Health Committee on March 9th, 2023

[The Chair, Liberal, Sean Casey]

I call this meeting to order. Welcome to meeting number 56 of the House of Commons Standing Committee on Health.

Today we meet with witnesses on our study of children's health. We'll then move to committee business at 12:30. One of the items we will consider is Bill S-203 and any other items that will come before the committee.

Today's meeting is taking place in a hybrid format pursuant to the House order of June 23, 2022.

To the witness we have via video conference, you will notice on the bottom of your screen that you have the choice of floor, English or French for interpretation. For those in the room, you have your earpiece and you can choose the desired channel.

Screenshots or taking photos of your screen is not permitted.

The proceedings today will be made available via the House of Commons website.

In accordance with our routine motion, I inform the committee that all witnesses have completed the required connection tests in advance of the meeting.

We'd now like to welcome the witnesses who are with us this afternoon.

I will now welcome Dr. Anne Monique Nuyt, chair and chief, department of pediatrics, faculty of medicine, Université de Montréal and Centre hospitalier universitaire Sainte-Justine, and Dr. Caroline Quach‑Thanh, pediatrician and infectious diseases microbiologist, Université de Montréal and Centre hospitalier universitaire Sainte-Justine.

We have Cindy Blackstock, executive director of the First Nations Child and Family Caring Society of Canada.

Thank you all for taking the time to appear today.

Each witness has up to five minutes for an opening statement.

Welcome, Dr. Nuyt.

You have the floor.

[Dr. Anne Monique Nuyt, Chair and Chief, Department of Pediatrics, Faculty of Medicine, Université de Montréal and Centre hospitalier universitaire Sainte-Justine, As an Individual]

Thank you, Mr. Chair.

Good morning, everyone.

I'm going to give my presentation in French, but I can answer questions in English or French.

Thank you for having invited me to appear before you to discuss subjects of particular importance for us and our country. I'm a pediatrician who specializes in neonatal intensive care, and a clinician investigator. I also hold a tier 1 Canada Research Chair. As you pointed out, Mr. Chair, I am here before you as the chair and chief of the department of pediatrics, in the faculty of medicine at the Université de Montréal and Centre hospitalier universitaire Sainte-Justine.

I am also the president of Pediatric Chairs of Canada, an organization that represents 17 university pediatrics departments in Canada. Our mission is to train all of Canada's pediatricians and, for some of our departments, those health professionals called “subspecialists”, such as pediatrician-cardiologists and respirologists. Our mission also includes furthering knowledge through research, establishing best practices in pediatric medicine and enhancing the quality of care in our hospitals.

I'd like to speak to you more specifically about three key issues that affect children, for which we need your commitment.

The first of these issues is the number of subspecialists in pediatrics. I know that my colleagues have already appeared and mentioned the major problem of access to community care from nurses, family physicians and general pediatricians. But even if that problem were addressed, many children would continue to require specialist and subspecialty care. Unlike adult medicine, most subspecialty care is provided at university pediatric hospitals, because that's often where the small teams of doctors with the required expertise are concentrated, and able to provide and continue to provide a high level of care. As department heads, our role is to find, recruit and retain these specialists.

Most of our pediatric hospitals encounter major challenges in fulfilling this mandate. Of course, the places available in pediatric subspecialty training programs are a provincial jurisdiction. This means that there are a few programs in a number of provinces that train subspecialty doctors for the whole country. Without a national coordinated and collaborative workforce plan, it will be impossible to train enough specialists to deal with the needs of Canada's children. That means that we often look beyond our borders to recruit subspecialists.

For example, at the moment, 25% of the subspecialty doctors in my department at Sainte-Justine were recruited internationally. That in itself allows for rewarding exchanges of knowledge and experience that are beneficial to everyone. However, credential recognition can vary from one province to another, even in countries that provide recognized training, like Belgium, France and the United States. The immigration process around the world is, of course, slow and burdensome. That's why it will be important to adopt a coordinated interprovincial approach under national leadership.

