Health Committee on Nov. 21st, 2017

[The Chair, Liberal, Bill Casey]

Ladies and gentlemen, I'll call the meeting to order.

Welcome to meeting number 79 of the Standing Committee on Health. This is our fourth meeting on antimicrobial resistance.

We welcome our witnesses today. We have, from the Alliance for the Prudent Use of Antibiotics, Jane Kramer by video conference from Boston, Massachusetts. From the TB Alliance, we have Willo Brock, senior vice-president, external affairs, by video conference. From the World Bank Group, we have Dr. Timothy Evans, senior director, health, nutrition, and population. As an individual, we have Gerard D. Wright, professor, department of biochemistry and biomedical sciences at McMaster University.

Welcome, all.

We're going to offer each of you the opportunity to make a maximum 10-minute statement, an opening statement, and then we'll go to questions from the panel.

Ms. Kramer, you can start off for 10 minutes.

[Jane A. Kramer, Director, Alliance for the Prudent Use of Antibiotics]

Thank you, Mr. Chair.

It's an honour to address the committee today. I want to compliment the staff and thank the clerk for his graciousness.

Let me start by taking a moment to explain what our organization is about. We were founded in 1981. We are the pioneering organization that first identified antibiotic resistance as a problem and the crisis that I think is broadly recognized today. We were founded as an education and advocacy group that is global in scope. Our mission is to recognize that there should be...to develop new medicines and new rapid diagnostics to detect microbes in the environment.

Let me launch into what the perspectives are internationally. There's an excellent template at the WHO website with a step-by-step guide for developing a national action plan. I won't go through it in any detail, but I commend it to you. All its elements represent our perspectives, which are stewardship, collaboration, the need to develop and innovate new medicines, and diagnostics. But it doesn't address animal food production, nor does it address the secret ingredient that is key to a nation's success in this area, which I will address towards the end of my quick talk here.

Antibiotic stewardship is a systematic effort to educate and persuade prescribers about antimicrobials and follow evidence-based prescribing in order to stem antibiotic overuse and thus antimicrobial resistance. We need to continue developing mechanisms for international communication that may signify new resistance trends with global and animal health implications, which is why our group has established chapters around the world. We've long had those chapters around the world, and they facilitate communications on a regional basis to identify trends in resistance.

Towards the essential goal of encouraging development of new medicines and rapid diagnostics consistent with and as enunciated in the U.S. national action plan, there is the CARB-X global partnership. This is a public-private partnership aimed at funding innovation. CARB-X stands for combatting antibiotic-resistant bacteria biopharmaceutical accelerator. This is a plan for $250 million over five years.

The group is comprised of the Wellcome Trust, the AMR Centre, Boston University law school, the Allergy and Infectious Disease Centre at the NIH, the Broad Institute, and also BARDA, which you may know. They have already amassed a handsome portfolio of early-stage pharmaceutical and biotech companies in just a couple of years of existence.

I want to move on to food and animal production. As you may know, antibiotics for growth promotion in poultry is declining in the U.S. and in Europe to a degree, but the BRIC countries are expected to boost consumption with their burgeoning middle class and their preference for meat in their diets.

Antibiotics-free meat is a result here in the U.S. of consumer demand, but what happens abroad affects all of us. This is a tragedy of the commons. It is a little frightening to think about that. As much as antibiotic use in poultry production is declining here, it's being boosted abroad.

Let me conclude by noting, and this might not sound altogether..., but Portugal was able to achieve near-universal elimination of hepatitis C. The secret ingredient that I mentioned before is something that Canada has. In thinking about the paradox of AMR, antimicrobial resistance, I am reminded that Canada is a leader in social responsibility with its diversity, its intellectual depth, its resources, its scale, and its progressive national health system.

Canada can be the world's model for managing the complex interplay and causes that would otherwise disrupt biodiversity. I think Canada is uniquely positioned to really solve, to stem, antibiotic resistance.

I look forward to your questions. Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now we go to Mr. Brock, from New York.

