Evidence of meeting #15 for Health in the 45th Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was infection.
A video is available from Parliament.
Bloc
Andréanne Larouche Bloc Shefford, QC
Thank you, Madam Chair.
Dr. Elsayed, in your opening remarks, you raised the issue of agriculture. You said that the antibiotics used in agriculture in the United States and Europe are not the same. Why is the reciprocity of standards for products imported here important?
Infectious Diseases Physician, Western University
Madam Chair, that is a very good question. I wasn't expecting to get that question today, but I'm happy to answer it.
Certainly, let's look at it from an individual perspective. If you are residing in Canada and you travel to a country where there is a high burden of antimicrobial resistance, and let's say you're there for a while or you're hospitalized, you will likely be colonized, meaning the normal bacterial composition of your skin or intestines will likely have some of those antibiotic-resistant bacteria. You're going to take it back with you, and you're not going to be able to get rid of it probably for about half a year. If you get medical care in another country, there's a high risk of getting an infection with an antimicrobial-resistant organism.
I was the first physician in southwestern Ontario to see an antibiotic-resistant infection from a certain strain that came from overseas in east Asia. There were no treatments available at the time. Fortunately, it was a urine infection and we decided just to watch it. It wasn't in the bloodstream.
The same thing would go for agricultural products that are imported into Canada. I don't think we really know what's going on in that regard. We do have data from the U.S. and Europe, but also from China, where there is a heavy use of antimicrobials in their agricultural practices. I don't know about specific countries. In Canada, the biggest use of antibiotics is in beef livestock. That accounts for a higher proportion than in other animals.
I would say that importing especially meat products is where the antibiotic-resistant issue would be of most concern. Fortunately, we have great dairy and beef industries in Canada, and hopefully most of what we use is from domestic sources. I know that we get sources from the United States.
I don't think it's an issue so much with plant-based products. There are not a lot of antibiotics used in crops. Although there are some, they're a minor component. It's more for meats.
I'm not an expert in that area. I gave a talk recently, during World Antimicrobial Awareness Week, which was held during the third week of November. It's celebrated across the world. I had a few PowerPoint slides showing how antibiotics are being used in our domestic cattle and in the food-producing animal industry. I kind of researched what was going on in other countries, but I don't have a lot of information because that's not my area of interest.
That's a very good question, and I believe that is a concern. If we're importing meats, then we need to look at that. It's also a health security issue, if you want to put it that way.
That's all I have to say. I appreciate the question and I'm happy to answer any more later on.
Andréanne Larouche Bloc Shefford, QC
This is one of the requests made by Canadian processors, who have an office in Granby, in my riding of Shefford. Animal products imported here are not subject to the same rules abroad. We've observed that there are consequences to the ways antibiotics are used.
Dr. Dhami, pharmacists play an important role, particularly in hospitals. A number of speakers raised the issue of inappropriate prescriptions. What role could you play specifically with regard to this problem?
Chief Pharmacy Officer, Canadian Society of Healthcare-Systems Pharmacy
As a pharmacist, we are the experts in drug therapy. Many pharmacists who specifically practise in the infectious diseases antimicrobial stewardship space have done extra specialization, certification and training to really get a good understanding of how antimicrobials are prescribed and those sort of bigger picture impacts.
As a pharmacist, if we observe or come across antimicrobials that are not guideline concordant, the first step is to have a conversation with the prescriber, whether that's a physician, nurse practitioner or a colleague pharmacist. A lot of pharmacists across the country now can prescribe antimicrobials for minor ailments. Really, the first step is to get the lay of the land of what's happening with the patient, assess the situation and understand if there's an opportunity to optimize the therapies that are prescribed.
There is actually a study out of Nova Scotia that compares antimicrobial prescribing amongst different health care professionals. Interestingly, pharmacists tend to be the health care professionals who are the most likely to prescribe within guidelines and maintain guideline concordance.
Liberal
The Chair Liberal Hedy Fry
I'm going to the next questioner. It's Mr. Strauss for the Conservatives for five minutes, please.
Conservative
Matt Strauss Conservative Kitchener South—Hespeler, ON
Thank you, everyone, for being here.
It's lovely to see southwestern Ontario so well represented and Kitchener-Waterloo in particular. It's also lovely to see Dr. Sameer Elsayed, who was my professor at Western some 15 years ago.
Dr. Elsayed, I won't ask you to answer this question, but when you were talking about the special access program—you outlined your CV and I know you to be a tremendous clinician and expert in the field—the idea of the special access program not giving you access to a medication you think is necessary and life-saving in a reasonable amount of time, I confess to just feeling enraged, because if Dr. Elsayed thinks it's necessary, then it's necessary.
Maybe I'll put that question to Dr. Wuerz.
What reflections do you have on that? I take it you're an infectious disease specialist—very much like Dr. Elsayed—in Winnipeg. This process seems crazy to me. If you think it's necessary, surely it should be offered.
Infectious Diseases Physician, Winnipeg Regional Health Authority
Madam Chair. absolutely, I believe that the process to obtain drugs through the special access program can often be a problematic one. I don't mean to fault the people working in that program, but the fact is that waiting up to three weeks for an antibiotic is absolutely unacceptable when we're talking about conditions like sepsis. Even a few days or a day is harmful or potentially harmful.
I've worked for almost 15 years as an infectious disease physician. I work in tuberculosis. In tuberculosis, we're seeing increasing risks of drug-resistant infections. The only option in the case of something called multi-drug resistant tuberculosis is to use antibiotics that are not available in Canada. Two out of the three antibiotics that are the first line for multi-drug resistant tuberculosis are not available in Canada, so it needs to be an application through the special access program.