The second issue I would like to point to on behalf of the entire Canadian university pediatrics community relates to the importance of access to quality data to accomplish our missions. We need data to support research into pediatric illnesses. We need data to set pediatric priorities for vaccination rates, obesity, developmental disorders and mental health in adolescents. And we also need data to monitor the quality of our specialist and subspecialty care

Every centre must, of course, compare itself to others to continue the provision and enhancement of care. Since we do not have many pediatric hospitals and because each specialty treats only a small number of children, it's often impossible to do comparisons between provinces, even the most populous among them. We believe that access to national data is a priority, particularly for quality pediatric care.

As for the third issue, I'd like to speak to you about access to children's medicine. As was clearly demonstrated by the work of the Goodman Pediatric Formulations Centre, under scientific director Dr. Litalien, Canada's regulatory arsenal is lagging well behind in promoting access to drugs for children in Canada, compared to other authorities like the United States Food and Drug Administration, the FDA, or the European Medicines Agency. The Goodman Pediatric Formulations Centre and the Institute for Safe Medication Practices Canada have in fact submitted a document on this topic to your committee.

There are two problems. The first is access to drugs, whether new or old, that could be used to treat children. For these to be available to children, companies have to request permission from Health Canada. Of course, the administrative burden of the process, combined with the small market represented by children, is not very attractive to the companies in question.

To address this, agencies like the FDA and the European Medicines Agency have, for more than 10 years now, introduced regulations requiring companies to submit an application for pediatric use, or to conduct studies on children, whenever they apply for approval of a new drug that might have a pediatric use.

We would like to point out that Health Canada has just set a priority on developing an action plan for pediatric drugs, and we are very grateful to them for this. We keenly hope that the experience of our international colleagues will be put to good use on behalf of Canadian children.

The second problem with medicines has to do with access to pediatric formulations—the syrups, if you will—of drugs that have already been approved for children.

It is of course important to have access to pediatric formulations for the treatment of children, and also important for the drug itself to have Health Canada approval, but it's equally important for the pediatric formulation to be tested, in terms of its concentration and stability, for example, in the syrup.

Here again, Canada lags far behind in its approval of pediatric formulations. To give you just one example of the scale of the problem, the pharmacy at our hospital, CHU Sainte-Justine, has to prepare its own in‑house formulations for approximately half of the drugs, meaning that it has to crush the pill into a syrup. A formulation for this already exists commercially and has the approval of the FDA or the European Medicines Agency.

The pediatric community is therefore requesting that the regulatory structure based on decisions from trusted countries, and also currently being studied by Health Canada, be considered a priority for children's medicines, and in particular for pediatric formulations. Drug needs for children are different than those for adults, and deserve special regulatory attention, and a more rapid system for introducing regulations.

Thank you once again for your invitation, for hearing us out and particularly for your attention to this issue in your study. We believe that it is essential to have frank and open communications between you as the decision-makers and the pediatrics community working in primary care and specialty care. Right now, the health and care of children need your special attention. We, the clinicians and researchers, simply want to make you aware of the circumstances in which we operate and to provide you with the reliable data you need to make the best possible well-informed decisions.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Nuyt.

Dr. Quach‑Thanh, I'd like to welcome you to the committee.

You have the floor.

[Dr. Caroline Quach-Thanh, Pediatrician, Infectious Diseases and Medical Microbiologist and Physician Lead, Infection Prevention and Control, Centre hospitalier universitaire Sainte-Justine, As an Individual]

Thank you, Mr. Chair.

I'd like to thank the members of the Standing Committee on Health for having invited me to appear in connection with its study on public health and the prevention of childhood illnesses.

I'm a pediatrician, infectious diseases microbiologist, and clinician investigator at the Centre hospitalier universitaire Sainte-Justine, and a full professor of microbiology and pediatrics at the Université de Montréal. I also hold the Canada Research Chair in Infection Prevention and Control: from Hospital to Community, a tier 1 chair.

I'm the director of the POPCORN network, which the Canadian Institutes of Health Research funded in 2022 for a two-year period. The purpose of the network is to make it possible to monitor the progress of a child's care in Canada's 16 pediatric hospitals with a view to strengthening national infrastructure, expertise and human capital in pediatric research, and studying the repercussions of interventions or events on the mental health and development of children in Canada.

The Canadian Institutes of Health Research had asked the network to study the impact of COVID‑19 on children, and an initial national conference is scheduled in May 2023 to communicate preliminary results and plan the next steps.