[Willo Brock, Senior Vice-President, External Affairs, TB Alliance]

Good afternoon, members of the committee. Thank you for the invitation to speak about antimicrobial resistance and its link to TB, tuberculosis. I'd like to begin with a short summary of that issue globally.

TB is the only major drug-resistant infection in existence that is transmitted through the air. All you need to do to contract it is to breathe. TB was declared a national and global health emergency in 1993. Since then, we've had 50 million people die from that disease. Another 28 million will die within 15 years, which is the time frame set globally for its elimination by the sustainable development target. At the current rate of progress, however, it will take 10 times as long to to get to that point of elimination.

The economic and human toll along the way for eradicating TB and the antimicrobial resistance that exists within TB is devastating, so the first lesson I want to convey is that the price of inaction in AMR is enormous.

In infectious diseases, TB is the leading killer in the world, with 1.7 million people dying from it in 2016. Of that number, and relevant for our discussion, are the 240,000 people who died from drug-resistant TB. The worrying fact in TB is also that the majority of new drug-resistant cases are now caused by primary infection, meaning that drug-resistant patients are directly infecting new patients. As a conclusion, I note that TB is responsible for almost one-third of the deaths globally that are caused by antimicrobial resistance.

New diagnostic tools and testing strategies are necessary and essential to find and treat the millions of cases of people with TB. The WHO estimates currently that nearly 40% of TB patients and 75% of all drug-resistant TB cases go undetected and never get diagnosed properly and put on treatment. Presumptive diagnosis is used rather than confirmed testing for TB, and the inappropriate use of drugs that evolves from that has increased drug-resistant strains of the disease, so another lesson to learn in the AMR debate is that testing and treating go hand in hand.

Treatment of TB with antibiotics is very complicated, unlike many other infections. It takes six months to nine months, with a regimen of at least four different drugs—four different antibiotics—that need to be adjusted based on body weight. Treatment is not always compatible with HIV antiretrovirals, which is a serious problem given that TB is the largest killer of people living with HIV. Treatment for multidrug-resistant TB requires almost 14,000 pills and 240 injections. Even then, the WHO reports only a 50% treatment success globally. Due to this complexity, treatment for the most drug-resistant patients can cost up to $1 million in a place like Canada.

In addition to the devastating effects on people in their most productive years, TB jeopardizes economic and social development. An analysis released last week and done by KPMG estimates that in 15 years' time, during the period of 2000 to 2015, TB-related mortality caused the loss of $616 billion for the global economy. If action is not taken, future TB-related mortality may lead to a further loss of almost a trillion dollars. Again, the cost of inaction is massive.

Also, no country is exempt. Forecasts indicate that the greatest human toll from TB will actually be in low- to middle-income countries in southeast Asia and Africa; however, the G20 countries will be the ones most affected economically, bearing almost two-thirds of the economic devastation of this disease. It's estimated that by 2050 drug-resistant TB may cause a lost economic output of almost $10 trillion inside the G20, and another $6 trillion outside the G20.

The latest WHO reports from 2016 show clearly that progress is too slow to reach our goals of eradication, but with a strengthened global commitment to research and development, I believe we can find new and highly innovative TB diagnostics and drugs that can bring the most devastating disease in history to an end. For exactly that reason, developing new drugs and regimens that can cure all forms of TB is why the TB Alliance, where I work, was established in the year 2000.

I would like to take a minute to update you on the progress we have made in that global fight since 2000, and what we can accomplish together in the next five to 10 years or so.

At TB Alliance, we now coordinate, as a public-private partnership, the largest pipeline of drugs, containing everything from early-stage candidates to treatments ready for registration in the next five years. We are actually on the doorstep of a major breakthrough in treating all forms of TB, including all drug-resistant forms. When we get sufficient investments, we can introduce for every person with TB an effective treatment that takes no more than six months, even to treat the most resistant forms of the disease, without the side effects, mortality, and failure that we currently see in treatment.

