Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 6 - Evidence - February 13, 2014
OTTAWA, Thursday, February 13, 2014
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:28 a.m. to resume its study on prescription pharmaceuticals in Canada.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I'm Kelvin Ogilvie, a senator from Nova Scotia and chair of the committee. I'm going to start the meeting by asking my colleagues to identify themselves, starting on my right today.
Senator Seidman: I'm Judith Seidman from Montreal, Quebec.
Senator Eaton: I'm Nicky Eaton from Ontario.
Senator Dyck: Lillian Dyck from Saskatchewan.
Senator Cordy: Jane Cordy from Nova Scotia.
Senator Enverga: Tobias Enverga from Ontario.
Senator Chaput: Maria Chaput from Manitoba.
Senator Eggleton: Art Eggleton from Ontario, and I'm deputy chair of the committee.
The Chair: We welcome our witnesses today and remind them that this is a continuation of our study on unintended consequences of prescription pharmaceuticals. Today's meeting is our second one dealing with the issue of antibiotic resistance.
We're delighted with the witnesses who have agreed to join us today. I will introduce them as I invite them to make their presentations. After both presentations are made, I'll open the floor up for questions. By early agreement, we will start with Dr. John Conly, Director of the Foothills Medical Centre.
Dr. John Conly, Director, Foothills Medical Centre, Alberta Health Services, Infection Prevention & Control (IPC): Thank you, Mr. Chairman, members of the Senate, and ladies and gentlemen. I am an infectious disease physician and still in active practice. I have been working in this area for the last two and a half decades, so I would like to express my great appreciation to be able to address this topic with you. I consider the loss of efficacy of our antibiotics to be a very serious issue.
Let me begin by indicating that antibiotic resistance is a major worldwide crisis. It has been rising for the last two decades — since the early to mid-1990s — and there have been many stark warnings that have come out through many organizations. You will probably remember the first report by the World Health Organization in 2000. The launch of their program was actually on September 11, 2001, the infamous 9/11, and it got buried by other news events of that day.
There have since been reports by the U.S. Institute of Medicine and the Center for Global Development out of Boston. Recently, it's hit the economic news, because in Davos, Switzerland in 2013, the World Economic Forum brought this forward, so it must be hitting some countries in the pocketbook, or a risk thereof, or it would not have come up in the economic arena.
It is a calamity. Why it is a calamity is based on many factors; it's multifactorial. One of the major drivers is the unabated and massive use of antibiotics in virtually all sectors of society, not only on the human side, but on the agri-food side. I understand you heard a bit about that yesterday.
We've seen single-drug resistance replaced by multi-drug resistance that has culminated in pan-resistance. We now have totally drug-resistant gonorrhea that cannot be treated. We also have the New Delhi metallo-beta-lactamase-1, NDM-1, that came out of the Indian subcontinent, and it has spread significantly. I'll touch on that in a few moments.
We've also had the propensity for rapid spread. These resistant microbes know no political boundaries. We've seen a significant reduction in research and development for new antibiotics at the same time that we've seen this rise, and it's culminating in what I would consider the perfect storm.
With the rising tide of antimicrobial resistance — these bad bugs — we've seen it escalate since the 1990s with totally drug-resistance gonorrhea, which is one of the most significant causes of sexually transmitted diseases. The WHO indicates there are over 100 million cases a year. This has arisen now in the EU and also Asia.
We've also seen the rise of NDM-1. It's particularly concerning because it has affected the germ known as E. coli that causes over 80 per cent of all urinary infections in people across the world. These "jumping genes" have gotten into the most common cause of bladder infections, and in many cases we have problems with effective treatments.
With NDM-1, just to give you an idea of the propensity for rapid spread, since it was first encountered and the first articles came out in 2010, it has now spread across the globe and is on every continent, save Antarctica. It's a major issue. It's currently an issue in Canada with the Canadian Nosocomial Infection Surveillance Program, which is a conglomeration of approximately 40 hospitals across the country.
There are over 213 cases of the carbapenem-resistant strains of germs, the majority of which are NDM-1. Many of you would be aware from the media that the first outbreak is currently occurring in the Fraser Valley in British Columbia.
With respect to the propensity for spread in a shrinking world, two Canadian authors, Brian Gushulak and Douglas MacPherson, actually looked at the mobility and migration in the world. It's quite significant. In 2007, they documented international arrivals that are moving between international borders. There were 900 million flights a year. That has now topped 1 billion. If we look at what happened with pandemic influenza and the rise of resistance, overnight it can spread from one part of the world to the other.
Following on the heels of the bad bugs is the problem of no drugs. The golden era of antibiotics is past; we've only had two new antibiotics that have come forward since 1982. The pipeline is drying up, and of the total number of new antibiotics approved at the FDA in the U.S. since 1982, we've seen a precipitous decline. When investigators looked at the new drugs in the pipeline, only 6 of 506 were actually antibiotics.
Juxtaposed against this is a concern of recurrent shortages. We run into it all the time, particularly with cheaper generic drugs. Thankfully a Canadian physician at Queen's University has started a website to follow this, and we're running into this not only with antibiotics but with many other drugs as well.
We are virtually bathed in an antibiotic ecosystem when we look at the use in human and veterinary medicine, and agriculture. The biggest concern is the use in the agri-food sector. It's probably a thousand-to-one when you look at the use in the veterinary agri-food side compared to human medicine. You can see it's used in intensive hog operations, cattle farming, chicken farming and fish farming. Our soils, water table and oceans are becoming saturated with antibiotics.
Unfortunately, 40 to 50 per cent of that use in humans is unnecessary, and 40 to 80 per cent is unnecessary in animals.
In closing, one of the concerns is: Are we heading towards another tragedy of the commons, as per the famous essay of the same name by Garrett Hardin in 1968. The tragedy of the commons is likened to a pasture where you have farmers who have their own fenced-in areas for the cattle to graze. They use up all the grass and then move out into the commons, which is a large, open pasture. Nobody was minding the commons. The cattle ate up all the grass on the commons. Then the cattle died, followed by the humans.
That is the essence of The Tragedy of the Commons, and you can liken that to the overuse of antibiotics: It's an inexhaustible commons. We're using them up, and we're going to create a crisis of antibiotic resistance where we have untreatable infections and the end of the antibiotic era.
Jared Diamond is an evolutionary biologist who has done work on the collapse of societies on Easter Island from deforestation as well as the Aztec empire. Are we heading into a new chapter in the book that will be written by Jared Diamond, "The Crisis of Antibiotic Loss and Antibiotic Resistance"?
Thank you for your attention.
The Chair: Thank you. I'll now turn to Dr. Patrick.
