Veterans Affairs Committee on May 13th, 2019

[Shaun Chen, Liberal, Scarborough North, ON]

To continue with Mr. McColeman's line of questioning, we understand from DND that currently the drug mefloquine is prescribed to servicewomen and -men only if they ask for it. For the past two years, they reported that only three people in the armed forces have been prescribed mefloquine.

I'm hearing from you, as our witnesses, that this drug should not be prescribed at all for servicewomen and -men given the conditions under which they work and the risk of potential long-term reactions. When a servicewoman or -man is deployed to an area where malaria is a real risk, and if all other anti-malarial medications are contraindicated, would you consider mefloquine as a drug of last resort for those who might be exposed to malaria?

[Dr. Edward Sellers]

I guess that's probably for me.

First of all, I can't conceive of a real situation where one of the alternatives—Malarone or something of that sort—would not be appropriate. I indicated in my comments that if a military person is asking for this drug, I think they would have to be misinformed about the risks, and that's very, very unusual. I think there are alternatives.

Now, if there were some circumstance that I can't think of, then yes, a careful history of the individual, of their past mental health, their family's mental health, a look for risk factors, and careful documentation and monitoring of them, warning them and telling them what they are to do if they have certain acute effects...because the acute effects are a bit of a warning that things are not going quite the way you want. These drugs quite commonly do have these acute effects—

[Shaun Chen, Liberal, Scarborough North, ON]

Dr. Sellers, I'm sorry, but I have limited time.

[Dr. Edward Sellers]

I want to make a footnote to this, and that is that there is evidence that women are more susceptible to mefloquine. I think that was given no mention at all in the surgeon general's report, yet the literature is fairly clear that it is an additional risk factor.

[Shaun Chen, Liberal, Scarborough North, ON]

Dr. Sellers, I just want to clarify. Are you are saying with respect to other anti-malarials that you cannot think of a situation where someone should have to choose mefloquine over those other options?

[Dr. Edward Sellers]

I think it would be very, very rare, and I've given a way that if you had to, you would carefully monitor and be able to intervene. We know how prescribing and dispensing can sometimes go. It's “take the pill,” and that's the end of it. In fact, the surgeon general's report documents the relatively poor attention paid to informing individuals about the risks and documenting what was done, the contraindications and so forth. There's already evidence that..... You know, it's what we would expect in medical practice.

[Shaun Chen, Liberal, Scarborough North, ON]

With respect to prescribing mefloquine, you've said that drug labelling is not sufficient. Patients need to be explicitly warned. How would that be done, in a general sense, for any doctor prescribing this to a patient?

[Dr. Edward Sellers]

We have other examples of drugs for which we have checklists, patient information and documents you can provide to inform individuals. Actually, I have them sign a contract that they have read it and understand it, and that explicitly tells them what the risks are and what I'm going to do to monitor them, such as bring them back at specified intervals to make sure they're doing okay.

I can think of a way that you could give mefloquine, but I can't think of a situation where you'd really have to. There are a number of alternatives out there, and others coming along—more modern kinds of approaches, vaccines and things of that sort.

[Shaun Chen, Liberal, Scarborough North, ON]

I'd like to hear Professor Quinn, if she has any comments with respect to my questions.

[Prof. Jane Quinn]

Yes, I agree with Dr. Sellers. I think it would be a very unlikely and unusual situation where the need for deployment was so high that the use of mefloquine as a drug of last resort would be advisable or acceptable. The review process would need to occur at least three weeks to a month prior to deployment, so that any medical review was occurring in-country, not out of country. The likelihood of this situation arising, in light of many other alternatives, and significantly safer alternatives.... I think the suggestion is a moot point.

[The Chair, Liberal, Neil Ellis]

Mr. Kitchen.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Doctors, thank you both for being here today. It's greatly appreciated. You definitely add to our study.

As you've heard from my colleague on the issue of how we know which soldiers have actually been exposed to mefloquine, we don't have those records. They were given a drug, and those records apparently don't exist. That's a big challenge. Ultimately, we do have soldiers who are suffering. They're presenting neurological and neuropsych disorders, and the challenge is whether the problem is mefloquine toxicity or PTSD.

In a perfect world, it would be great to have a protein—for example, the Bence-Jones protein, which makes it evident that a person has multiple myeloma—but we don't have that. What prompted this question, Dr. Sellers, is your earlier comment about a transport protein that gets mefloquine out of the brain. I'm interested to hear a little more about that. Is that new research? Is that purely being theorized? I wonder if you could tell us.