We've also made significant progress in highlighting the path that over the next 10 years will allow us to treat all patients, however they are currently diagnosed with resistance, in three months or less with the same once-a-day, all oral, highly effective, safe, and affordable TB treatment.

This means we can eradicate drug-resistant TB in the next 10 years. Science is not holding us back, but a lack of funding and political will is. The current glacial pace of TB research funding is well-documented and is costing both lives and livelihoods.

To succeed, I think we can learn a number of lessons in antimicrobial resistance in the wider sense because we've been fighting TB for such a long time.

First of all, I want to mention as a conclusion that we cannot address antimicrobial resistance without dealing with TB. The global response to AMR is fundamentally incomplete if it neglects TB.

We also need global coordinated and pooled investments into research. Product development is expensive and can best be done globally and in a coordinated manner to share risk and broaden transparency. It requires a global action plan and investment, whereas many national R and D plans and grants are strictly linked to national R and D capacity and economic interests.

Despite recognizing TB as the cornerstone of the global fight against AMR, it has often been excluded from health funding programs, for instance the new CARB-X program that my previous colleague talked about. However, I would like to call out JPI-AMR, which is a funding scheme for early research in antimicrobial resistance where Canada participates as a funder and that has announced for the first time in 2018, it will include TB in its portfolio of potential diseases it will allow funding to go to. I want to recognize that, and mention that TB needs to be included in all such AMR programs in the future.

Another point I would like to stress is that academic research is obviously very important, but it is not the same as product development. Many governments believe that their significant investment in academic research and early discovery will be translated into products by effectively using the pharmaceutical industry. However, TB is a poverty-related disease and doesn't have a market. In antimicrobial resistance, one of the things we want to do is use the antibiotics we have as little as possible. That's in effect exactly against what a pharmaceutical company would look for in a market, and therefore, there's very little interest from industry to go into this market space.

In addition to direct benefits to patients, we need to invest in tomorrow's cure as the ethical imperative. In dealing with TB and AMR, it's vital to provide universal health coverage and boost economic prosperity. New technologies will not only save millions of lives but also boost economic prosperity. It will lead to dramatically lower costs for health care systems, given the price we currently pay for dealing with drug-resistant TB. It will drastically reduce the burden on our overworked health care providers and free up resources for overstretched government budgets.

I would like to end by indicating the critical role Canada has in having, fulfilling, and realizing G7 and G20 commitments that were made this year, in 2017, specifically to support increased investments in research and product development. Canada will host the G7 in 2018 and should be building on prior commitments and acting to make research and product development an integral part of the search for solutions in AMR. This should include supporting new or enlarged mechanisms for the development of new drugs, diagnostics, and vaccines working against TB. The recommendations in the recent OECD report on “Tackling Antimicrobial Resistance: Ensuring Sustainable R&D” should serve as a guideline. The report suggests that to improve the R and D pipeline and bring four new antibiotics to the market over the next 10 years, we need an additional globally pooled fund of $500 million U.S. per year, and TB should be included in such a plan.

In conclusion, I would like to share my belief that the major limiting factor to a world without TB is a stronger commitment from the global community, including all of you. Without sufficient investment, we will fall short in our combined efforts to once and for all eradicate TB.

I would like to thank you and the committee for providing this opportunity for dialogue, and obviously I would be open to any questions you may have.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now we go to the World Bank Group, Dr. Timothy Evans, for 10 minutes.

[Dr. Timothy G. Evans, Senior Director, Health, Nutrition and Population Global Practice, World Bank Group]

Thank you very much.

Thanks for the opportunity to appear before the committee on this issue and to provide an international perspective.

As a Canadian who grew up on a farm, did a graduate degree in agricultural economics, practised medicine, and has spent the last two decades working in global health on the frontiers of west Africa and south Asia as well as with multilaterals such as the World Health Organization and the World Bank, I will say it is a great privilege and honour to be allowed back into Canada to share some perspectives on this issue.