Dr. David Patrick, Medical Epidemiology Lead for Antimicrobial Resistance, BC Centre for Disease Control: Dr. Conly, has made clear the gravity of the problem, so I want to echo that and also focus on actions that can be taken at the government and society levels to mitigate the threat.
I am also an infectious disease physician; I also trained in epidemiology. That means that I focus on this problem as it relates to populations, specifically in Western Canada.
Now, 2013 was a year in which governments woke up. We heard from the U.K. Chief Medical Officer, the European Centre for Disease Prevention and Control, and from the U.S. Centers for Disease Control that we are in a crisis. We were talking about estimates of 23,000 deaths in the U.S. and 25,000 in Europe that are attributable to antimicrobial organisms. That would mean about 2,000 in Canada, although our statistics are not as good.
The deaths are the tip of the iceberg. I can go through data in B.C. and identify tens of thousands of illness episodes suffered by ordinary people. Routine bladder infections are now harder to treat. One in four skin abscesses are now harder to treat due to resistance. In the U.S., they've estimated that about 2 million infections a year occur related to resistant organisms now.
When the U.K.'s Chief Medical Health Officer painted this as an apocalyptic scenario, she was talking about the fact that much of our surgery, our cancer treatment and other areas in health — not just our treatment of infectious diseases but our treatment of everything else — is dependent on our having antibiotics that will work to handle infection when it occurs.
Just a reminder: Less than 100 years ago, deaths from pneumonia, when there was bacteria in the bloodstream, were 25 to 100 per cent, and we don't want to go back there.
We understand the drivers of resistance. Many microbes have the genes for resistance and have had them for a long time. They can swap them back and forth. What makes this a growing problem is natural selection at work. Whenever we use antibiotics in agri-food or in humans, even for the very best reasons, we kill off some bacteria, leaving the resistant strains to comprise the future population.
Emergence, then, is driven by antibiotic use in people and pets, where a large proportion of use is unnecessary, as we've heard from Dr. Conly, and by antibiotic use in food production, where a very large proportion of use is unnecessary.
Once they're here, the organisms spread. They spread more rapidly in denser conditions, so if we have crowded hospital rooms or animal pens, we see that dynamic apply. We're able to address these things to an extent through programs of hygiene and sanitation, particularly in the developed world, by keeping our hospitals spotlessly clean. But I want to outline four broad approaches being vetted by the World Health Organization as responses for society and government.
First of all, government agencies must maintain a clear picture of what's going on through timely — and I underscore "timely" — ongoing surveillance. Second, we have to reduce this unnecessary use of antibiotics in humans and animals through processes including education, feedback to prescribers and regulation. We have to encourage community practices that limit spread of resistance genes, and this means really good cleanliness in hospitals. As well, all of this will just slow down the emergence of resistance because we continue to need to use antibiotics. This means we need to think about how we adopt new ways to encourage the development of new antibiotics.
If surveillance is the first job of government, the question is how are we faring? A report is being concluded that was sponsored by the National Collaborating Centre for Infectious Diseases and performed by the Canadian Association for Medical Microbiology and Infectious Disease, and we have the picture. It's mixed. We're doing a good job with tracking the use of antibiotics at the community level thanks to a group out of Guelph known as the Canadian Integrated Program for Antimicrobial Resistance Surveillance, or CIPARS. Similar data are not available for Canadian hospitals where about 50 per cent of antibiotics are used, though CIPARS and other groups are working to change that. But in agriculture, we have a black hole. With the exception of a few sectors like B.C. aquaculture, where it's been tracked voluntarily, we have no picture of who is using antibiotics for what, and it's virtually untrackable because of loopholes and importation regulations.
When it comes down to tracking the rise of resistant organisms, this Canadian Nosocomial Infection Surveillance Program does a good job. However, there is almost no data on resistant organisms affecting most people living in the community, although we've shown it can be achieved by collaborating with private labs in B.C. We also have some information on antibiotic resistance in food animals.
Why would better surveillance actually help us do a better job? I can look at a lab table and it will tell me that 20 per cent of these E. coli Dr. Conly speaks about are resistant to an important drug. I could just consider that an issue. If we analyze it in detail, we see there's not a lot of problem in young adults, but we have a catastrophe in the elderly in long-term care, where resistant rates are 50, 60, 70 per cent. We need this information in real time to focus our programs.
What can government do in the field of surveillance? The first thing is to assure that our existing reports are available in a timely fashion as information for action by Canadians. Our internal review by federal communications apparatus has caused years of delay in publishing data on antibiotic use in Canada, yet these data are not political. We should expect to see that they are published as information for action bought and paid for by Canadians.
The Public Health Agency should be encouraged to back a winning horse in its outfit that's already surveying antibiotic use. Then I think it's up to the provinces and territories to step up when it comes down to seeing what's going on in the community with respect to resistant organisms because they fund the labs that have the data. The role of the Public Health Agency could easily be then to facilitate rolled-up reports so we get the national picture. This is very much like the European model.
The agency should also continue support for the Canadian Nosocomial Infection Surveillance Program for hospital trends, but to set timeliness standards for getting those reports out because those reports have been years late at times, too.
What works to reduce unnecessary antibiotic use? There's good literature out there. Our first approach is to prevent people from having infections in the first place using such strategies as vaccines, cleanliness and other prevention programs. But if we need to reduce antibiotic use, programs that focus on educating both the prescribers and the public at the same time have demonstrated more effect, and the very best results occur when there's a feedback loop telling the prescriber whether they're prescribing according to guidelines or wisely. In hospitals this is accomplished by audit teams that help promote best practice. The gold standard is shaping up in some U.S. health maintenance organizations where they're using smart electronic records not just to make sure antibiotic prescriptions are correct but that all prescriptions represent optimal practice.
We can see progress in this. As I mentioned in my report, we see a 50 per cent reduction in the rate of prescribing antibiotics to children in British Columbia between 1996 and 2010 and this is sustained effort from family doctors and pediatricians and from the "Do Bugs Need Drugs?" program that we share between B.C. and Alberta.
What can governments do to enhance this prevention and control? We can support programs that prevent infection. We had a national immunization strategy that did a really good job over the last decade. It's now expired and it would be a good idea to see a further role in immunization of the federal government.
Equally, Health Canada really needs to stop the licensure of sham vaccines, known as nosodes, which do not work and leave Canadian children unprotected if ill-informed parents choose to use them instead of actual vaccines. It's a shame that we've actually licensed them.
Federal and provincial governments should consider a role in promoting programs of consumer and provider education as well. Basically, if we're investing as a nation in electronic health records, they shouldn't be dumb records anymore. They should be smart records that provide elements of feedback. This applies to all prescription drugs, all health care.
