Evidence of meeting #119 for Veterans Affairs in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was mefloquine.
A recording is available from Parliament.
4:15 p.m.
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
Let me interrupt there. I want Mr. Eyolfson to finish off.
Go ahead, Doug.
4:15 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Thank you, Mr. Bratina.
Dr. Libman, are you familiar with the study I mentioned before, the one of U.S. veterans in Iraq and Afghanistan who were followed from 2001 to 2008?
4:15 p.m.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
Yes.
4:15 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
What is your take on that? Would you say this is a reliable form of study? Can you make conclusions regarding the long-term neuropsychiatric effects based on the sample size and the length of time that people were followed?
4:15 p.m.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
It's true that these observational cohort studies don't provide the same level of confidence. Nevertheless, we have this study, and it follows the same direction as a number of other studies—some in military groups, some in non-military groups, short-term travellers and long-term travellers. We have accumulating evidence that generally points in the same direction, which is that it's been very difficult to show that the long-term events after mefloquine happen at a rate any different from what you see with any other drug.
The evidence is that either it doesn't happen, or if it does happen, it has to be very rare. The accumulated evidence of this study, together with all the other ones, such as what is presented in the Cochrane review, is that it has to be very rare. Then there's the question of whether the rarity of adverse events negates their value, when the drug is used in certain ways. There are always ways, when there are adverse events, to switch to other drugs. What I would say, however, based on the evidence, is that either there are no long-term effects or those effects are very rare. It's very hard to tell the two apart.
4:15 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Thank you.
Are you familiar with the work of Dr. Remington Nevin?
4:15 p.m.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
I am.
4:15 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
How would you evaluate the scientific veracity of his claims that there's a brain stem injury and there's significant neuropsychiatric effects in these? What is the quality of his evidence, in your view?
4:15 p.m.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
Without going into all the details, I would say that the medical community does not generally believe there is reliability in the types of reports he's giving. These reports are not regarded as having nearly the quality of evidence and reliability as does the accumulation of studies such as the ones you mentioned and the others that have been reviewed.
May 15th, 2019 / 4:15 p.m.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
Thank you.
Thank you both for your testimonies today.
Dr. Libman, are you familiar with research conducted on soldiers from countries other than Canada who were prescribed mefloquine and participated in the conflict in Somalia?
4:15 p.m.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
Sorry, I missed a little bit of that question.
4:15 p.m.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
Have you seen any research from other countries whose soldiers participated in the conflict in Somalia in 1992 and 1993 and were prescribed mefloquine?
4:20 p.m.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
Off the top of my head, I can't comment on studies done specifically on the Somali veterans. I'm aware of studies done on military populations, particularly the American military, but I can't tell you off the top of my head where those soldiers served or the exact dates they may have been exposed to mefloquine. Specifically on that, I can't answer. There are definitely, as we just talked about, several studies on military populations deployed in combat zones.
4:20 p.m.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
Right. I'll be very open. Here's one point I want to get some collaboration or elaboration on. I have read that, before the conflict in Somalia, with our Canadian Armed Forces who participated in that, we were really seen as a peacekeeping nation with the United Nations. A number of reports said we weren't as prepared as we maybe should have been in that conflict, in terms of what our soldiers were facing on the ground.
Would that have had any impact on some of the long-lasting impacts that some of these soldiers have exhibited?
4:20 p.m.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
It's a little out of my domain in terms of commenting specifically on that. Clearly, one difficulty, though, is that anybody—soldiers or anybody else—who's in a difficult, stressful type of situation is prone to the psychiatric consequences of that. That's part of what makes this situation so difficult, which is that anybody who's put in a stressful situation can have long-term effects from that. Trying to tease out whether some of those effects might be due to medication as opposed to the rest of the situation is always going to be somewhat difficult.
That's why these studies have been done in general, and also in military populations, trying to see whether there's a difference in taking one drug or another drug. Does that make a difference? That's the only way you can decide whether it's the drug.
As best we can tell, with quite big studies, there doesn't seem to be a difference between one drug and another in that particular question, which is the long-term psychiatric effects.
4:20 p.m.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
In the short term, there is a difference.
4:20 p.m.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
Dr. Croft, I'm wondering if you can tell me the drug company that did the research and development work on mefloquine and that also holds the patent.
4:20 p.m.
Consultant Public Health Physician, As an Individual
Yes. The drug was discovered by the U.S. Army at the Walter Reed Army Institute of Research in Maryland, outside Washington. Because the U.S. Army isn't allowed to engage in commercial dealings, it had to hand it over to a drug company, so it gave mefloquine to Hoffman-LaRoche, a Swiss international company. It was Hoffman-LaRoche that then took on the practice of marketing it.
Of course, the difficulty was that the drug had been developed to treat malaria. In Vietnam, soldiers were acquiring malaria at the rate of 1% of the combat unit per day, so every day a regimental commanding officer would have six of his men go down with malaria, which was not good. The parasite had developed resistance to chloroquine, so there was an urgent need for a malaria treatment drug, and that was mefloquine.
As soon as the drug got into its hands, Hoffman-LaRoche moved the goalposts because there isn't so much of a market for treatment drugs, and it marketed it as a preventive drug. That's the danger. For treatment of malaria you would tolerate a degree of, shall we say, adverse effects from the drug. When you're a healthy traveller, you want a drug that keeps you healthy and well.
4:20 p.m.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
If I can just jump in there, the typical framework, then, for studying a drug before it's ever released to the public, was that conducted by Hoffman-LaRoche?
4:20 p.m.
Consultant Public Health Physician, As an Individual
It wasn't. It took over the Walter Reed framework of experiments. Walter Reed had done two trials on prisoners, believe or not. In the 1970s they got these prisoners and they said, “Right, we have a new drug and we want to try it out on you.”
4:20 p.m.
Liberal
4:20 p.m.
Consultant Public Health Physician, As an Individual
Yes, another inquiry. They infected them with malaria and they gave them mefloquine. It stops malaria. It treats malaria, so it's a good drug for both treating and preventing malaria. Then they gave it to Hoffman-LaRoche.
Hoffman-LaRoche was in a hurry to get it out. It really bypassed the pivotal phase, what are called phase three studies, which it should have carried out on tourists because that's the anticipated population. There were no pivotal randomized controlled trials of the drug on tourists until 2001, when another company did a trial.
