Veterans Affairs Committee on Nov. 3rd, 2016

[Colin Fraser, Liberal, West Nova, NS]

Thank you very much, Mr. Chair.

Thank you, everyone, for your attendance today and for your very good information. It will help us understand this a little bit better.

I appreciate, and I think everyone does, the dangers associated with malaria and the need to make sure that our Canadian Forces and veterans are protected against malaria in tropical theatre deployments. I appreciate that backgrounder.

With regard to what's being prescribed now as antimalarials, do we have a sense of the number of people in the forces using mefloquine and the number being prescribed other types of antimalarials right now?

[BGen Hugh MacKay]

Andrew is my expert on this. Fifty-one individuals were prescribed mefloquine in 2013. We're down to 42 persons who were prescribed mefloquine after a discussion with a clinician. Sixteen times that would have received Malarone.

[Lieutenant-Colonel Andrew Currie, Section Head, Communicable Disease Control Program, Directorate of Force Health Protection, Department of National Defence]

It is Malarone and doxycycline.

[Colin Fraser, Liberal, West Nova, NS]

The overwhelming number are receiving the other types.

[BGen Hugh MacKay]

Only 4.3% now, I think, of the prescriptions for people who receive medications to protect against malaria are for mefloquine. The vast majority of the rest are for Malarone, followed by doxycycline. As I said, the numbers are small. It was 43 who had mefloquine. About 800 got other types of antimalarials.

[Colin Fraser, Liberal, West Nova, NS]

Do we know if the ones prescribed mefloquine right now and taking mefloquine, or who did in the recent past, had been using the other types of anti-malaria drugs and for whatever reason, as a drug of last resort, for example, are now using mefloquine because of the side effects of those other types? Do we know how many used different drugs before using mefloquine, of the ones who are using it now?

[BGen Hugh MacKay]

I don't have that information available.

[Colin Fraser, Liberal, West Nova, NS]

Could we find out?

[LCol Andrew Currie]

Our pharmacy people actually track that. Although I don't have the numbers strictly in front of me, we're talking about ones and twos who actually do that crossover.

Interestingly enough, you actually get the same sort of crossover when people who don't tolerate one medication cross over to mefloquine, or maybe they like the dosing regime. You will also get people crossing over from the other. Sometimes that actually happens in theatre.

[Colin Fraser, Liberal, West Nova, NS]

That was going to be my next question. You only take mefloquine once a week.

[LCol Andrew Currie]

Correct.

[Colin Fraser, Liberal, West Nova, NS]

Some people prefer that, so you'll see crossover and people switching to mefloquine or between both types.

[LCol Andrew Currie]

Correct.

The other aspect is how long you're going to stay. For example, for someone who's going to be 10 days some place, it probably makes more sense to use a daily product as opposed to....

[Colin Fraser, Liberal, West Nova, NS]

Right.

This could be a dumb question, but how is the drug actually prescribed? What doctor do they see to get it prescribed, and how many doctors are prescribing this stuff before our forces are sent into theatre?

[BGen Hugh MacKay]

That would be very mission specific.

Any of our physicians could be called upon to prescribe anti-malaria medication. We also, though, have recently permitted, as is the case across many of the provincial jurisdictions, pharmacists to have that discussion and provide malaria chemoprophylaxis to patients.

[Colin Fraser, Liberal, West Nova, NS]

Before a prescription would happen, though, the individual would meet with probably a doctor, a physician in the forces, and have a discussion about possible side effects and the pros and cons of the different types of antimalarials. Would that be the norm?

[BGen Hugh MacKay]

There are two processes. The small number of people who are going away, as I explained earlier, will likely have that encounter with a physician.

When we have larger groups of personnel going out, there may be a larger body of people brought together for a briefing by either a physician or a pharmacist about all aspects of the medication with respect to dosing, advantages, disadvantages, and adverse effects. That group of people would also fill in a screening form we have, which we would then review on an individual basis. We would then have them see a clinician, either a physician or a pharmacist, to receive the medication.

[Colin Fraser, Liberal, West Nova, NS]

Thank you.