You've heard about food production. I'm not a vet or a farmer. But we value the nutrition that's brought to our population and to Canadian tables by our producers. I would disagree with Dr. Conly on only one thing. We see eight times more antibiotics used in food production than in all of human medicine by weight. We see drug-resistant bacteria on Canadian meat, coming through the food chain and causing infections in humans. The concern I would share with producers has to be that consumers would be worried about getting untreatable infections on their food. What we need to do is work to preserve and save the reputation of our meat production.
Some antibiotic use in food production may be necessary to treat sick animals, as you likely heard yesterday, but much routine use is questionable. I went into some detail in this report about how very questionable antibiotics as growth promoters are, particularly in poultry production. In parts of the EU, they've ceased using antibiotics for that reason and the industry is doing fine, thank you very much.
What may governments do with regard to antibiotic use in food production? We can contribute to better surveillance of antibiotic use in food production and veterinary practice. We can seek collaborative or voluntary reductions and restrictions on use with producers on the model of B.C. aquaculture and close importation loopholes that lead to untracked use.
If I was a food producer in Canada right now, I could take my pickup truck across the border, load it up with antibiotics, promise the folks at the border that I'm just going to use it on my own property, and no one would be able to track the use. It's not prescribed. I'd just be dumping into my animals. That loophole is known as "own-use provision" and should be closed. We need to improve the regulation of antibiotic use and study a prescription-only model of use, at least for antibiotics that are of high importance to human health when applied in agriculture.
It's also important as a nation-state to consider that we've entered a free trade agreement with the EU. There's a market that is very aware of the risk of antibiotic resistance. Much of Northern European has already taken the steps we're talking about taking here.
Globally, Dr. Conly has identified the fact that we have much bigger problems with resistant organisms in some countries. We have to remember that this is part of our development mandate. We're not just about promoting Canadian mining. We're about promoting health globally because it comes back home to roost along the way.
Finally, others will no doubt have commented on the government's role in drug development. The market has failed here, senators, for obvious reasons. Why would you want to make a drug to keep in the cupboard to use once in the lifetime of a person when you can make blue pills that are used every day by an individual? We need to think about economic incentives for industry to get back in the game.
One suggestion has been extending especially long patent protection for antibiotic drugs because you don't want to see the cost of production, of development, recovered in just 5 years. You want to see it recovered over maybe 50. The other is, of course, that we can put development prizes up front so that if somebody comes up with a successful antibiotic and makes it available, the cost of discovery is taken care of up front.
Finally, if you're wondering about one reference that talks about how nation-states should address this problem, the WHO has put one out. I've given you the reference. It's available free online: "The evolving threat of antimicrobial resistance — Options for action." We should note that the World Health Organization calls on all member states to have a national action plan to deal with antibiotic resistance. Such a strategy could address the role of government in producing this surveillance information, reducing unnecessary use, slowing spread through the community, and encouraging antibiotic drug discovery. Canada at this point in time has no such strategy, and I hope this report will urge that we do.
The Chair: Thank you both. I open the floor up to my colleagues.
Senator Eggleton: Thank you, gentlemen, for your presentation. It's kind of a knock-out blow, you might say. Nobody wants to shout "fire" in a crowded theatre and create panic, but I'm certainly hearing from you today, as we've heard from others, that this is a crisis situation. In fact, the World Health Organization has called antibiotic resistance a global crisis that threatens to turn many common infections like strep throat into life-threatening ones. We've had similar kinds of alarm bells being rung by other agencies, other organizations and individuals around the world.
Trying to determine what we do in Canada and what we can do to improve upon what we do in Canada, I noticed, Dr. Conly, towards the end of your written submission you said that Canada is in fact an embarrassment. Canada is an "international embarrassment with its lack of a coordinated action plan, especially after demonstrating leadership in the area as far back as 1997."
What has happened here? Why has this fallen apart? We have the Public Health Agency that has put this surveillance system in place, CIPARS, yet a media report from last November says:
Infectious disease experts say Ottawa is treating national microbial surveillance reports like "sensitive government documents." And the doctors are so frustrated, they are releasing the data they can obtain on their own website.
Somehow we've lost a forward direction on this. How do we get back? You've made some suggestions, and I'd like to ask you about a couple of aspects of them.
Should we be banning the excessive use to promote growth in animals, particularly in poultry and pigs, et cetera? Should the government have a regulation to ban that or should we follow the EU model? I understand they have a user fee for the non-human use of antibiotics. What kind of direction should we go on that?
And what should we be doing at this point about the inability to get some action from the pharmaceutical industry in terms of development of new antibiotics? We know that bringing a drug onto the market is a very costly endeavour for them. What kind of government incentives could we create to help them to do that?
Also, dealing with the current shortage, we have a shortage of various drugs as well, including antibiotics. Again, the generics, I suppose, being low cost, are not attracting too much interest from the industry because they can make more money on something else. I think you have both pointed that out.
Can you give us some guidance on those questions?
Dr. Conly: There are a number of points you've made. My comment — I can have a sharp tongue, and I placed it into the document about an "embarrassment." I was around in 1997 when we had the first national consensus conference on antimicrobial resistance. We actually had our act together before the House of Lords released their report in the U.K. That led to the formation of the Canadian Committee on Antibiotic Resistance. There was indeed a Canadian national action plan that was published in 2002. The WHO actually lauded Canada as a leader in the area. Then for some reason the wheels fell off; the federal Public Health Agency disbanded CCAR in 2009. A report was forwarded in 2009 that there should be a new trans-disciplinary coordinated approach from the agri-food, veterinary, human sides, and here we are five years later and nothing has happened. I am critical of the Public Health Agency for not getting their act together.
There are some good points. Certainly, CIPARS is an excellent example. Dr. Patrick has outlined that. The CNISP program, which was under threat a year ago, has quite significantly reduced funding. Those are big errors in my mind, perhaps driven by the government's wish to be very fiscally conservative in terms of some issues in public health. In my opinion, it's the wrong direction to go and I will not apologize for making that statement. Canada has taken a step backwards compared to its leadership role at the turn of the century, in my opinion.
So we do have a national action plan, but it was never acted on.
The next item, growth promotion, is a very difficult issue. When I was the chairman of the board for the Canadian Committee on Antibiotic Resistance, we actually worked closely with Scott McEwan, John Prescott and a number of veterinarians in the group in Guelph. A large document was produced to look at this exact issue. You've got other groups: the Canadian Animal Health Institute, for example. There's a lot of debate about whether the use of antibiotics for growth promotion is actually driving resistance. Many of us believe there is. The evidence is what I consider softer. There's no hard, concrete evidence that one plus one equals two. It's a smoking-gun type of evidence, almost akin to the association of smoking and lung cancer. It took years for that to be brought forward.