It goes without saying, but I'm going to say it nonetheless, that antimicrobials represent one of the greatest marvels of modern medicine. In less than a century, billions globally have benefited from antimicrobials, and hundreds of millions of lives have been saved. The benefits, however, have been far from equitably distributed, and far too many people, especially in poorer countries and communities, remain without access to these invaluable life-saving commodities. The magnitude of this shortfall is non-trivial. Many of the deaths of over two million children due to pneumonia and diarrhea every year could be prevented if health systems were able to provide timely access to good-quality, low-cost antimicrobials.

The access deficit we're all concerned about in making sure people have access to life-saving medicines is actually being accelerated by antimicrobial resistance. We just heard about the case of tuberculosis, which is really the cause célèbre in terms of the driver of AMR globally. But in the context of concerns about AMR, the World Bank, with support from the Public Health Agency of Canada and from other governments, undertook a study on the economic costs and impact of AMR, entitled “Drug-Resistant Infections: A Threat to Our Economic Future”, which we published in March 2017.

This report simulated the costs of AMR to the global economy using scenarios, and in the optimistic case of low impact, AMR by 2050 would amount to a reduction of 1.1% of global GDP. By 2030 this would shave about $1 trillion off global GDP annually. In the high-impact scenario, the reduction of global GDP in 2050 would be 3.8% with an annual shortfall of $3.4 trillion in global GDP as of 2030.

To put this in perspective, at their worst, the costs could be as great as the losses incurred during the 2008-09 financial crisis. However, the AMR impact is much worse for two reasons: one, the GDP loss would be expected not once but annually over the 20-year period 2030-50, and, two, it would disproportionately affect lower-income economies.

A critical dimension of the cost relates to international trade, especially with respect to livestock and livestock products, with reductions of as much as 11% projected in low-income countries. Along with that, we would anticipate costs of health care to rise—from taking care of much more complicated patients—by as much as 25% in low-income countries.

If we look at the aggregate impact against the World Bank's primary goal of eliminating extreme poverty, in the high-impact scenario, 28 million people would be impoverished by AMR by 2050, the large majority of whom live in low-income countries.

AMR is not just a health care issue; it is a development issue, which if unaddressed threatens to derail economies and the achievement of our most fundamental development goal at the World Bank, which is to eliminate extreme poverty.

The report not only spelled a picture of doom and gloom in terms of the costs of inaction but also looked at why investing in AMR makes good sense. We used two standard metrics to assess interventions. One is the net present value. We found that between $10 trillion and $26 trillion of benefits could be realized with a $0.2 trillion investment globally over the period 2017-50. When we look at the other investment criterion—expected economic rate of return—that would be somewhere between 31% and 88% depending on how effective the interventions were on an annual investment of $9 billion. It's a very good EER or expected economic rate of return.

If the benefits of action make good health and economic sense, what's the way forward? Recognizing the growing political consensus to tackle AMR, let me just touch on a few areas where the World Bank is actively engaged.

In the area of health, we are actively promoting an agenda of universal health coverage, together with the WHO. There are three reasons why this is good for AMR.

The first reason is universal immunization. If all children in the world had access to pneumococcal conjugate vaccine, not only would this save millions of lives, but this would be an incredibly cost-effective investment to stem antibiotic resistance to pneumococcal infection. The World Bank, as a co-founder of Gavi, the Vaccine Alliance, to which the Government of Canada is a major contributor, introduced an advanced market commitment in 2008 as an incentive to vaccine manufacturers to produce pneumococcal conjugate vaccine in sufficient quantities with a guaranteed price. The impact of the AMC has been to accelerate introduction of PCV in low-income countries. However, we're still well short of 100% coverage.

The second reason is to look at how we finance health systems. Universal health coverage means moving from systems of health financing, where patients pay for care when they're ill, to systems that prepay and pool resources through insurance or tax. There are lots of reasons why this makes sense as an equitable and efficient way of financing health systems, but it also makes good sense for antimicrobial resistance.