I acquired my expertise as a clinician and researcher in the field of infection prevention and vaccination. I will therefore focus on these areas, to avoid hearing my children say, “Stay in your lane, mom.”

Although we all take vaccination for granted and have the impression that vaccine-preventable diseases are a thing of the past, it's important to realize the extent to which today's world is still experiencing a resurgence of illnesses that we thought had disappeared.

One example is poliomyelitis. Until last year, no one would have thought that a case might occur in the state of New York. But wastewater surveillance, here and elsewhere, has shown that the virus is being shed and that in the absence of vaccination, people are still exposed to the risk of infection. Most of us are too young to remember the harm caused by polio, and the deaths and paralysis suffered by children who had otherwise been in perfect health.

Similarly, measles is still affecting people, even in developed countries, when the vaccination rate falls below 95%. Almost 20,000 people were recently exposed to a case of measles in Kentucky. There is a risk that a case could enter the country, and young children are most at risk of experiencing a serious illness as a result.

Why is immunization coverage so low? In 2019, a survey of immunization coverage by the Institut national de santé publique du Québec showed that by the age of 15 months, approximately 95% of children had received all their vaccinations against poliomyelitis, measles and pneumococcal diseases. However, the vaccination records show that immunization coverage for measles is closer to 85%. The actual figure is likely somewhere between the two, but the assessment of how the pandemic affected immunization coverage remains to be carried out.

It would appear that concerns about the efficacy and safety of COVID‑19 vaccines probably eroded the confidence of some parents in other vaccines that have been used for decades. This trust needs to be restored or we risk seeing a resurgence of these vaccine-preventable diseases and all the complications that come with them: meningitis, encephalitis, deafness, long-term side effects and deaths. Infectious diseases are also democratic: they will affect everyone, but will have more of an impact on those who are medically and socio-demographically most vulnerable. Health inequities are also reflected in infectious diseases.

A child who goes to a day care is expected to catch 8 to 12 colds a year. The pandemic led to the reappearance of many different respiratory viruses, the end result of which was a significant increase in secondary bacterial infections, such as orbital cellulitis, mastoiditis, pulmonary abscess, meningitis and intracranial abscess.

To date, the antibiotic resistance of these bacteria has remained relatively stable in Canada, but inappropriate use of antibiotics, the difficulty of diagnosing and differentiating a viral infection from a bacterial infection, combined with globalization, could be a threat to treatments that we now take for granted.

Antibiotic resistance is potentially the next pandemic we will have to face. Not only that, but more and more studies are beginning to reveal a link between exposure to various environmental contaminants and lowered immune response. This research needs to be continued from the standpoint of a concept based on a “one health” approach that promotes an integrated, systemic and unified approach to human, animal and environmental health.

Efforts are currently being made to determine whether the recent increase in viral infections is due simply to a cohort effect, with serious bacterial infections simply the outcome of the larger number of viral infections in circulation, or rather due to the emergence of more virulent bacterial clones.

It's therefore critical to establish surveillance programs, including genomic surveillance, for infectious diseases across Canada.

One of the cornerstones of infection prevention is ensuring that measures introduced do not cause any serious collateral damage. The subtleties involved are often difficult to communicate to the public. Research and evaluation are therefore essential in support of public health decisions. The POPCORN platform could answer these questions, but the best option would have been to factor in and assess child health earlier on during the pandemic.

I'll conclude by saying that it's impossible to overstate the importance of infection prevention, as well as the data and research required to maintain the current health status of children. More investment in this key sector would save lives and public funds.

It's important for us to understand and measure the impact of the pandemic on immunization coverage and to restore parental confidence, where needed, by using open and valid data.

It will be important to ensure that effective surveillance programs, including genomic surveillance programs, can measure the burden of infectious diseases and vaccine-preventable diseases, and to make the results available to everyone.

It's essential to make sure that children's health is factored into research priorities and that there is more than just short-term funding for networks.

The resources and measures required to prevent the emergence of antibiotic resistance must be allocated.

The “One Health” concept needs to be promoted in health decision-making and research with respect to children.

Thank you for your attention.

I'd be happy to answer your questions.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Quach-Thanh.

Next, I'm honoured to call on Dr. Cindy Blackstock, executive director of First Nations Child and Family Caring Society of Canada, to address the committee.