You have groups in the multi-billion-dollar food industry who say that if they don't use growth promoters they lose a few pounds per cow or chicken. That's money in their pocketbook, and they will complain to their MPs and you, as senators that they're losing money now because you've taken away their antibiotics to allow their animals to grow. They can't produce as many chickens or fish.
It's a complex area. One needs to look at incentivizing the agri-food industry if you're going to be able to do it. In the end, it's the right thing to do.
As far as incentives for the farming industry, I've outlined in my document what the Infectious Diseases Society of America has outlined. They've talked about a four-fold strategy to create patent extension for antimicrobials that are present already in the system. It takes years to get it to market, and if you lose your patent two years after you've finally got it to market, that's a major disincentive for industry. Patent protection is one issue. I know the Government of Canada has acted on that and other areas.
Another is incentives for government to look at new classes of antimicrobials, which is an important issue.
I would add another item, and that is for our generic industry to look at ensuring we have production of our existing resources such as penicillin, tetracyclines. Because we're seeing worldwide shortages now, and some of those shortages you touched on are, many of us believe, secondary to the loss of these agents to pricier drugs. Because from a pharmaceutical industry, and they're beholden to their shareholders, looking at a drug like penicillin that might be used once or twice in a year compared to a lifestyle drug like Viagra that someone might want to use very frequently, there's not a lot of money to be made. So we need to incentivize our generic drug industry to ensure we have got products that are not frequently used, cheaper to make, but are absolutely necessary. That's very important. They outline a couple other areas for incentivization for new antimicrobials as well.
So, yes, there are many things that can be done within the area of the pharmaceutical industry, both the brand name and the generic drug industry.
Dr. Patrick: Just to add to Dr. Conly's comments, first of all, in the field of surveillance, for Senator Eggleton, we really have to look at our surveillance in Canada as weak. There are a couple of areas that are being reasonably well done by the group in Guelph, but most of the rest is entirely missing. We definitely need to see that coordinated at a national level.
The Public Health Agency cannot do this alone, but they certainly can play a coordinating role in terms of how some of this stuff comes together.
This applies, really, to all monitoring and surveillance data of any kind in Canada. These data just need to be available in a timely fashion.
If you're an epidemiologist like me, your very definition of surveillance is: It's information for action and it's available for those who need to act to change things in a timely fashion. We've lost that definition entirely at the national level in this country with surveillance information. We need to bring it back.
Secondly, when it comes down to agriculture, Dr. Conly has spoken quite a bit about how difficult the argument can be, but it will be forced upon us by last fall's FDA announcement that antibiotics are gradually going to be removed from American food production. If we want continued access to the North American market, let alone to seize the opportunity of the European market, we've got to be innovative in this particular area.
I think most provincial agriculture ministries are beginning to see that, with the exception of my own, actually, because we don't have a big hog and cattle export thing, and most of the poultry production is domestic.
Around antibiotic development, you've heard about the patent extension concepts and other things with industry. One other thing that could be done by regulators is that as new compounds become available, the cost of getting them through large, randomized and controlled clinical trials on hundreds of people is enormous, and it's very difficult to do that when you're dealing with, at this point in time, rare resistant infections.
There is a process for getting drugs in an expedited special-access fashion for people with cancer. This happened with early HIV therapies and so forth. So there's talk about having more of an expedited pipeline so we can get some experience in human beings who have no other option but to try a new drug early on. It sounds a little bit willy-nilly on the regulatory side, but we will be there soon. We will need to have expedited access to newer drugs.
Senator Seidman: I'd like to ask you a little more about surveillance and also about education. Both of you referred to these two elements.
I understand the critical importance of timely surveillance, but there are the issues around CIPARS and the Public Health Agency.
Dr. Patrick, you said in your presentation that the role of PHAC in resistance surveillance should be to facilitate rolled-up reports — I presume you are talking about the provincial-territorial reporting systems — that summarize national trends on the European model. I would really appreciate hearing about that, if I might.
There was also a reference made to B.C. and Alberta and their programs of consumer and provider education and guidelines for wise antibiotic use. There is the whole aspect that public education can play in the use of antibiotics, and I know that you've been involved in a study that looked at antibiotic use and that it's used mostly for viral infections as opposed to bacterial infections. If you could comment on the role of education as well as surveillance, I would appreciate it.
Dr. Patrick: With regard to this European model that I'm talking about, Europe, of course, has a bunch of independent nations, and yet the EU has this system called EARS-Net that surveys antibiotic resistance. As one of our colleagues from Edmonton famously quipped, "It's easier to know exactly what's going on in Lithuania than it is in any place in Canada." Small European countries are well marked on this.
Now, the reason I bring up that model is that our health care delivery system is a provincial and territorial system. The laboratories that do these tests, that give us the resistance results, are either run by the provinces or funded by the provinces in terms of private labs.
We've had an experiment going on in B.C. with a large private lab where we were able to work with those data and with Public Health, produce reports, and know what's going on in the community in terms of resistance; so it's achievable, technically, if there's a will to do it at the provincial level.
It's not fair to ask the Public Health Agency to do that; they don't have the jurisdiction. But what the agency can do is help to set collaborative standards where the information is collected in a similar way so that it can be rolled up, it can be compared province to province. We can see where we're winning and we can see where we're losing.
That's what I'm talking about in terms of the European model. If they can do it in Europe, we can do it in Canada.
The second question related to educational programs. Specifically, there was a program that originated in northern Alberta in the late 1990s known as the "Do Bugs Need Drugs?" program. This isn't the only program in the world that does this, but it focuses on consumer awareness as well as physician awareness.
The mechanisms for consumer awareness are myriad. Yes, there is some television advertising about colds and flus not needing antibiotics and that kind of thing, but also we indoctrinate the young health sciences students. So the medical cohorts and the nursing students go out to Grade 2 classrooms and pass the messages around to the kids who pass it to their parents. This is also done for day cares and long-term care facilities. It is a very broad thing with trying to remove the consumer pressure to ask that busy doctor for a prescription.
At the same time, guidelines have been produced by that core group originally from northern Alberta, but a lot of Canadian infectious disease specialists pulled together on those. They differ from a lot of commercially produced antibiotic-prescribing guidelines because where you have a condition like acute bronchitis where there is no real value to taking antibiotics, they provide you with a symptomatic treatment that you should give somebody to make them feel better, but you're not jumping in with the antibiotic. They also emphasize first-line antibiotics so that we preserve the broad spectrum ones for serious infections. These are disseminated to all of the physicians and many other prescribers in both Alberta and B.C. as a book and more recently an app that can be readily updated. So that's the nature of the program.
