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.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
Then may I ask you, knowing what's been suggested now, if Hoffman-LaRoche has gone back and done any further study or analysis, looking at making some changes to its original research and development?
Consultant Public Health Physician, As an Individual
With drug companies, once they have a drug licensed, they see no merit in doing that. They just want to sell as much of the drug as they can. You can see why they'd want to do that.
They haven't done the sorts of studies that one would have wished into the adverse effects, the long-term studies. They could have done a case-controlled study, for example, of rare adverse effects. That hasn't been done by Hoffman-LaRoche, so the answer is no.
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
Thank you, Mr. Chair.
Doctors, thank you both for being here today. We appreciate that.
Dr. Croft, you mentioned the civilian population and travelling, and Dr. Libman, you're involved with travelling with CATMAT, etc. Part of what we've heard from veterans, not only in this study but in previous studies we've done, is about the serious side effects and issues they've had to deal with. As well, we also heard from civilians who have been travelling around the world and in Asia. They've been given mefloquine and then been told by Australians to get off that medication and take things like doxycycline.
With that said, Health Canada has come out with a checklist on contraindications for mefloquine, and basically in a change to their monograph, they've added that “the risk of permanent dizziness, vertigo, tinnitus and loss of balance has been clarified”. They've identified that for the health care practitioners and professionals, to make sure they're aware of that fact.
In fact, they even go down to the “Key messages to convey to patients” section, to say this:
Serious mental and nervous system side effects may occur at any time while taking mefloquine, and in a small number of people, may last for months or years after stopping mefloquine. In some people, dizziness, vertigo, tinnitus, and loss of balance may become permanent.
The Canadian military, in the last six months, has come out and said that they will no longer use mefloquine—
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
—because of its side effects, and will only do it if they're being asked for it.
Dr. Libman, I see that CATMAT still recommends atovaquone-proguanil, which is Malarone, doxycycline and mefloquine. We have Health Canada saying it's no good, the military saying it's no good, yet CATMAT is telling Canadians to continue to take it.
I'm wondering if you can comment on that, because the side effects we're seeing—and we're seeing them even more from our veterans—are quite extensive.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
With regard to CATMAT, I would clarify that the CATMAT recommendations are intended for clinicians, not for the general public. It's not meant as a source of advice for the general public. It's meant to guide clinicians who are themselves advising travellers.
The warnings that came onto mefloquine are there because there have been cases that have been reported, not because it has been definitively shown that those cases were due to mefloquine but that it is a potential risk. That's there for the reason that it's a potential risk to be taken into account when advising anybody. It does seem to be very rare.
In our practice with travellers, as opposed to the military, we do this on a case-to-case basis. We talk to people. There are some advantages, for example, to mefloquine. One of the biggest problems we have, as I mentioned very briefly at the beginning, is that people don't take the medication. They are prescribed something, they don't take it, and then they get malaria and they get sick.
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
Correct. They don't take it because of the side effects that they hear about and the issues that it causes. The reality is that it's not a vaccine. It's not given to somebody to build up an immunity. It's purely given as a medication during the time frame that they're in theatre.
There are concerns on that short-term list and they're identified by Health Canada. We need to make certain that we're not doing that same thing to our soldiers and subjecting them to this disorder.
Professor, Department of Medicine, McGill University Health Centre, As an Individual
I think that the issue is really.... Again, I can't speak specifically to the choice of what to give to soldiers in general, or a specific soldier, but the question is always whether the benefits outweigh the risks for a particular individual.
I can say that when we talk to particular individuals, there are many people who prefer mefloquine. It's easier. It's cheaper. They tolerate it well. They don't have effects. They take the drug, especially because it's a weekly drug versus a daily drug.
I'm sure that's something that has been mentioned at another time. The fact that it's weekly rather than daily encourages some people. It makes taking the drug much easier, and they're much more likely to actually take it. In some cases, that outweighs what we consider to be the very small risk of these kinds of complications. The risk of getting malaria so vastly outweighs the risk of these particular things you mentioned that giving people something they feel comfortable taking, and that they do take, is a very important concern when we're advising individuals.
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
Sir, in your research, have you ever examined any veterans who have been on—
Professor, Department of Medicine, McGill University Health Centre, As an Individual
I do not deal with the military as a rule. We've seen a small number of sick military, but we are not involved in management, generally speaking, of military cases.
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
You have never examined them. Is that correct?
Professor, Department of Medicine, McGill University Health Centre, As an Individual
No, I've occasionally seen sick soldiers who have been hospitalized. That's it.
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
Thank you.
Dr. Croft, in March of this year, Australia announced a $2.1-million initiative to support veterans who have taken mefloquine. This includes a comprehensive health assessment for their veterans, including those with concerns about injury related to taking the mefloquine. Do you agree with that initiative?
Consultant Public Health Physician, As an Individual
It sounds a rather modest amount—$2.1 million—given that I'm sure there are hundreds of Australians damaged. Yes, I agree with the principle. The sum seems to me to be insufficient, but yes, I think that kind of initiative is needed. Even though it's not possible to do experimental studies with mefloquine because it's ethically ruled out, it's still possible to do retrospective studies like case control studies to establish more clearly what the exact risks were with the individuals who took mefloquine. That kind of research could perhaps be covered by these government grants.
Liberal
The Chair Liberal Neil Ellis
Thank you.
Mr. Chen, you're up. I think you said you're splitting your time with Mr. Eyolfson.
Liberal
Shaun Chen Liberal Scarborough North, ON
Yes, thank you, Mr. Chair.
Dr. Croft, you mentioned that there are drugs that are safer and as effective as mefloquine.
Liberal
Shaun Chen Liberal Scarborough North, ON
Currently, it's been recorded by the Canadian Armed Forces that within the past two years, only three servicemen and women have been prescribed mefloquine and that the practice currently is that the drug is given only if specifically requested. Can you speak to the alternatives and what you would do in this case? Do you agree with this policy of prescribing it to those who request it?
Consultant Public Health Physician, As an Individual
Yes, there are some people who can take mefloquine without experiencing problems at all. Therefore, if you've taken mefloquine in the past and you're one of the lucky ones who didn't suffer, then you might well want to take it again because it's the devil you know. Those people will be few and as time goes on they'll be fewer and fewer because the number of people who have taken mefloquine is still shrinking exponentially. I can see a case for keeping it as a last resort, but it should just be there as an absolute last resort for those who specifically want it.
Liberal
Shaun Chen Liberal Scarborough North, ON
Not everyone can make an informed decision if they don't have the information, and too often we rely on drug labelling to provide information on the risks of taking medications.
What do you think is needed in terms of how members of the Canadian Armed Forces can be better informed and educated before they are asked to make that decision?
Consultant Public Health Physician, As an Individual
I think that, to be absolutely safe, it should simply be taken out of the pharmacopoeia and not be there as an option at all, because people might get muddled up as to what the implications of taking this drug are. They might not be aware of its reputation. They might think taking a drug once a week is better than taking it once a day, which I disagree with, by the way. When you're deployed, every day is the same. You don't think, “Today's Monday”. It's just another day. I feel that, on deployment, it's much better to build your daily routine around taking your malaria drug. Personally, my own view—
Liberal
Shaun Chen Liberal Scarborough North, ON
You're saying to remove it altogether and not provide it as an option.
Consultant Public Health Physician, As an Individual
Yes, take it out altogether.