Evidence of meeting #18 for Health in the 45th Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was amr.
A video is available from Parliament.
Liberal
Sonia Sidhu Liberal Brampton South, ON
You talked about global stewardship. What approaches or best practices are most worth adapting to the Canadian context? Whether in surveillance, drug access or innovation, where do you see the most significant gaps, and how do we fill them?
Professor of Medicine, University of Toronto, As an Individual
There's really no silver bullet. It's doubling down on our efforts toward antimicrobial stewardship at a hospital level, as well as at an outpatient level, for which a lot of the antibiotics are used. This is being done.
The question is with regard to implementation. There are best practices and guidelines available. One of the issues, of course—as we already alluded to in some of the earlier conversations—is that Canada doesn't have a health care system; it has 10 health care systems. Within each of the 10 health care systems, you have an in-patient system, an outpatient system, a rehabilitation system and a home care system, none of which communicate. These are very challenging hurdles to overcome. Of course, they can be overcome, but again, we have standards and guidelines to adhere to. A lot of work needs to be done to ensure that people actually adhere to the guidelines.
Liberal
Sonia Sidhu Liberal Brampton South, ON
The other thing you mentioned in your speech is incorporating AMR into defence investment. What specific capabilities should Canada fund under a security lens? How should the federal government integrate AMR into national security and defence planning?
Professor of Medicine, University of Toronto, As an Individual
I'm glad you brought that up.
When we talk about health security, we often talk about different things. There's the health side of health security, in which we talk about vaccine independence, creating rapid diagnostic tests and access to antibiotics. Sometimes we call that health security. However, there's also the security end of the spectrum of health security, as in preventing bioterrorism events.
There are nefarious actors out there. There are bioterror agents out there. Certain countries have developed drug-resistant pathogens like anthrax and botulism. We know that. People have tried to steal Ebola virus, for example, and that's why there's security around such outbreaks.
What can Canada do? It's extremely important, first of all, to recognize that bioterrorism is a real threat. We also have a funding mechanism. We can appreciate that we are going to spend a lot of money on security. We can appreciate that this is a true security threat. This can help fund RDTs, medical countermeasures, vaccinations and drug development.
It's not as though there are completely separate pots for health and security. They are closely intertwined. When you benefit security, you can have a cross-benefit to health, and vice versa.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Dr. Leung, in your previous testimony, you highlighted that while Canada has multiple AM surveillance systems, our core problem is fragmentation, in that data is not being aggregated across settings in a way that's timely.
Today, I see that everyone is talking about timely data that is actionable. You pointed this out for hospital surveillance in particular, in which reports can be out of date and may not support planning. What should be done so that we can improve the system?
Infectious Diseases Physician and Medical Microbiologist, As an Individual
For the systems that are currently in place, we need to look at them again and understand their governance structures, along with their accountability for reporting, so that there's more transparency and understanding of why there are delays in data sharing, and as well, when they receive the information, what their role is in ensuring accessibility to help inform practices and measure the impacts of the programs.
Right now, for example, if I wanted to understand gonorrhea resistance in Canada as we implement a program in British Columbia, it is very challenging to get any of the data across not only for British Columbia but also for other provinces. That's not for research purposes. This is for program implementation purposes and understanding AMR interventions.
Liberal
The Chair Liberal Hedy Fry
Thank you very much, Sonia.
I'll now go to Monsieur Blanchette-Joncas.
You have six minutes, please.
Bloc
Maxime Blanchette-Joncas Bloc Rimouski—La Matapédia, QC
Thank you, Madam Chair.
I would like to acknowledge the witnesses who are here today. I would also like to acknowledge my colleagues. I'm honoured and delighted to be joining this committee. We look forward to a great deal of co‑operation and success in committee business.
Dr. Weiss, does federal underfunding for public health, prevention and monitoring actually limit the ability of Quebec hospitals to effectively prevent and control antimicrobial resistance?
Chief, Division of Infectious Diseases and Medical Microbiology, Jewish General Hospital, As an Individual
I think that the main challenge lies in the fragmented nature of the system as a whole, both in Quebec and across Canada. Quebec, for example—but this also applies to the other provinces, as some of my colleagues have already said—faces a type of dichotomy between so‑called inpatients, meaning the hospital setting, and the outpatient setting. That's the first issue. We're fully aware, for example, that most antibiotics are consumed in the outpatient setting.
The second issue concerns the additional fragmentation between animal and human environments. We talked about this aspect. There are occasional collaborations. I'm well acquainted, for example, with my colleagues at the agriculture, fisheries and food department, as I am with my colleagues at Agriculture and Agri‑food Canada. By the way, they do an excellent job, sometimes even better than the human health sector, up to a point. However, these collaborations are often academic, ad hoc and limited, so to speak.