Since it came in in B.C., we have been tracking pretty good measurable reduction in utilization for the target areas, mostly respiratory infections in children. We're going to have to retool, because as Dr. Conly is hinting, we're having a growing problem with resistance in urinary tract infections, and we've got to think about how to address that at population level, too.
Dr. Conly: The only thing that I might add to the discussion, and Dr. Patrick has been very eloquent in outlining a response, pertains to the surveillance for community-based infections. We have a good handle on some of the hospital base through the CNIS program, but the community is a "black hole," I think he mentioned in his comments and I'll just reiterate that. There is no coordinated approach and it would require some political will on the part of the FPT process to be able to make certain that you have got population-based surveillance for the common community acquired infections. Examples are urinary infections, which 80 per cent of women will have at one point in their lifetime; pharyngitis from strep A infections; pneumonia occurring in the community. Those are very common community infections. We don't have the standard approach.
In the United States, through the Centers for Disease Control, they have the ABCs, the active bacterial core surveillance. It's population-based. It has a population of approximately 40 million through 16 states. We do not have that in Canada. There was inkling of it that was done with community MRSA but it has not been sustained or coordinated generally through lack of funding. So something that could be done is to provide the Public Health Agency with a mandate to coordinate community-based surveillance within population-based centres across Canada to give the Canadian population an idea of what the resistant germs are for the most common community-associated infections.
As far as the issue of education is concerned, the only point I'll make is that many provinces do pieces on television programs or newspaper ads about not using antibiotics for viral infections, as Dr. Patrick mentioned. Bronchitis is a common is one; the common cold is another. It might be helpful for the federal government in the transfer process — because it's complicated, I recognize, in the health system — to direct monies to the provinces so that in the transfer payments we're putting a parcel of money away, and we would like you to devote X amount or X percentage for advertising to the general public on educational programs. It could be funded by the federal government, transferred to the provinces but specified that this should be used and indicated that it's from the federal government for the benefit of the health of the population of the Canadian public. That is something else that could be tangibly done to move education forward.
Senator Seidman: Those are really helpful answers.
I would like to clarify CIPARS because my understanding is CIPARS was directed at community surveillance, and you're saying community surveillance is a big black hole. Could I have a bit of clarification?
Dr. Patrick: The Canadian Integrated Program for Antibiotic Resistance Surveillance is attached to the Public Health Agency of Canada but in collaboration with the CFIA and the National Microbiology Lab. They have done a good job with the surveillance of antibiotic use. They have done this by purchasing a commercial database and doing a great analysis on it. It allows us to compare use across the country. Newfoundland has got a problem right now. They're using more antibiotics per capita than other places, and if I was running health in Newfoundland, I would have liked to known that four years ago, not today. But they've done a great job of surveying antibiotic use.
On the other hand, surveillance of antibiotic resistant organisms is the black hole. If you take a look province by province in the country, there really are very few pictures of it, but there may be some really simple opportunities. It's neat to look at how CIPARS did that. They found a really good commercial source of information. When you take a look at the labs that are doing much of this community testing now in Canada, some of them are government run, but many of them are private, and there are some very large private firms. Virtually all the testing being done in B.C. is being done by one large commercial lab, and much of the testing in Ontario, for example.
I don't know which other provinces that firm is represented in, but one or two relationships with a firm like that that has the data between CIPARS or provinces, and you could have a picture by next year that's crystal clear.
Dr. Conly: Just to clarify further on Dr. Patrick's answer, he alluded to this at the beginning. CIPARS, if you remember its origins, is through the Canadian Food Inspection Agency, the veterinary circles. What they look at in the community are microbes that might be associated with food production or animal source infections. For example, they look at salmonella, a common cause of food poisoning, shigella another common cause of food poisoning, and campylobacter. They're predominantly agents of diarrheal illness. They do not focus on pneumonia, urinary and bladder infections or on throat infections, which are very common. They focus on those germs that might come through the food production cycle. Strep A, staph infections that cause boils and soft tissue infections, bladder infections, kidney infections, pneumonia — none of those are food production sources of microbes. On all those intestinal type germs they focus on, they do a great job. But diarrhea is one type of infection, and as I have outlined there are many other types. We need to be able to hit not just those germs that affect the intestines and cause diarrheal illness but all of the other areas in the body as well. You could pick the four most common, for example. That's the black hole.
Senator Seth: Thank you, Dr. Conly and Dr. Patrick.
My question is for Dr. Patrick. I understand you did mention the program called "Do Bugs need Drugs?" This program was adopted in British Columbia, and initially was adopted in Alberta in order to do targets both for public and health care professionals with the aim of reducing the unnecessary prescribing of antibiotics.
When it was switched or changed from Alberta to British Columbia, was there any change in the program, or why was it implemented? Were the results better, or what was the difference between these two places?
Dr. Patrick: The question relates to "Do Bugs Need Drugs?"
When we in British Columbia saw that we needed to address this issue, we thought we could invent something de novo or we could look around for something that seemed to be well conceived and working, because there is a lot of time put into materials, prescribing guides and things. It was evident to us that the program being used in Alberta had the attributes we were looking for.
What was really interesting is it didn't take too much effort to convince the provincial pharmaceutical services branch to fund the program because it actually saves money. If you bring the rate of prescriptions down, you save more money than the program costs and you have positive health benefits. So this is in the golden quadrant of "must fund" for government.
We found we didn't need to change the program dramatically as it moved to B.C. I disagree with Dr. Conly on just about everything in life because he is an Albertan, but we found the main attributes of the program were perfectly workable, the advertising materials, the materials for physicians and so forth.
Admittedly, if you went broader and tried to take a common approach across the federation, I think you would find more difficulty having a common program that way. There's a different program going on in Ontario, and some of that is good because you have slightly different resistance patterns in different places and you need a little bit of nuance.
We still work as a two-province management team on the program in terms of its overall development and continuation.
Senator Seth: My second question is related to the same thing. I understand that "Do Bugs Need Drugs?" has two arms. One is public related, where you advertise, do the TV advertisements and the brochures, and the other is related to health professionals — the pharmacists and the physicians. Can you elaborate here on how the two arms of the program are different and how you measure the success of the two areas?
Dr. Patrick: It's necessarily different because in some respects when you're speaking to consumers and professionals, you're speaking a different language. With the professionals, we can get away with some technical jargon and still get our messages across some of the time.
Between me and my colleague Dr. Hill, who speaks a lot for the program in B.C., we spoke last year to about 2,000 of the 10,000 estimated prescribers in the province at various different events.