Welcome, Dr. Blackstock. You have the floor.

[Dr. Cindy Blackstock, Executive Director, First Nations Child and Family Caring Society of Canada]

Thank you, and a very good morning, Chair and members. I would like to recognize that this testimony is occurring on the unceded and unsurrendered territory of the Algonquin nation.

In 2008 the World Health Organization said inequality is killing on a grand scale. There are all kinds of inequality flowing from capitalist markets and other things, but there's also inequality that is directly sourced to the decisions that are made in this House and made in the Senate. That's the story I want to talk about today: how that inequality has killed first nations children, how it's contributing to the deaths of first nations children today, and, most importantly, what you all can do about it.

In 1907 there were headlines across the country such as “Absolute Inattention to the Bare Necessities of Health” and “Startling Death Rolls Revealed”. What were they talking about? Canada's own medical inspector for the Indian department had found that the federal government was underfunding health care for first nations children in those schools. “By how much?”, you might ask. Well, the people living here in Ottawa received three times the amount of health care funding that all “Indians” across the country did. That gross inequality, coupled with poor health practices, was resulting in death rates of 25% per year, growing to 50% over three years.

The Government of Canada accepted those statistics; they did nothing about the inequality.

Where does that inequality come from? It comes from the Indian Act, under which the federal government funds public services on reserve—everything from water to health to education to child care—and the provinces fund those for everyone else. Since Confederation, they have underfunded those services, creating a cascade of poor health outcomes for first nations children.

Now, that decision—it was a decision rather than a failure—by Canada to not remedy those inequalities created ripples that we saw, sadly, in the headlines of 2021 and 2022 about the children in unmarked graves.

In 2005 Jordan River Anderson was in the hospital in Winnipeg. At the age of two he would have gone home. His pediatrician said it was time, but he didn't go home, because he was a first nations child and there was a dispute between the Government of Canada and the Government of Manitoba about who should pay for his at-home care. Make no mistake: If he had been non-indigenous, he would have gone home. He died in the hospital because of who he was, having never spent a day in a family home.

In 2007 all members of the House of Commons—and I want to thank all members of all parties—stood in unanimous support of Jordan's principle, which is about first nations kids getting the help they need when they need it. It's something every Canadian could get behind, but it has taken now 16 years of litigation and 25 non-compliance orders to get the Government of Canada to a place where it's beginning to put a proper label on Jordan's principle. In the wake of that—in the non-compliance period—the deaths of two children have been linked to Canada's non-compliance as it refused to provide medical care for mental health to two children who later died by suicide at the age of 12. We don't know if those deaths could have been prevented, but we know that there would have been a chance to prevent those deaths of those sacred children had those children received the types of supports they could have had.

Jordan's principle is a very basic principle of Canadian health. We talk about universal health care, but actually when we get down to it, we really don't have that in Canada.

We've done some work to decide what can be fixed about Jordan's principle. What we're finding now, thankfully, due to the tribunal and the collective work of first nations leadership, is that we're now giving out about $2 million in services resulting from Jordan's principle—which is a good thing—in health, education and other social supports, but we're also finding that it's funding gaps in these other underfunded services. You see, since Confederation there hasn't been a comprehensive plan to cost out all of those inequalities and remedy them all.

We know governments are capable of doing this. In fact we, along with allies, did this in the Second World War with the Marshall Plan. We rebuilt Europe by creating a multidisciplinary plan. Surely this is something we can do here, and the Spirit Bear Plan is the way to do that. We want to put the hands of that calculation out in the public parlance and get someone like the Parliamentary Budget Officer to cost out all of these inequalities and put to bed for all time what amounts to an apartheid public service system with respect to first nations kids that contributes to their poor health outcomes.

In the case of Jordan's principle, a large majority of the requests that come in are actually for low dollar-value items. They are huge dollar-value items to that family but low dollar-value items for the government, yet a request for a 150 bucks to buy baby formula is put through the same red tape as a request for $5 million. That's not a good use of public servants' efforts.

We'd like to see that calibrated so that, like any business you might run, you have a certain dollar threshold below which it's nominally approved as long as there's a professional note saying the child needs that service. It's not without any check systems. These types of things would create vast efficiencies.