I would say that both Canada and Quebec lack the integration needed to monitor antibiotic consumption in real time and to set up computer systems that would give us a quick idea of potential problems. I would say that our major problem in Canada is what we offer on the international market in terms of drug consumption. We are a small market of 2%, which is shrinking in the face of other emerging markets. No major Canadian or Quebec company or multinational company produces antibiotics. We often have subsidiaries that depend on foreign countries, and hence on foreign goodwill, for investment and research, for example. Sometimes debates and battles take place within Canada to attract these foreign companies. Sometimes, in the end, the provinces compete to try to get someone in from the outside, when no major local players are available to take over.
One problem with all this, as we saw during the COVID‑19 pandemic, is our heavy dependence on the goodwill of others. This is a key issue to resolve for the future of the Canadian market. For example, one company tried to produce the 100 most important drugs in Canada, in the event of a local production problem. I think that this is worth noting. I would say, as many of my colleagues have already stated, that the monitoring and research network in Canada remains fragmented.
As my colleague, Gerry Wright, said earlier, Canada and Quebec often have excellent but fragile research teams. My colleague, Michel G. Bergeron, at CHUL in Quebec City, helped pioneer the field of antibiotic resistance in Canada. He often works in relative isolation. In order to break into the international arena, researchers must often start collaborating with organizations outside the country, precisely because of the difficulty of working inside the country.
So I know my colleagues quite well, especially Dr. Leung. We worked together.
Bloc
Maxime Blanchette-Joncas Bloc Rimouski—La Matapédia, QC
Dr. Weiss, I must move on, since time is running out. However, this still answers my question. Look, I understand what you're saying. I've heard it all before. We're too dependent.
Let me remind you of a very inconvenient truth. Canada was the only G7 country unable to produce its own vaccine against COVID‑19. The reason isn't a lack of talent, but rather a lack of investment. In the past 20 years, from 2000 to 2020, we were the only G7 country to cut research and development investment. So, I've already heard and analyzed what you're telling me.
You spoke about the major pharmaceutical companies. They were all operating in the greater Montreal area in the early 2000s. So, I'm trying to make a correlation. If we want to reduce our dependence on major foreign pharmaceutical companies, and if we want our own supply chain, we need a solid action plan for innovation. Yet I've noticed that Canada remains at the back of the pack. It's all well and good to have better coordination. However, when we don't invest in research and development, it's harder to attract vaccine suppliers and producers.
Chief, Division of Infectious Diseases and Medical Microbiology, Jewish General Hospital, As an Individual
Let me say two things. Indeed, if we look at the G7 countries, Canada probably invests the least overall in research in proportion to its gross national product. So there's definitely room for improvement.
Then again, when it comes to COVID‑19 vaccines, you could also say that the only country that ultimately succeeded—for reasons involving investment and money—was the United States. Neither France, nor Great Britain, nor Germany, nor Italy succeeded in creating vaccines. In the end, everyone depended on the United States.
However, ultimately, I would say that, if we wanted to increase investment in research in proportion to the gross national product, which would affect the health sciences in particular, with our aging population, and given what Dr. Bogoch rightly said earlier about the strategic threats facing Canada and Quebec, we would indeed need more investment, including in rapid diagnosis, production and logistical capacity. I would even add that this matter doesn't just concern vaccines. It also concerns all aspects of infection prevention and control, which were lacking during COVID‑19, such as masks. Other materials could also be considered.
Liberal
The Chair Liberal Hedy Fry
Thank you very much, Doctor.
I'll now go to a second round. The second round is a five-minute round.
I want our new member from the Bloc to know that you will have six minutes in this round, because we're having a full two-hour meeting. In two hour-long meetings, you get two sixes. The committee all decided to be very co-operative, and you are going to have a six-minute round in the second round.
I'll go to the second round with Ms. Konanz from the Conservatives.
You have five minutes, please, Helena.
Conservative
Helena Konanz Conservative Similkameen—South Okanagan—West Kootenay, BC
Thank you, Chair.
My first question is for Dr. Weiss.
You've touched on and talked a lot about the overuse of antibiotics. You mentioned that they're sold in other countries over the counter. They're given out less and less here in Canada. People, when they travel, stock up on antibiotics, because they can buy them. Who knows? Some of it may be counterfeit, but they're stocking up and bringing it back.
What do you say about this, and how much of an issue is it?
Chief, Division of Infectious Diseases and Medical Microbiology, Jewish General Hospital, As an Individual
In fact, this is a very interesting question that you're raising. How much of an issue is it? We don't really know, because we don't monitor these types of things.
There are definitely people bringing them back on a volunteer basis or not on a volunteer basis. Sometimes it's because they simply bought antibiotics outside the country, and they're bringing them back here. That's definitely an issue.