It's necessary to give information to physicians because we're talking to them about specific diagnoses, specific antibiotics or specific non-use of antibiotics or about alternate therapies.
With the public, the messaging should be in terms of an intelligent layperson. In fact, the messaging has been put across so that a lot of kids get it. They understand that when you've just got a runny nose and a cold, that's not the time for antibiotics. Most people with the flu don't require antibiotics, although they might benefit from an antiviral.
We're also intent not just on reducing unnecessary antibiotic use but on this prevention message. The single most useful prevention message to the public is really one of hand-washing and other related good hygiene because that can demonstrably reduce rates of diarrheal and respiratory illness when applied broadly.
Does that answer your question, senator?
Senator Seth: Yes.
As you both mentioned, animals are well fed with antibiotics to treat prophylactic infections or with antiseptics for cleaning, et cetera, and then we ingest that meat. When we ingest it, do we think about any study that can be done to see what the effect on humans would be? That bothers me.
Are we becoming resistant? Is it harmful to us? Have we done any such study? Do we need to do such a study?
These are very disturbing questions that come to mind because everything today is well fed and well prepared, but our immune systems are getting out of whack so that when we get sick, we are struggling with resistance. What should be done about this?
Dr. Patrick: It's important to distinguish two things when we talk about antibiotic use in food and the risk to humans. First, do we eat the antibiotics when they're fed to animals? For the most part, Canadian production has a very good washout phase so that you're not at risk of actually consuming the chemicals in most of the food you would eat. But that's not the issue. The issue is that those antibiotics, when used in animals, will select for drug-resistant organisms. Even more important is resistance to genes. You can have an organism on your pork that's not harmful to anyone, but it carries a gene that can be passed to a harmful organism in your gut. So it's about the pollution with resistance genes. And we're not just talking about the pollution of our bodies; we're talking about rivers, water systems, sewage outtakes and everything else. That's a huge issue in the Indian subcontinent right now.
Yes, there's clearly a risk. As I've mentioned in my brief, we can definitely see, using the same evidence you would see used on CSI, human beings getting infections with drug-resistant organisms that clearly came from meat. We're not doing that kind of investigation all the time, so the magnitude of it is hard to come across, but I think if we've got a signal, then we have common cause with our producers in trying to reduce the risk of that going forward.
As Dr. Conly said, the use of antibiotics in agriculture is complex because animals get sick, too. They need to be looked after, and it's very important to involve both producers and vets in coming up with sensible solutions along the way that will not lead to horrific losses. But growth promotion is an area where there is very little need.
We did mention that one way to prevent resistant infections in humans is to go for better hygiene. I recently spoke to poultry producers, and they're completely revamping their operations to provide for better cleaning and a little more space for the chickens. They would need to use fewer antibiotics under circumstances like that.
So there are ways to engineer a lower dependency on antibiotic use in the agri-food industry. If the U.S. market is going in the direction we're expecting it to, we'll have to play along.
Dr. Conly: Just to add to this, there are two issues. One is antibiotic residues in animals, which is a very big issue. Particularly, as Dr. Patrick has said, with the U.S. heading in the direction of the EU, just for your information, there was a dispute between Russia and the United States over antibiotic residues with tetracycline in the chicken broiler industry, and Russia actually banned the import of American chickens a few years ago.
You may argue, if you look underneath the front covers of that issue, that it was just protectionism for the industry within Russia. In fact, it's a very sensitive one because many countries are now looking to be able to monitor for residue in meats to see if there are antibiotics, and that becomes a trade barrier issue.
With respect to the antibiotic resistance genes or organisms that may be present, a number of studies have been done where they've gone to supermarkets. There was one in the Washington, D.C., area and there was one done in Manitoba. They went to the grocery store and took pork, chicken and beef and swabbed them. In 20 per cent of the samples, they found some element of antibiotic-resistant organisms being carried on the meat. If you think of someone handling that meat or undercooking it, you can obviously pick up those organisms and/or, as Dr. Patrick said, the genes carried on them, and then you have them enter into the microbiome within your own intestinal flora, which is a very rich source of germs in the body.
So it's very important to look at the use of antibiotics in food animal production and the preparation of that food. I need only remind you of the huge outbreak of E. coli O15H7 in Ontario several years ago and how that affected many individuals. One could have easily picked up E. coli that had antibiotic-resistant genes present as well.
So it's a twofold story, both the residues in the meat and then the carriage of either whole organisms in undercooked meat or the resistance genes, as Dr. Patrick has mentioned.
Senator Eaton: As we feed antibiotics to chickens, poultry, pork and beef, is it becoming more common now for animals to pass diseases on to us? In other words, if you think of the bird flu — didn't H1N1 originally come from pigs? If they're becoming more resistant to antibiotics, which they must be if they get it in their food all the time, won't that have an impact on us as well?
Dr. Patrick: That's an interesting question, senator. I think there are continued efforts in food production and food packaging to minimize the microbes that are present on the surface of meat, but there's almost no way to do so and eliminate the presence of intestinal organisms that can occasionally cause illness in humans.
I would not say that we have evidence that infections are being passed more commonly between animals and humans now.
Senator Eaton: What about the bird flu?
Dr. Patrick: I'll get to that in a moment, if I may.
Bacterial infections are not necessarily being passed more commonly from animals to humans now. The concern is that those infections that are being passed are more likely to be difficult to treat, and that's an issue.
So far, we're speaking here about bacteria. The bird flu is a viral infection. Influenza viruses circulate in wild birds and all kinds of other animals, and pigs are famously a mixing vessel that can take bits and pieces of one virus, combine them with another and come up with something new. That's what happened with the swine flu — or the H1N1 pandemic in 1998-99. That probably would have been promoted by relative crowding in production or the possibility that there was a mixture of influenza viruses from birds that were allowed to get close to the pigs.
Senator Eaton: So those are viruses?
Dr. Patrick: Those are viruses. Hopefully if you have better biosecurity, less crowding and better ventilation in animal facilities, there would be a lower risk of that. But no amount of use of antibiotics would have contributed to that in any clear way.
The Chair: We're dealing with the antibiotic side, not the viral side.
Senator Eaton: Thank you. That was my ignorance.
Dr. Conly: One point I'll make is that it is understood, and the World Health Organization has said this, that probably 80 per cent of the new infectious diseases that will emerge will be what we call zoonotic; in other words, they come from the animal world. You may have heard of this whole issue of the One Health Initiative. That's where we look at human and animal health as one big conglomerate.
Senator Eaton: Isn't that being done in Manitoba?