The other thing we're looking for is.... The litigation is ongoing, but we still don't have an answer for what is going to happen for Jordan's principle beyond year five. The agreement in principle is a positive thing, but we need to know that this discrimination is never going to happen again for any child in this nation.

When we all saw the children in unmarked graves and when we all wore the orange T-shirts, we were making a promise to the residential school survivors to make sure that what happened to them doesn't happen to their grandchildren. We have solutions on the books to be able to remedy this. This is not a problem without a solution. This is a solution without, so far, the political will to implement it. With all of you, I'm sure we can get that done.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Blackstock.

We're going to now move to rounds of questions, beginning with the Conservatives.

Dr. Ellis, you have six minutes, please.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much, Chair, and thank you to all the witnesses for being here today on the very important topic of children's health. There's certainly a nice range of opinions here today. I think it's very important that we understand that.

Dr. Nuyt, I will start with you.

You are someone with some expertise in this. You spoke specifically in your opening statement about it and, through you, Chair, you talked about finding, recruiting and retaining pediatricians. Of course, this is a very difficult topic that we're all very well aware of, not just in Canada but perhaps around the world as well.

Maybe you could share with the committee some of your thoughts around how we can best do that.

[Dr. Anne Monique Nuyt]

As I briefly concluded in that paragraph, even though I understand that this is a provincial jurisdiction, I think we need to have a global plan across Canada for planning the needs. When I talked about pediatrician retention, I specifically spoke about what happens in our tertiary care hospitals. I'm not talking about the community pediatricians; I'm talking about the specialists and subspecialists.

I think first we have to plan appropriately for the whole country how many we need to train—not just province by province. For example, in pediatric nephrology, 17 university hospitals need pediatric nephrologists, but there are just six or seven centres in three provinces that train them. Obviously, if the calculation is made only within the province, it won't be enough. That is needed.

I think it's very interesting to be able to recruit specialists from other countries who might not have all the expertise for every single little thing that we need. In a way, if this could be facilitated in terms of the recognition of diplomas, especially from medical schools in other countries that we know are of equivalent quality, I think that could be of great importance. I know certain provinces have made certain agreements with certain countries. That would certainly be of help.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much.

Through you, Chair, another thing you touched on was retention of pediatricians.

As we go through our careers as physicians, part of the difficulty is for people who work in a fee-for-service environment. Of course, there's no ability to have a pension plan other than what you save for yourself. Do you have any ideas on how we may be able to better plan ahead for when physicians might retire or how to retain them longer?

[Dr. Anne Monique Nuyt]

I won't talk specifically about salaries, but I will bring two questions to the importance of retention.

One is that many pediatricians and subspecialists in the university hospitals have tasks other than caring for patients. They have to teach the next generation of pediatricians and teach family doctors about pediatrics. They have to do research, because we're responsible for generating new knowledge. That part needs to be taken into account when we're thinking how much we pay those who are in university hospitals. That's number one.

Number two is that the major complaint I hear from my colleagues about pursuing their careers is the lack of multidisciplinary help. It's the lack of the other professionals they need to do their job, like nutritionists, nurses and respiration therapists. There is such a lack of all these professionals. They are essential to do the care that every specialist needs to do. It's burning them out.

Burning out is when you can't do the job you're supposed to do and you want to do it.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you for that.

The other topic I'd like to touch on is that you did mention the concept of data. Certainly it is something that we talk about a lot. We've talked a lot about it in this committee. We hear a lot about data and we know the importance of it.

Part of the difficulty, though, is how to collect that data. What systems do you use? How do you communicate among provinces and territories and the federal government to make this meaningful and, for instance, to understand exactly how many pediatricians we have? How many pediatric nephrologists do we have? They're perhaps easier to count because there aren't many of them, but general pediatricians in communities.... To understand exactly how many we have, how much work they're doing and when they might retire, etc., do you have any ideas around that?

[Dr. Anne Monique Nuyt]

I'm not a professional health service planner—I'm just a regular doctor—but I can see there's a problem, so thank you for bringing this up again. All these data are within provinces, and I think that to bring this topic to the interprovincial discussions could probably be.... It's just a matter of helping each other here.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Through you, Chair, that's certainly one of the issues we've had—provinces working in silos. I think that perhaps we do need to look to the pediatric community. Perhaps you're a little better at this than adults' physicians are on that idea of camaraderie. Maybe we can get some better ideas on how to share things through the pediatricians, so I thank you for that.