Dr. Stewart, let me move to you. You touched on mefloquine, one of its advantages being that it only requires one dosage a week. Are there other reasons to explain why someone would choose mefloquine over another malarial?

[Dr. John Patrick Stewart]

Each anti-malaria prevention therapy has its own advantages and disadvantages. Compared with some of the other therapies, if you have kidney problems, if you have photosensitivity, if you have a history of allergy or cardiac problems, mefloquine may be a better choice. It's really a conversation.

Each has its own side-effect profile, and what Health Canada does in the product monographs is present in the document what the drug is indicated for, the dosage, and the warnings, precautions, contraindications, and so forth. It's up to the physician and the patient to sit down and look at the options to see what works best for them.

There are a number of considerations. They all have side effects; none of them is side-effect free. You have to consider the unique circumstances of a patient—the situation, the duration, and so forth.

[The Chair, Liberal, Neil Ellis]

I'm sorry, you're out of time.

Mr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair.

Thank you all for coming. My first question is for Dr. Stewart. This is a perfect lead-in to what I was going to ask.

We've spent a lot of time talking about these rare but serious side effects of mefloquine. Can you briefly describe some of the more serious side effects that you might have with Malarone and doxycycline? I know that photosensitivity is one of them with doxycycline.

[Dr. John Patrick Stewart]

They're listed in the product monograph and they vary. You can go by organ system, and they're listed. They can include severe allergic reactions that can be life-threatening; they can include excessive toxicity, skin reactions, GI reactions—vomiting, and diarrhea. Malarone can cause a chronic cough. Doxycycline is an antibiotic, so it can also cause GI side effects—clostridium difficile, diarrhea.

They both have the possibility of photosensitivity. In many of the areas where malaria is prevalent, there is high sun exposure. These are concerns.

This is why it's important that the physicians involved with prescribing these drugs understand the various side-effect profiles. Many of the severe risks associated with all of them are quite rare, but when they happen, they're quite serious. You have to be aware and have to inform the patient to seek advice from their practitioner; that's why the guidelines are there. The document that CATMAT puts out lists all the considerations of the various drugs that are extracted from the product monograph that Health Canada puts out and from other international information. It really is a consideration at the interface between the physician and the patient, however, as to the best choice and what the strategy is if that choice is not optimal once the patient starts it.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Sure.

This may be a very difficult if not impossible question to answer. Generally if you're looking at risk-benefit profiles, would all three be equivalent? Even though they're rare, would you say there are more, or a higher frequency, of these rare side effects with mefloquine compared with the others. I'm a physician myself and I hate it when someone asks this question, but if you were prescribing these and comparing the risk versus benefit of all three, can you think of one that you would say has the best risk-benefit profile of all three?

[Dr. John Patrick Stewart]

My role is to represent Health Canada. It's not the role of Health Canada to do that; the role is to provide the information effectively. Then, at the interface with the patient, that decision has to be made, and there are many considerations in that regarding, including patient tolerance, side effects, their health, economics—it's all there. So I wouldn't say that one is better than the other.

That's why we have organizations, such as CATMAT, that can sit down.... It takes a number of experts to sit together and consider it and then put out the recommendations. I wouldn't say that Health Canada has a best drug to recommend; its role is to explain the evidence around each product. Then, one of the uses of practice guidelines is that they inform practitioners about what the considerations of a given illness are, what products are available, and what you need to understand before you choose one.

It wouldn't be fair to say that one is better than the other.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

No, I understand.

General, again, I seem to be in the habit of asking very difficult questions, and I don't know if there's data about this. We do know that PTSD itself is an unfortunate and tragic occurrence in personnel who deploy in any combat situation. We have personnel who deployed in different theatres in different parts of the world, in some of which malaria is not an issue, so you wouldn't be prescribing antimalarial prophylaxis because they wouldn't need it.

Do we have any data on rates of PTSD diagnosis in soldiers in theatres where they've served and this was not an issue, and we know we would not have had any antimalarial prophylaxis because it wasn't an issue, versus in theatres where you had to have such prophylaxis?