Dr. Conly: It's being done actually on a Canadian basis and even globally. Many countries are now being captivated by the One Health Initiative. In fact, Canada is one of the leaders in this area, to be able to look at the common world that we share as humans and animals together, and many of the bacterial infections we have are wrapped up into a One Health scenario. That's why we must be able to start thinking this is a continuum, not that we've got the humans in one silo, the animals in another and the fish in another. In fact, we're all one big ecosystem known as One Health.
Senator Eaton: I would like to move to another area. We've talked about community and schools. What about hospitals? We've talked about cancer patients, people with very complex diseases. What can we do about helping hospitals to be more hygienic, safer environments for people with multiple problems?
Dr. Conly: That's an excellent question. When we look at the issue of the hospital environment, often in hospitals we have the most acutely ill individuals, and the chemotherapy and radiotherapy are much more rigorous than they were years ago. There have been many advances in medical science over the years.
So we have individuals whose immune systems are more compromised than ever before, and that becomes a hotbed of activity. We have to use greater poundage of antibiotics per unit of time, if you like. It's a very intense environment now in the in-hospital environment.
It becomes even more important to look at, as Dr. Patrick mentioned earlier, having good surveillance of antibiotic use in our hospitals, trying to promote stewardship within the hospitals. We have had the release of Accreditation Canada's program with ROP — required organizational practice — that will come into effect in May of this year. It will require that there be active stewardship programs in all Canadian hospitals. That's one very positive development that has occurred.
We also need to be able to look at the hygiene issue because we have issues in all Canadian hospitals about cleanliness. We hear this over and over again, from the Quebec C. difficile outbreak to the spread of resistant germs in the hospital environment.
It's a difficult one, because this is often under provincial control. One of the things that's easy to cut is housekeeping, and that's one of the things that we have to look at. We need to keep our hospitals extremely hygienic, and we need to have very good infection control. It's very important to have adequately funded infection-control programs in all of our Canadian institutions.
We work closely with the pharmacy groups to have good antibiotic stewardship surveillance for drug-resistant programs, and that's a very important element as well. As you're aware, that's under provincial jurisdictional control, but the message cannot be overstated. We need to be able to fund adequately our infection-control and stewardship programs to ensure not only the hygienic and clean environment that all patients and health care workers would expect, but also to have adequate surveillance and educational programs which are usually run through a hospital's infection-control program.
Senator Eaton: I hear now in hospitals, certainly in Ontario, they can wear their uniforms to and from the hospital. In other words, they go back out into the community; they go for lunch; they come back wearing their scrubs; they walk in to kneel over a patient. They have stopped doing in-house laundry where they had lockers, where they would take their clothes off and put on hospital gear. I you can think of any recommendations we could put in our report, please forward them to our clerk. That would be very helpful to us.
The Chair: A quick comment and then to follow up, as the senator has requested, with more detail.
Dr. Patrick: Yes.
One area I think is important to mention is that the infrastructure of Canadian hospitals. It's no accident that the outbreak that Dr. Conly is referring to in the Fraser Health Authority in British Columbia is occurring in an older facility with crowded rooms and with multiple patients in the rooms. That's no longer the standard to which we're supposed to be building hospitals. We obviously have to build our way out of the risk to a certain extent, too, along the way. I just wanted to add that point.
Senator Nancy Ruth: Thank you for being here.
There were two things you said, Dr. Patrick, that I wanted you to explain a little bit more to me. You said stop sham vaccines, stop licensing them. I don't know what "sham vaccines" are, so if you could explain that, I'd appreciate it.
You also talked about smart records, not dumb records, are needed. Could you say a bit more about that?
Dr. Patrick: I sure can.
We have a Natural Products Directorate at Health Canada that has been in action for a few years, licensing natural things and so forth. The only thing required to get these things licensed is that they're safe, not that they work. That's a requirement of a pharmaceutical that gets listed. When you begin to have a natural product that creeps into an area where you have something that works to save lives on a massive scale, like vaccines, you have put the public at risk, because if you drop immunization rates in the country, we can again see outbreaks of measles, polio, whatever you like, if parents take this stuff up.
It is a clear-cut mistake, an abdication of duty by Health Canada, to have licensed these products, and they need to be removed from the Canadian market.
What are nosodes? As far as I can tell, they're extremely diluted water, like homeopathic type of things. They don't contain any content that would create a successful immune reaction against the organisms that are there. They're probably harmless to give to someone, but the harm is that if someone takes those and thinks they're somehow protected magically from a pathogen, they do not work objectively.
Your second question was in regard to my clarifying the need for smart electronic health records of all kinds in Canadian health care. This is for patient safety, prescription accuracy and that kind of thing.
Most of the legacy electronic health records in our hospitals and in our practice simply are recording information. We have an era now where you can get instant apps for this that give you instant feedback on whether your idea is correct, whether you're in the right place.
What we need are systems that help health care providers navigate patterns of care better, that tell them where they are, that give them feedback if they're proposing to do something a little silly and off-base.
We do this in aviation. We have checklists before we take off in our aircraft, and I'm grateful for that, but we don't do it in health care. We should have systems that make the best practice, the easiest practice, and we should stop investing in dumb electronic health systems. We call it a systems engineering approach. It actually comes from engineering, not medicine. That should be built into the IT/IM systems, in my opinion.
Senator Nancy Ruth: You've made several comments about Canada's free trade agreements with both Europe and the U.S. market. You talked about your presentation to the chicken farmers and their giving more space and less antibiotics.
Is it your opinion that the producers, the animal and fish producers, whoever they are, will reduce antibiotics simply because they can't trade, and does there need to be government regulation that forces them to do so, so Canada can trade in these products?
Dr. Patrick: Senator, you probably would get a better answer from somebody involved in the production business. I think we would be at risk of not going lockstep with FDA regulations as they change, because much of our exports at present are to the United States.
Producers will change based on whether they think it's going to affect their ability to sell in markets. That's going to vary based on sector and province. When I mentioned the B.C. poultry industry, they don't export very much, so the incentive to follow along with regulations for the FDA is lower than other groups. But we have hog industries in Central Canada and cattle in Alberta that really want to put a lot of product over the border, and I think they will probably have a strong internal incentive to play along.
It will help, I think, if our regulatory apparatus takes a close look at the U.S. regulatory apparatus and doesn't fall behind. During the last decade, John and I were hoping we would pull ahead and do the right thing first, but it doesn't look like that's happened.
Senator Nancy Ruth: This would apply to dairy products. I'm from Ontario, and the cheese manufacturers are a wee bit upset about the trade deal with the European market, which is larger than the U.S. market; it's 550 million people, or something. But antibiotics are processed through the whole of the food chain. How would you see cheese manufacturers, for instance, pushing the dairy industry so they can compete?