The program is infuriating, to use the honourable member's words. We have a case with a very clear-cut indication, with multiple international bodies agreeing what should be the accepted treatment, yet it takes days or longer to obtain the approval and sometimes the response you will get is quite variable. Maybe you'll get a response back asking if you can justify that a little further or saying that you didn't include what you're going to monitor for or what have you. Other times, it will go through. The process is opaque, takes too long and needs to be streamlined.
Conservative
Matt Strauss Conservative Kitchener South—Hespeler, ON
Thank you for the answer.
You're very polite to say you didn't mean to fault anybody in the program, but I think I do mean to fault them. It's totally unacceptable. I won't move a motion now, but maybe I'll put it in the committee's ear that we need to call officials from that program to justify this. I am an intensivist. I deal with life-threatening emergencies, and it would just drive me bananas if Dr. Elsayed were there saying that my patient needed a medicine to survive and a bureaucrat was not providing it.
Dr. Elsayed, you spoke a little bit about how the AMR program or antimicrobial stewardship program doesn't twist arms, but that it is educational. When I think about the program as being educational.... Actually, I had a bout of hemorrhagic enterocolitis this past summer. The family physician I saw was using AI to recommend drugs to me. If AI were integrated into hospital EMRs to say, for example, that a patient with pneumonia has been on antibiotics for 10 days longer than they need to be, it seems that a lot of that could be automated.
What do you think of that? Is there interest in moving towards that?
Infectious Diseases Physician, Western University
Madam Chair, I'm happy to answer that question.
It's nice to see the honourable member again. I worked with him before—supervised him before.
The antimicrobial stewardship programs in Canada, as I mentioned, act in an advisory role. However, they do have influence on what types of antimicrobials physicians can prescribe, so there's a restriction policy that we have in place, as I mentioned.
In terms of AI, artificial intelligence, its adoption in health care is slow. Certainly there's a lot of opportunity perhaps to automate things that might help clinicians, but that's a work in progress. As an aside, we were planning on having an AI certificate pathway for our trainees at Western who are doing infectious diseases training, and we had strong endorsement from the division chair for that. Certainly that's something that I think we need to look at seriously. AI is here, and it's not going to go away. We have to find ways to integrate it into health care.
Liberal
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
Thank you, Chair.
Thank you all for coming. This is very useful.
Dr. Wuerz, it's particularly good to see you again. We worked together in ICU through the pandemic. Those were adventurous times, to say the least.
Dr. Wuerz, we were talking about having these guidelines. How do we transmit them in real time to primary care physicians? Primary care physicians take CME and do their journal reading, but as you well know, it's very, very hard to keep up with everything, particularly in primary care. You also have to know a bit of cardiology, a bit of respirology, these sorts of things.
What would be the solution to getting these real-time latest practice guidelines out to primary care providers?
Infectious Diseases Physician, Winnipeg Regional Health Authority
Madam Chair, I also appreciate the question by the honourable member, whom I know quite well from the work we did through the pandemic.
Yes, I appreciate that the problem of ensuring that antibiotics are used appropriately is multi-faceted and really needs to address very strongly those who use these antibiotics the most, the frontline primary care clinicians.
There are many effective strategies that have been used. I think the key is that it's not just one thing that is needed. One important effort is the publication nationally of guidelines for treatment of common conditions. We have such guidelines, but we really need to bring those guidelines to the clinicians who are working on the front lines. That's where antimicrobial stewardship programs can really play a key role. It's not just about having those guidelines out there in space, because as the member said, these clinicians can be quite busy and not necessarily up to date on the latest guideline that has come out.
An antimicrobial stewardship program will effectively bring that information to the level of the patient and the provider. Then they look at the situation and evaluate it and ask if there is an opportunity to apply appropriate antimicrobial stewardship and improve the treatment of the individual patient. It's at the patient level. It's not manipulative in any way. It's a guidance that's provided by a program and by experts to better deliver the care that is needed right at the ground level.
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
Thank you for that.
Dr. Elsayed, you talked about this before. You've been asked a couple of questions about it. I've had an interest in this for a while, since I first found out that antibiotics are used in animal husbandry. As you said, these are often given in livestock operations, mostly beef, because they promote growth. The question I have is, how do the farmers access it?
To make an outrageous hypothetical, if I were a teacher and decided I wanted to make my students healthier by distributing antibiotics, I could not obtain them because I would need a physician prescription to do that, and no physician would do that of course. How are the livestock producers getting these antibiotics? Are there veterinarians who are prescribing or approving them for purchase by these producers?
Infectious Diseases Physician, Western University
Madam Chair, during the COVID-19 pandemic, people were hyped up about getting ivermectin as a supposed therapy for COVID-19. Again, there is controversy about whether it actually works or not, but people were accessing it through animal feedlot stores or through non-conventional routes. They were getting access to these drugs where normally for humans we would have to go through pharmacies or special access programs to get this medication—
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
Sorry, I apologize for cutting you off. I'm running out of time.
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
This really predates COVID, so the question I'm getting at is, do feed stores sell these antibiotics? How do these operators get these antibiotics? Do they need a prescription from a veterinarian? How do they legally obtain them?
Infectious Diseases Physician, Western University
I don't.... That's why I was alluding to pre-COVID, because now I believe there's still a lack of regulation in terms of how farmers can get access to antibiotics. Because I'm not a farmer, I don't know how they are getting access, but I do know that they can get access to these medications far easier than we can in health care, so there needs—
Liberal
The Chair Liberal Hedy Fry
Thank you very much.
I'm going to a third round.
I'm going to Mr. Bailey for the Conservatives.
You have five minutes, please.