In pay-as-you-go financing systems, antimicrobial resistance rates are much higher and in pooling systems, they're much lower when you compare across countries. We're looking at ways in which we can accelerate the move toward prepayment systems for universal health coverage, in particular, working through our global financing facility for “Every Woman Every Child”, which is also an initiative supported by the Government of Canada, which aims to transform financing of health systems in low-income countries.

The third reason is to make sure that we secure essential public health capacity everywhere. The Ebola crisis in west Africa in 2014, like SARS in 2003, alerted the world to the dangers of turning a blind eye to the systems necessary to keep the public's health safe. Chief among these essential capacities are laboratories for disease surveillance. We've found that regional networks of laboratories in Africa provide particularly cost-effective ways of building AMR surveillance.

Two weeks ago, I was in Uganda and saw a reference laboratory for tuberculosis that was receiving sputum samples from as far away as Liberia and Somalia. They were doing highly sophisticated drug-susceptibility testing to monitor TB resistance in these countries. The scale efficiencies in establishing networks of core public health capacities are a designated focus of IDA. IDA is the World Bank Group's fund for the poorest countries, to which the government of Canada is a major contributor.

Beyond health, we're also investing through our agricultural global practice and recognizing the ubiquitous use of antibiotics as growth promoters for livestock and aquaculture. Building on the One Health principles, we've adopted a three-pronged strategy in agriculture: mitigate to reduce use, adapt to reduce the need, and innovate to optimize the use. We're encouraged by recent evidence that restricting the use of antibiotics in food-producing animals is associated with a reduction in AMR. Similarly, we are inspired by the innovative use of vaccines for salmon that has decreased dependence on antimicrobial use in the Norwegian salmon farm industry.

However, given the complex realities of livestock and aquaculture systems in low-income countries, we believe that more basic information and innovation are required. In that regard, we're working very closely with IDRC, the International Development Research Centre, to pioneer an interdisciplinary research agenda that could generate a much better understanding of current patterns and trends on AMR use in livestock production and stimulate innovation towards lower- or no-use antimicrobial systems in low-income countries.

With that, I would like to close and thank the Government of Canada for the opportunity to provide this perspective. I congratulate the committee for considering how to accelerate more concerted action on AMR, both at home and abroad.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you. I appreciate your stopwatch.

Now we go to Dr. Wright.

My notes here say that when you are not doing research at Harvard or McMaster, you are a drummer in a rock band, so we're looking forward to your presentation.

[Professor Gerard D. Wright, Professor, Department of Biochemistry and Biomedical Sciences, McMaster University, As an Individual]

Thank you. At the end, I can do a little presentation for you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

You have 10 minutes.

[Prof. Gerard D. Wright]

Thank you very much, Mr. Chairman, and thank you for the invitation to come and speak here today.

For some background, I am not just a drummer in a rock band. I am the director of the Michael G. DeGroote Institute for Infectious Disease Research at McMaster University, where we are bringing together a multidisciplinary team of over 30 clinicians, microbiologists, chemists, biochemists, and mathematicians, and over 200 young people training in this area as undergraduates, graduates, and post-doctoral fellows. Our objective here is to change the challenges you've just heard about so eloquently from the other presenters.

I've been working in this field for 27 years. I started as a post-doctoral fellow at Harvard Medical School, working on vancomycin resistance when it first emerged in the Boston area, and I was involved in the team that actually figured out the biochemical mechanism of this. Before that, vancomycin was known as an “irresistible antibiotic”. That is, we thought there was no way bacteria could become resistant to it. It turns out, of course, that this is false. It is false for all antibiotics. All antibiotics are susceptible to resistance. There is no such thing as an irresistible antibiotic.

Since I came back to Canada, my team and I have published over 250 publications in this area. We are working incredibly hard to solve this problem. We have also discovered a brand new compound from a soil sample in New Brunswick that actually inhibits resistance to carbapenems, and this is now in preclinical development. We are trying to do the whole gamut, at McMaster.