If I have time, at some point I'll come back to medications, but with regard to medication shortages, especially in the pediatric world, whether it be acetaminophen and ibuprofen—over-the-counter medications, as you well know—or any pediatric oral antibiotics, at the current time we have a critical shortage, as all of you know as well. That's something I think that we'll need to touch on here at this committee to understand why those shortages exist and how to overcome them.

I appreciate that.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Ellis.

Next is Dr. Hanley, please, for six minutes.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you to the witnesses for being here today.

Thanks to all three of you for appearing here today.

Dr. Nuyt, I won't have time to ask you questions, but I appreciate your recommendations. They echo those of some of our witnesses earlier in the study, as well as in our important workforce crisis study.

Ms. Blackstock, it's pleasure to meet you. I know that you've been in the Yukon many times. I appreciate that you have never been one to mince words and I appreciate your frankness in this room as well.

In the Yukon, just last month we celebrated the 50th anniversary of “Together Today for our Children Tomorrow”. That was the beginning of the modern treaty process, not just for Yukon but for the country. Over the next few decades, we came to realize self-governance in 11 out of the 14 first nations. I think the agreements on self-governance and the progress we've made so far in the Yukon in child health and well-being are not coincidental.

I want to pay a bit more attention to Jordan's principle. As an example of the many areas of progress since Jordan's principle—admittedly driven by the courts, but now we do have it—I was in Haines Junction just this past week at the Shäwthän Näzhi recovery support program, an amazing family support program for recovering adults to support those families in recovery. They said that this would not have been possible without Jordan's principle.

As we contemplate your recommendations on the Spirit Bear plan, do you see the ongoing Jordan's principle and the extension of it as a transition to something more comprehensive and enduring to continue to right the wrongs?

[Dr. Cindy Blackstock]

Yes. Thank you very much, member.

The type of story you're telling is something that echoes across the country in terms of the wonderful outcomes that can come from remedying these inequalities and getting services for kids. We know, for example, from the Nobel Prize-winning economist James Heckman, that for every dollar government spends on a child, it will save many times that number downstream. This is something that I know my colleagues will agree with.

Although we're spending money on Jordan's principle now, we can expect to get savings in the public purse downstream, but more importantly, this could be the first generation of first nation kids who never have to recover from their childhoods. That's the importance of Jordan's principle and the equality measures that it represents.

Jordan's principle is a legal requirement now in the country and is something that should be embraced. Especially those who are really fiscally prudent should embrace it and preserve it, but if we're able to continue on with it as a measure, we need to plug the holes in the other underfunded services, because that's really the answer, right? It's to make sure that when a first nation child goes into a school, it doesn't have black mould and that there are a number of teachers there who can support that young person. Also, as you're pointing out in terms of the tie to self-government, we need to make sure the services are culturally appropriate and take into context the culture and language of that particular student.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you very much.

I'm going to turn to Dr. Quach-Thanh.

First of all, congratulations to the translator for being able to keep up with you as you read through an encyclopedia of recommendations.

I want to focus on a couple of areas. As one, you did mention the importance of recognizing antibiotic resistance. This is such a huge area, and we have slowed down our attention on it over the pandemic, as with many other areas. Could you review very quickly a few key policy steps that we need to be looking at for addressing antibiotic resistance, particularly using the One Health concept that you referred to?

[Dr. Caroline Quach-Thanh]

Absolutely. Thank you.

Thank you to the translator for being so good. I know I speak quickly.

Just to set the stage, antibiotic resistance occurs when a type of bacteria that we were able to treat with a regular antibiotic is not treatable any more. In some countries, we're seeing more and more death associated with it because a urinary tract infection, which is something quite common, could be non-treatable and lead to death, which should not be seen nowadays.

The policy steps that have been taken and that we still need to keep on taking include, first of all, having data on what antibiotics are being used and what antibiotic resistance we're seeing with various infections. Again, as Dr. Nuyt was saying, it's not that easy to have access to data across the country.

