completes our seven-minute round.

At this time I'm going to turn the chair over to our vice-chair, Ms. Gladu, who is going to take over.

Do you have any questions? No.

Thanks.

[The Vice-Chair, Conservative, Marilyn Gladu]

Very good. Thank you.

I want to thank the witnesses who spoke today. Your testimony is valuable to us. This is obviously an even more serious issue than I had previously thought. Thank you very much.

There was a witness who said there were 10 recommendations. I think it was Dr. Shevchuk. If you could send those to the clerk, that would really help our committee as we consider what to do.

Thanks so much.

At this time we're going to turn to committee business. No?

[John Oliver, Liberal, Oakville, ON]

We still have a five-minute round and a three-minute round of questions.

[The Vice-Chair, Conservative, Marilyn Gladu]

You would prefer to do that? We can't stay past 5:30 today.

[John Oliver, Liberal, Oakville, ON]

Okay.

I have one quick question. Is the committee okay if I ask it?

[The Vice-Chair, Conservative, Marilyn Gladu]

I'm fine to have you ask a question.

[John Oliver, Liberal, Oakville, ON]

It's for Dr. Rau.

Thank you very much to all the witnesses for coming.

There was a fourth recommendation that you didn't get to address in your opening remarks. It was that there be global initiatives for new antibiotic development. Do you want to say a few words about that? I'm looking for anything we can get on recommendations to bring forward.

Also, you talked about the need for surveillance. We've heard a lot about CARSS, the Canadian antimicrobial resistance surveillance system. They just put out a report. Is that not adequate? I'm curious as to why surveillance continues to be viewed as a problem.

[Dr. Neil Rau]

I think the challenge with CARSS, although it's a very good initial step, is that it's not comprehensive and does not feel the pulse of all the places where health care is being delivered.

Not only do we need to know about teaching hospitals where there's a problem, but we also need to know where there's no problem so that we're not wasting resources where there is no problem. It's the Brandon versus Brampton argument that I made.

Speaking of antibiotic development, I cited a reference in my PowerPoint slides on the WHO pipeline. Without getting overly burdensome, there are a few promising drugs, but there is a discovery void, and one of the big problems for big pharma is that it is not cost-effective to develop a new antibiotic. What's really needed now are government-funded initiatives paired with pharma to make it financially viable to pursue a short course of therapy.

If you're a drug company, you want a drug that can hook people, like opioids. If you want a drug that really gets people hooked, you want them on it forever. You don't want them on it for just 10 days in a hospital. It's really hard to make it cost-effective unless you make it $10,000 for a course.

You need government funding from multiple countries' governments through global initiatives to bring new drug classes to market. TB is an ignored disease affecting people in developing countries who aren't going to pay the list price. It will be like what happened with hepatitis C drugs, so you need global funding initiatives. Just as we help with other UN agencies, we need to do our part in funding these drug development strategies in partnerships with pharma, rather than relying on pharma, because pharma is not going to do it.

[John Oliver, Liberal, Oakville, ON]

Thank you for letting me ask that last question.

[The Vice-Chair, Conservative, Marilyn Gladu]

No problem. That was actually one of my questions too, so I was glad to get the answer.

Thanks again to the witnesses. We're going to briefly suspend while you exit the room, and then we'll go to our committee business.

[Proceedings continue in camera]