[Dr. Edward Sellers]

It's not very new research. It's been known for a long time that this class of compounds is transported by a particular mechanism that's presumably there to protect the brain. A lot of drugs are pushed out of the brain by this transporter. No, this is just one possible explanation for why some people seem to be particularly susceptible, with their genetic variance of this, which would explain why some people might get very high levels of mefloquine in their brain.

There are other risk factors, too. It's not mefloquine or PTSD. It's perfectly possible that mefloquine and PTSD could occur in an individual, along with other symptomatology. That's the nature of neuropsychiatric problems: depression, anxiety and things of this sort. They rarely travel alone. You have the concept that mefloquine can travel on its own, but also, as a risk factor, contribute to neuropsychiatric problems. That doesn't mean it's unimportant, but that the context of mefloquine use is very important. Obviously, the military are exposed to extremely stressful situations in some cases, and there could well be an interaction between that exposure and the drug. Without the drug, maybe the interaction wouldn't result in a long-term, chronic, neurotoxicity.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Dr. Quinn, do you have anything that you would like to add to that?

[Prof. Jane Quinn]

I'd really just support what Dr. Sellers has said. This is a complex syndrome and there are multiple players coming into that presentation of the clinical symptomology. However, we do know that there are specific liver enzymes that are involved in drug metabolism that would put a person at higher risk of also having those higher levels accumulating in the brain or being able to reduce the levels in the blood stream more effectively over time. The P-glycoprotein family, which is the transporter that Dr. Sellers is talking about, also has genetic variability and will also facilitate higher levels accumulating in the brain in individuals with particular genetic allelotypes.

There is a genetic screening process that patients who take certain types of toxic drugs—particularly for cancer treatments, for example—need to undergo in order to know that those drugs are going to be metabolized appropriately. That screening process can be undertaken in all individuals for all drug types. It can also inform who potentially may or may not be more susceptible to having a potentially more significant reaction under this accumulated set of circumstances.

I think there is science out there that absolutely supports all of that screening that could occur. It's just something that should be implemented.

[The Chair, Liberal, Neil Ellis]

You have 15 seconds.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Should we be accepting and following what Australia has done in recognition of this?

[Prof. Jane Quinn]

Absolutely.

[The Chair, Liberal, Neil Ellis]

Ms. Blaney.

[Rachel Blaney, NDP, North Island—Powell River, BC]

One of the things that occurs to me as we do this study is the reality of the particular group of people we're talking about here. One question that's come up a couple of times is: Are we making sure that our armed forces have informed decision-making about medication that they're taking?

The other part that I think is really important is that as they may be experiencing some of the impacts of taking mefloquine, what is keeping them from disclosing? When you look at it, career prospects and looking at the future are challenges that provide barriers for people.

When I look at what's happened over the course of time of this medication being in the system, I'm very concerned about people who may be serving our country right now who are having some of these symptoms, but they don't want to talk about it because they don't want to see their careers get shut down.

Are the folks who serve us getting informed information about the medication that they're taking? I'm wondering if you can speak to that in that nuance of this particular group of people we're talking about. We're not talking about people who are going for a vacation. We're talking about people who are serving our country.

Dr. Quinn, if I could start with you.

[Prof. Jane Quinn]

That's absolutely the reality for many. Disclosure, particularly the neuropsychiatric side effects related to mefloquine in serving military members, is a black box subject. Certainly my husband experienced that. I know that many of his colleagues who experienced side effects would never report them for fear of their careers being damaged by that process.

One of the issues compounding that has been that when people have come forward and disclosed their issues associated with quinoline antimalarials, they have had to do that in the broad public domain to gain recognition. They have often been openly attacked or faced very negative career consequences because of that. I think that absolutely has been the experience within military circles to date, so changing the attitude around reporting is something that is critically important.

I know that a lot of military organizations are working to try to get that safe disclosure environment as part of the modern military concept. It is a significant challenge and it certainly is an impediment to many people coming forward to report their side effects, even if they were side effects that occurred a very long time ago and are now related to relatively minor health issues.

[Rachel Blaney, NDP, North Island—Powell River, BC]

Thank you. I think that's my time.

[The Chair, Liberal, Neil Ellis]

Thank you. That ends our testimony today.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

I would like to ask a couple more questions. We certainly have time before the clock goes.

[The Chair, Liberal, Neil Ellis]

Do I have the unanimous consent of the committee to do that? If there is anybody else? Show your hands if you want to go at all.

Just Cathay, for five minutes.