There are a few programs that exist at the federal level. CNISP is one of those programs. It looks at nosocomial infections or health care-associated infections. We're able to follow antibiotic use and antimicrobial resistance. However, this program is limited to only 65 hospitals out of the 600-and-something that exist in Canada, so again, as Anne Monique said, particularly in pediatrics, if we want to have data that we're able to compare to, we need something that is national and not just provincial. That is the first step.

The second step, when we're talking about One Health, means that whatever you use or you see in animals will eventually end up in humans, whether that be through food or through close exposure. When we see antibiotic-resistant organisms arise in, let's say, chicken farms, it's very possible that people who are close to those chickens will acquire those organisms. Eventually there will be transmission between humans and we won't be able to treat those any more, so surveillance in both the veterinary world and the human world is necessary, and we really need to have the possibility to do genomics to understand if one strain is related to another or not.

At this point in time, these programs exist, but they are in specialized laboratories, in public health laboratories. We need to have better access to those and make sure that those programs are well funded across the country at the federal level and in the provinces, as well as in the national microbiology lab.

The last thing is to promote innovation in terms of new antibiotics. You are not going to see a lot of new antibiotics come up. Manufacturers and pharmaceutical industries are not tempted to put new antibiotics out on the market. It costs them a lot of money. It's labour intensive. Again, when a new antibiotic comes out, the last population that has access to it is pediatrics, so that's coming around to what Dr. Nuyt was saying in terms of the availability of drugs.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Quach-Thanh.

Mr. Thériault, you have the floor for six minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Mr. Chair.

We are privileged to have such knowledgeable witnesses with us here this morning. It would be extremely interesting to be able to speak to them for hours, but I have only six minutes.

First, Dr. Nuyt, my colleague Mr. Ellis asked you some of the questions I would have asked. I'll get back to you if I have time later, on your research into the impact of premature births, particularly on child health.

Dr. Quach‑Thanh, you said something that struck me. You said that antibiotic resistance was potentially the next pandemic we would be facing. That's a rather chilling prospect.

Can you tell us more about this? I'm sure there are some facts we need to know about from the clinical, socio-demographic and socio-economic standpoints.

What do we have to do to prevent this from happening?

[Dr. Caroline Quach-Thanh]

Thank you for the question, Mr. Thériault.

I think I may have partly answered it earlier, but I would add that the World Health Organization, the WHO, did in fact put antimicrobial resistance on its list of 10 threats to global health. When a human being or an animal is exposed to antibiotics, the so‑called “good bacteria” can develop resistance and transmit these genes to pathogens that will no longer be treatable.

Let's look at children, for example, particularly those who get frequent urinary infections because their urinary system is somewhat tangled and complex and there is reflux from the bladder to the kidneys. These children tend to be treated recurrently for urinary infections. As their care progresses, often even in their first year of life, they will be dealing with a bacterium that can't be treated with the usual orally administered antibiotics. So a urinary infection that should be easy to deal with will require hospitalization and the administration of very broad spectrum intravenous antibiotics for 10 to 14 days, and these may continue to contribute to antibiotic resistance.

It's therefore important to understand when to use antibiotics and when not to because it's a viral infection. Access to diagnostic tools, even remotely, is essential in family doctors' offices and in clinics, in order to be able to differentiate between bacterial and viral infections. Primary care doctors are very good, but they have to rely on their clinical experience. They may think it's a bacterial infection when it's only a viral infection. As I was saying, children may experience fever from 8 to 12 times a year because they will contract 8 to 12 viruses a year during their first years in a day care centre.

[Luc Thériault, Bloc, Montcalm, QC]

In these offices, do we have the technology required to rapidly make this distinction?

[Dr. Caroline Quach-Thanh]

For the time being, no, but I think research and innovation should be promoted so that remote biomedical examinations can be carried out. It would facilitate the work.

During the pandemic, there were rapid antigen tests to detect SARS‑CoV‑2. There are such tests for group a streptococcal illnesses, including pharyngitis, and also for other respiratory viruses. They're not perfect, although they are helpful, but they're not readily accessible yet. There are other very expensive tests based on the polymerase chain reaction, or PCR, method.

It's a matter of finding ways of providing access to these technologies in primary care centres.

[Luc Thériault, Bloc, Montcalm, QC]

It may be expensive, but if antibiotic resistance were indeed to become a pandemic, having failed to take timely and appropriate preventive action would end up being a lot more expensive.

Is that right?