Evidence of meeting #79 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

Jane A. Kramer  Director, Alliance for the Prudent Use of Antibiotics
Willo Brock  Senior Vice-President, External Affairs, TB Alliance
Timothy G. Evans  Senior Director, Health, Nutrition and Population Global Practice, World Bank Group
Gerard D. Wright  Professor, Department of Biochemistry and Biomedical Sciences, McMaster University, As an Individual

4:15 p.m.

Liberal

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

Thank you.

I believe that's my time.

4:15 p.m.

Liberal

The Chair Liberal Bill Casey

Thanks very much.

Now we go to Mr. Webber.

4:15 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Thank you, Mr. Chair. Thank you to the presenters for being here today.

Dr. Wright, you caught my attention with the fact that you went through a bit of an infection and took quite some time to deal with it. I have a very similar story as well with a blood infection that I had about three years ago that took two months of antibiotic use, through an IV pump on the side of my hip, to get rid of that darned infection that came from hand-shaking. Yes, it's a very dangerous career.

4:15 p.m.

Prof. Gerard D. Wright

I was just going to say you're in the wrong business.

4:15 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Did you catch your infection in a lab, researching?

4:15 p.m.

Prof. Gerard D. Wright

No, I did not. I should have been clear. I got the infection through food contamination. It started as gastroenteritis, and then it ended up as a bloodstream infection. We are very careful in the lab. We've never had any issues at all.

4:15 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

One thing that my doctors were very cognizant of is the fact that they started off with a low dose, and if that didn't take care of it they'd continue to increase the dosage until they got to the super-antibiotic that they threw in me, which took care of it. But that was a two-month process. Would it not have been best to lay it all out and shoot it all into me right at the start, and eliminate it?

4:15 p.m.

Prof. Gerard D. Wright

Well, you don't want to do that, necessarily, at the beginning, because all these drugs come with side effects. What you want to do, obviously, is to start with something where you have the best chances of success with the lowest number of side effects.

Your specific issue, though, is very similar to mine, in the sense that one thing we have a challenge with in treating drug-resistant infections is diagnostics. Oftentimes infections, like a bloodstream infection, show up as general symptoms as opposed to a specific bug giving you a specific infection, so a lot of treatment is empirical. As a result, you have this issue, in particular when it comes to drug resistance, trying to figure these things out.

As we move forward into the future—and we've heard this, I think, from almost all the speakers today—molecular diagnostics is the way of the future, at least in these kinds of situations. It's harder to do, obviously, in resource-poor areas, but certainly that's an area where there's tremendous opportunity for innovation and big data, and all that kind of stuff.

4:20 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Interesting.

You mentioned also that you are working with other researchers around the country, the Canadian Anti-infective Innovation Network. Is it strictly Canadian research going on there? What about around the world? Are you collaborating with other researchers around the world and sharing your studies and your results?

4:20 p.m.

Prof. Gerard D. Wright

Yes, of course. Science is, by nature, a collaborative effort. We have partners across the globe we work with. We have partners in Nigeria, in Europe, and in the United States that we work with. The idea of the Canadian Anti-infective Innovation Network was really to coalesce researchers and stakeholders within this area within Canada, to give us a voice, to say that this is a really significant issue and we have some great people who can help solve it.

4:20 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Excellent.

You mentioned the AMR framework as well that was developed here by the Government of Canada, earlier in 2017. Were you engaged in that at all, putting together this framework?

4:20 p.m.

Prof. Gerard D. Wright

I wasn't on any of the panels, but I was involved. I was consulted tangentially, yes.

4:20 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Right. Does it address the critical components of AMR?

4:20 p.m.

Prof. Gerard D. Wright

Absolutely. It has all the pieces; it only needs an implementation strategy.

4:20 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Quickly to Ms. Kramer, is it Dr. Kramer or Ms. Kramer?

4:20 p.m.

Director, Alliance for the Prudent Use of Antibiotics

Jane A. Kramer

I'm not a doctor. I'm a lawyer.

4:20 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

All right, Ms. Kramer. On your website you explain that your organization works with a number of organizations in the United States, the Infectious Diseases Society of America, the American Medical Association and such, to promote U.S. public policy and legislation that will maintain incentives for pharmaceutical antibiotic development and appropriate use.

Can you describe some of the existing incentives that are out there right now for pharmaceutical antibiotic development and appropriate use in the United States?

4:20 p.m.

Director, Alliance for the Prudent Use of Antibiotics

Jane A. Kramer

Yes, sir. What I did describe was the CARB-X project in my quick talk. The other is the GAIN legislation. It's called the GAIN Act. That provides longer intellectual property and different reimbursement incentives for antibiotics. That's something to think about. It's a little bit complex. That's really primarily it, the incentives. GAIN is an acronym, and I don't remember what the acronym stands for, but I will send it to you after this session so everybody knows what it is.

That's really what it is. It's longer intellectual property and it's slightly better reimbursement. Essentially it asks for the drugs not to be used or to be used extremely judiciously so that there is stewardship of the antibiotics.