Antibiotics have really changed the way we die. Prior to the antibiotic era, almost half of us would die of an infectious disease. Now only 3% to 4% of us do. This is a remarkable achievement.

Antibiotics are also very special molecules in a different way. An analogy that is often used is that antibiotics are like fire extinguishers. Fire extinguishers are great for putting out fires, and that's what we use antibiotics for when we have an acute infection. However, fire extinguishers are also great just in case you have a fire. Antibiotics are there to enable us to do all sorts of incredibly risky procedures in medicine that, prior to the discovery of antibiotics, we simply couldn't do. We couldn't ablate someone's immune system to treat their cancer, safely transplant a heart, put in a new hip, or take care of preterm infants without infection control—in particular, the acute infection control given to us by antibiotics.

The other thing that's special about antibiotics is that they are unique among drugs. They are susceptible to evolution. You will never evolve resistance to your blood pressure medicine, your birth control pills, or your cholesterol-lowering agents, but bacteria will always evolve resistance to antibiotics. It's just part of the world of biology. We have discovered, in my lab, that antibiotic reaches deep back in time. We have identified resistance elements in Yukon permafrost. This has been around for a long time, and there is no way we can actually solve this problem completely. This is something we have to continue to fight on a regular basis.

This is where the crisis comes from. The drugs we have relied on, which were discovered mostly in the 1950s and 1960s, are no longer working.

I have some personal experience with this. I actually got a blood infection caused by a salmonella that was resistant to ciprofloxacin, which was the first drug I was put on when it was revealed that I had this thing. I know first-hand what it's like to have an antibiotic fail. I also know first-hand what it's like to have an antibiotic in an IV bottle that actually works, and the difference that 24 hours will make when you have this situation is stunning.

We, in Canada, have to address this crisis with the intensity it deserves.

You've heard all these predictions of the economic impact in the future, the current economic impact, and the impact it has on lives, but let me tell you a story right now. In our hospital at McMaster University, one of our clinicians, whom I was talking to yesterday, is dealing with a patient who has multidrug-resistant pseudomonal isolates in the lungs and also recently got a multidrug-resistant klebsiella infection. The chances are this person is going to die. They are going to die because we have drugs that no longer work. They wouldn't have before, but the resistance is causing this problem.

So what are we going to do? The reality is that the pharmaceutical companies, as you've heard before, cannot be relied on to solve this problem. We're going to have to solve this problem ourselves.

The AMR framework that was released by Health Canada is a great road map. It emphasizes stewardship, surveillance, and innovation in discovery. I want to speak in particular to the innovation in discovery element. Just to calibrate, in Europe the effort to stimulate antibiotic discovery is being resourced by the innovative medicines initiative to the tune of 700 million euros. We heard about CARB-X, and that approach is $500 million U.S. Canada is nowhere to be found on this scale yet. We have to do something about it.

To deal with this, my colleague, Bob Hancock, who is at the University of British Columbia, and I have collected researchers and academics in small and medium-sized companies across Canada in governments and not-for-profits working in this area in Canada. We call this network the Canadian anti-microbial innovation network. What we're seeking to do is raise awareness to this problem and also provide an opportunity for investment in what we are good at in Canada.

One of the things that was discovered in Canada is a compound called tazobactam. It is an inhibitor of drug resistance. It was discovered at the University of Alberta in the 1980s. Tazobactam is given to patients all around the world. It was created here in Canada, and I bet you have never heard of it.

We need to do more of this. We're good at inhibiting resistance. We're good at finding alternatives to antibiotics. We're great at finding new vaccines and in using modern genomics to solve this problem, in particular in surveillance.

At McMaster, we've created the comprehensive antibiotic-resistance database that is used every day by researchers and clinicians around the world. It is the most accessed antibiotic-resistance database in the world, and it has no funding.

The other thing I want to leave you with is that we have to continue to invest in this area, and Canada has to take its place on the world stage in this area. We have the ability to make a significant contribution in this area. We have the talent. We have the young people who want to make a difference in this area. We have the infrastructure that has been the legacy of things such as the Canada Foundation for Innovation. We are all set to go.