The issue we have in Canada is that we are in this global village in terms of antibiotic use. I always tell people that infectious disease is the only specialty in medicine in which anything that happens on the other side of the world will have an impact on you. I tell my patients, if their neighbour has diabetes, it's very sad, but it's not going to impact the patient directly. If their neighbour has Ebola, the first thing they're going to ask is, “When was the last time I saw my neighbour?” Obviously, infectious conditions can be transmitted to people. Whatever happens in Asia, Africa, South America, Europe or wherever, you can bring back resistance with you.
In fact, I think there was a study done in Switzerland and another one in Sweden in which they decided to swab tourists who went abroad and came back, and they asked them to give a stool sample. They asked them to make sure they were healthy and that nothing had happened during their trip. About 25% of these people were carrying resistant bacteria in their gut. Obviously, these bacteria are not being declared to customs officers when people come back, but they travel as a Trojan horse—entering the country and potentially creating issues.
We see this every day in our hospital, for example, in young, healthy women coming back from the Indian subcontinent with simple infections such as cystitis, a bladder infection that is sometimes caused by a very resistant antibiotic, and we have to give intravenous antibiotics, with all the logistical consequences, costs, etc.
I would say that the flux of bringing back antibiotics into the country may be marginal. I don't know the answer, because nobody is looking at this carefully. Yes, it could be a problem in certain things. I think the fact that people are travelling and bringing back resistant micro-organisms is also part of the bigger picture.
Conservative
Helena Konanz Conservative Similkameen—South Okanagan—West Kootenay, BC
Thank you. That's a really interesting answer.
My next question is for Kim Neudorf.
How do you see the present ability of the federal government to act with urgency to bring in or develop new medicines for Canada? Is it still too bureaucratic, from your point of view?
Patient Partner, Patients for Patient Safety Canada
Based on everything I've heard from the experts and people around the panel today, it does seem to be problematic. It seems to be cumbersome.
I was recently reading about gonorrhea AMR. Something exists currently in the U.S. that's a different medication and doesn't fall along the antibiotic line. Two different medications are ready and available to them, whereas here in Canada, my understanding is that we have increased the dose of the antibiotic in order to try to curb this resistant organism.
Conservative
Helena Konanz Conservative Similkameen—South Okanagan—West Kootenay, BC
I'm sorry to interrupt you. I think I only have a little time left. I just want to follow up with a question.
I represent a region of the country in which patients' access to health care is not consistent. We literally have ER rooms that suddenly close at least one day a month.
You're talking about patient safety issues in everything, including AMR and health infection prevention. What do you think about the danger of having ERs closing throughout my region and throughout the country?
Patient Partner, Patients for Patient Safety Canada
It is very much a concern, and I think it drives some of the public's misuse of antimicrobial medications. We can look at access from many different angles—not just crowded emergency rooms. It will push us to stockpile or hoard medications and only take part of those medications, so we can perhaps use them when we think we need them. We put them on our shelves and use them when they're five years old.
Patient Partner, Patients for Patient Safety Canada
That's because we don't want to sit in an emergency room for five hours. Then, of course, there are other issues around sepsis as well; maybe we are sitting at home too long when we need an antibiotic for that particular issue.
Liberal
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
Thank you, everyone, for coming.
Dr. Bogoch, you spoke about how 80% of antimicrobial use is in animals and how a lot of that is put in feed for growth.
I've asked this question previous times. I've never been able to get a really solid answer about this. In the human setting, at least in Canada, you cannot get antibiotics for human use unless you see a doctor and get a prescription. The doctor has presumably diagnosed an infection, prescribed the antibiotic and then it is dispensed to you.
What is the mechanism that there is not such a control on dispensing antibiotics in the agricultural sector? How are people getting a hold of them when they are so restricted in human use?
Professor of Medicine, University of Toronto, As an Individual
That's a great point.
For starters, I'm not going to comment on veterinary practices in Canada. I just don't know the answer to that.
Globally, as one of the other speakers mentioned, you don't need prescriptions. These drugs are readily available. They're commercially available, and they're used en masse in agricultural settings and in human health settings. You can literally walk into a pharmacy, write something on a napkin, give the pharmacist whatever you want, and they'll sell it to you. This does not just happen at an individual level. Sadly, it happens at scale in several Asian and African countries. It's not happening so much in North America, where we have tight regulatory controls, and the same with Europe.
As we mentioned before, the drug resistance develops and through people travelling or through trade we see the spread of dangerous antimicrobial organisms. For example, NDM-1 started in India. Another, MCR-1, started in China. These spread around the world.
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
Thank you.
As for the Canadian perspective, is this still permitted, or have they restricted this practice in Canada?
Professor of Medicine, University of Toronto, As an Individual
It's tremendously restricted in Canada. I don't know all the details of the restrictions, but I know that we're not pouring antibiotics into livestock in Canada—