As you may know, there hasn't been a new class of antibiotics. Dr. Wright can confirm this for me, but I think there hasn't been a new class of antibiotics since the 1980s. What we need are new classes of drugs to deal with the new microbes that are out there, or the evolving microbes that are out there. That's what these incentives are designed to do. We want to encourage drug makers and biotech firms to keep attempting to innovate.

I'm well aware that because of your health system, which I strongly support, there is a great need to limit reimbursement of medicines in Canada. It's something that may be somewhat in conflict with your system, but it is really something that you need to consider and you need to look at. You really do need to think about it. It's a balance you need to strike.

4:25 p.m.

Conservative

Len Webber Conservative Calgary Confederation, AB

Thank you.

4:25 p.m.

Liberal

The Chair Liberal Bill Casey

Thanks very much.

Go ahead, Mr. Davies.

4:25 p.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

Thank you, Mr. Chair.

Thank you to all the witnesses for being with us.

Dr. Brock, I'm going to drill into tuberculosis a bit, if I can. It's my understanding that we have a problem with tuberculosis, particularly in Canada's north and among our indigenous communities. It think there's a domestic interest that I'd like to explore a bit with you.

What is the difference between multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis? How common are those two variations?

4:25 p.m.

Senior Vice-President, External Affairs, TB Alliance

Willo Brock

First of all, like my predecessor, I'm not a doctor but an administrator at best. There's a difference between multidrug resistant and extensively drug resistant. In the current first-line treatment, if you have regular TB, you treat that with four drugs in a regimen that lasts six months and those four drugs were developed in 1976 when that regimen came together. We've been working for the last 50 years with that treatment.

If you're resistant to at least two of the first-line drugs, you're considered multidrug resistant. There's a class of mono-resistance, and what is currently being recognized by WHO is that even people who are resistant to just one of the four drugs are already significantly worse off in their treatment outcomes than patients who are resistant to at least two drugs. But if you're two drugs, you're getting into multidrug resistance and what is going to be used then is what's called second-line drugs. These are drugs that have some known activity against TB, but they are significantly worse off. As I mentioned, you need daily injections for six months. Your prior esteemed colleague talked about walking around for two months with an injection. Multidrug-resistant patients go to a clinic every day for six months to get an injection, and on top of that take five or six pills. You see behind me here on the picture a hand that is holding one day of drugs for multidrug-resistant TB.

When you then also have resistance to one of those second-line drugs, you come into the territory of extensively drug-resistant TB. That's the third layer of resistance where even the second-line drugs, our fallback drugs that are already absolutely not great and only have 50% success rate around the world in terms of treating patients, are no longer working. Then you really get a kitchen sink of any type of antibiotic that might have some degree of success, which means that you're working between normally three and five years if you're lucky enough to survive. About 30% of patients survive extensively drug-resistant TB around the world, so 70% of patients die. Those are the three levels.

How common is it? Around the world, around 9% of patients now are multidrug-resistant. As I mentioned before, the number of deaths is about 240,000 but the number of new patients every year is about 600,000, according to the World Health Organization, out of the 10 million people infected every year. Sorry, that's about 6%. Within that group, about 30,000 new infections globally are with this extensively drug-resistant TB, so these are the patients who are the worst off, who are the most infectious because we have no way to treat them and therefore they will remain infectious.

In Canada, a case of XDR would be extremely rare. I think there has been one or two cases in the last five or six years. Multidrug-resistant TB is a bit more common. There's a handful of cases every year. However, obviously with that complexity, it makes dealing with that situation extremely hard. As you mentioned, an indigenous community in the northern territories actually has a rate of TB that is very comparable to some parts of Africa.

It's only because Canada is such a big country and has such a great health care system overall that the number of patients in the indigenous communities is not recognized for the effect it has. They are actually in a fairly severe situation, and your prior colleague mentioned one of these issues as trying to actually diagnose that, diagnosing patients, and then diagnosing their resistance pattern so that we can treat them well.

4:30 p.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

I understand that there may be a link between extensively drug-resistant tuberculosis and HIV/AIDS. Why in some places is extensively drug-resistant tuberculosis linked with HIV?

4:30 p.m.

Senior Vice-President, External Affairs, TB Alliance

Willo Brock

HIV and TB are linked anyway, irrespective of the resistance pattern behind it, because HIV suppresses your immune system. That's exactly the environment where TB thrives, so a suppressed immune system significantly increases the risk of TB. About one-third of the world's population has a latent form of TB in their body. Your normal immune system will allow you to fight that latency and possibly never have it come up. When you get HIV and your immune system goes down, the bug becomes active and you get TB.

Obviously, when you then have multidrug-resistant TB or extensively drug-resistant TB, you're fighting it harder. In cases like in Africa where there's a very large undetected pool of people living with HIV—because they are not diagnosed for HIV—because they're not put on antiretrovirals, their immune system goes down and therefore you will see that there are a lot more patients with TB. The combination of HIV and TB care needs to be very closely aligned.

4:30 p.m.

NDP

Don Davies NDP Vancouver Kingsway, BC

What advice would you give the Canadian government in terms of taking effective action both domestically to help address TB, and particularly the drug-resistant forms of it, and as an international player on the world stage?