Just as Churchill said to the United States government back in the early 1940s, give us the tools. Give us the tools and we will do great things.

I'll finish there. Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now we'll go to our seven-minute round of questions. Some will be in English and some in French. We have translation facilities if you require them.

We're going to start with Dr. Eyolfson, for seven minutes.

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

Thank you, Mr. Chair. Thank you all for coming. It's very interesting.

I worked in emergency departments for almost 20 years as an ER doctor. I'm familiar with much of what you're saying and have seen this wave coming for a number of years.

Dr. Kramer, you mentioned early on in your presentation that certain countries are still using antibiotics. I didn't catch the word you used before “countries”.

[Jane A. Kramer]

I said BRIC countries: Brazil, Russia, India, and China.

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

Thank you very much.

Do you know if in North America we're importing significant amounts of meat from these countries?

[Jane A. Kramer]

It's not terribly significant, no.

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

Thank you.

To your knowledge, are the antibiotics that are used in humans being used other than for illnesses in agriculture right now in North America?

[Jane A. Kramer]

It's probably 25% of the grand proportion.

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

That's interesting, because we've heard from others, particularly in the agricultural industry, who are saying something to the effect that no antibiotics that are important in human biology are being used in agriculture in North America.

I had a little trouble with that statement, but you're confirming something that I thought was the case.

[Jane A. Kramer]

There's a larger percentage used in swine production. Certainly, it's used widely for growth promotion in swine production. There's great controversy about how the animals are grown, or produced, in close confinement. I know you had as witnesses the animal producers, as well as veterinarians; I looked at the testimony and the briefs. When they're grown in close confinement, the possibility of more disease is greater. Therefore, you need to use it to prevent disease. However, growth promotion is the greatest use. That is the reality.

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

Okay, and do you know what kinds of antibiotics are being used in North America, particularly in the swine industry?

[Jane A. Kramer]

No, I don't. It's just not my expertise. Sorry.

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

No problem. Again, this is my experience with human medicine. I have very little experience with veterinarian medicine, but as a general rule, we find that other than very specific, rare cases, using antibiotics prophylactically is not good medical practice.

For instance, if there's an outbreak of some bacterial illness at a day care, you generally don't give antibiotics to all the kids who are there. We know it doesn't work and creates more problems than it solves. If you have animals in close quarters, is there actually a scientific basis for preventing disease by using antibiotics in these animals?

[Jane A. Kramer]

We would be skeptical about that. You have a big industry in Canada for food production. You might consider convening the industry and the veterinarian community and having it out, just really discussing it. That's really what I was referring to. This is something you can put your arms around and manage. I really think it's generally manageable in your country. With Guelph, the other universities, and the industry, you could manage it productively and effectively.

It's something where you have a discussion. We would help facilitate it if you wanted, maybe with other non-profits and NGOs, just to facilitate the agenda, together with members of the committee maybe.

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

All right. Thank you very much.

Dr. Brock, you talked about antibiotic-resistant tuberculosis. Are you familiar with what the incidence of AMR TB is in Canada?

[Willo Brock]

I don't know the exact numbers. I know there's a very low percentage of cases of drug-resistant TB in Canada. There are only a handful. However, as I mentioned, given the expense and complexity of treating TB, even a couple of cases—25 cases a year—is an incredible pressure on the health care system. As I mentioned, people being in treatment for two years, being hospitalized, often needing to be brought to specialized centres and therefore being away from families and economic opportunities, is really a great burden. The number I mentioned—of an extensively drug-resistant patient possibly costing up to a million Canadian dollars for treatment—is obviously a massive issue.

In addition to the public health issue, the infectious nature of the disease makes the patient not just an issue for the health care system, but also raises concerns regarding the confinement of that patient, avoiding further outbreaks, and finding potential family members and community members who may have been infected through that patient in the time before they were diagnosed.

It's a relatively small problem, but it's already at the point where even a handful of cases becomes seriously problematic.