Dr. Conly: As with Dr. Patrick, I'm not an expert in the production area. I come from the human side. I can only reflect.
My son went into economics, and from what I've learned, the market will drive the economy. If you've got two large trading partners, the EU and the U.S., and they have declared that they want to see antibiotic-free food production, and you're in a market where you've got antibiotic-laden products, they're not going to trade with you. Very quickly, the market will change and the producers will change, because otherwise they have no market to ply their goods. It's a standard market-driven economy. I have a rudimentary understanding of economics, but that would be my answer.
Senator Nancy Ruth: But you're not suggesting that we don't regulate as well?
Dr. Conly: I believe that legislation and regulation can be very helpful to be able to move it along, but it's a complex issue. What will happen is if you suddenly, overnight, made a legislated system whereby you could not use antibiotics, suddenly all those farmers on the production side would start complaining, "We've lost X amount of pounds per chicken, per cow, per hog. We now can sell X amount less. We're going to be laying off 15,000 workers." That will resonate quickly. It has to be done strategically and in a fashion where it is sensitive to the producers and phased in over time so there's not a death knell that occurs immediately.
Senator Enverga: Thank you for the presentations.
This is the second day we have heard about the alarming reports with regard to the use of antibiotics. So far, drug development has really slowed down so that there are no new drugs coming in. Unfortunately, most of the countries that will be affected by this are the poor ones, if ever there's going to be an outbreak of new microbes or something to do with that.
In this regard, would you suggest that the government grab the bull by the horns and create its own drug development agency, as opposed to waiting for those drug makers to do it?
Dr. Patrick: It's interesting. When we take a look at what happened with antibiotic production in the middle of the 20th century, a lot of the compounds that came online very quickly were low-hanging fruit. Fleming had shown that penicillin came from a mould, so people started looking at other compounds that came off moulds; and lo and behold there were other antibiotics; and then we got along a little further with more advanced chemical synthesis and development. But the incentive has been taken out of the market. The low-hanging fruit are gone, so we do have to consider things.
I'm not sure that government-based research is the only answer. It's one that can be considered. What Connaught labs did for immunization in Canada, back in Toronto, which was a government-funded facility, helped put immunization on the map globally. I think they're celebrating their one-hundredth anniversary; a great piece of Canadian history there. So I'm not against government-based work.
Right now, there are a number of new biological platforms based on the rapid acceleration in gene sequencing technology that can allow for the in silico, or "in computer," design of drugs that are aimed at targets identified through this process. We have very strong genome science centres in many places in Canada. It could be that this is more that government provides requests for proposals for scientists who are looking at modifying these platforms to accelerate drug identification. These are through the new sciences of genomics, proteomics, transcriptomics that are strong in Quebec, B.C., Ontario, and other places. I think government could get on board, but government could also fund through CIHR and other groups.
Dr. Conly: Thank you for that question, Senator Enverga. The answer to the question of whether we should fund a drug development agency is, in my opinion, no. Dr. Patrick mentioned this, and I'll just echo — and I did indicate this on page 8 of my report. The Infectious Diseases Society of America provided four theme areas. I'll call attention to those.
One was legislative solutions to fuel innovation. They suggested creating a commission that would then focus on prioritizing new drug discovery. That can be done by funding research priorities through NSERC, CIHR or other traditional funding agencies in Canada to say this is a priority for new drug discovery in the era of antibiotics.
Second were modifications to existing programs and policies. You can incentivize centres, public-private partnerships, to be able to focus on prioritization of new drug discovery. There are many rich microbiomes in this country, if you look at the territory that Canada covers. If you look at the oil sands, for example, it has something in the order of 1026 microbes, and they've only looked at the first one or two centimeters of the entire platform of the oil sands. That is a rich milieu from which to look at screening for large numbers of new, novel compounds, and it is unique to Canada.
For example, investing in the oil sands for drug discovery is an area that has not even been touched on. In fact, it's something that should be done, in my opinion. I had a graduate student who we were going to send to the hot springs, the glaciers and the oil sands to take samples. We were going to then combine efforts with a group in China to screen for new compounds.
That type of work needs to be incentivized, because we have very rich and unique microbiomes and settings in this country that we have not even tapped into, and we need to somehow incentivize the ability to have people do that.
The third item that was brought up was to look at your funding agencies. They talked about the NIAID, National Institute of Allergy and Infectious Diseases in the U.S. — we have similar organizations in Canada — to enhance their role in driving the look and development process for new products.
Then, finally, to look at new funding models to be able to incentivize our private and generic drug makers to look at drug discovery. Right now there seems to be no incentive for new drug discovery or being innovative in looking at unique sources to be able to screen for new compounds.
All of those can be potential solutions, so not creating a new agency but in fact incentivizing existing resources and actually looking beyond and thinking outside of the box to look at some of our unique environmental niches in this country to screen for new, novel compounds. We have not even tapped any of that potential.
Senator Enverga: I believe a lot of new technologies are coming, like gene sequencing, which you mentioned. Is there a possibility that we can create some sort of vaccine or something that will be a shield for us from certain types of microbes? Is there a possibility with that, which government can help develop at the same time?
Dr. Patrick: If I can address that. I just wanted to say I didn't know that Dr. Conly was going to ship bacteria in a pipeline across northern British Columbia, but anyway.
Dr. Conly: We are only screening for new compounds.
Dr. Patrick: Back to the question.
Novel and imaginative approaches are definitely part of the answer. Look at the problem. The reason we're getting more resistant organisms is because we use drugs that kill bacteria. We kill the susceptible ones; the resistant ones are left over.
How else can we deal with infectious diseases? We can design drugs that stop the disease process but don't kill the microbe. They don't select for antibiotic resistance.
The big microbiome that we haven't tapped is inside all of us. We have more organisms sitting inside our gut than you have human cells in your entire body, by a factor of 10 or 12. This is very rich. We're already seeing that manipulation of the microbiome in your gut can be used to treat and protect against certain infectious diseases, and this is another burgeoning field. So we could design drugs that don't kill. We could work with microbes that are on our side in order to combat things.
Your question about vaccines to prevent infections is absolutely a critical one. We can use our immune systems to prevent them from becoming established. There are clearly big areas where we're dealing with specific organisms that cause a large amount of infections in the urinary tract, or a large amount of skin and soft tissue infections, where we're only targeting one or two bacteria. If we broke through on vaccines for those things over the next couple of decades, we would reduce our need for antibiotics quite a bit.
Senator Chaput: Most of my questions have been answered, so I will just have a brief one. I want to know what you think of this. We've been using antibiotics in Canada for many years, freely and loosely. How many years have we been using antibiotics in Canada?
Dr. Patrick: Seventy years.
Senator Chaput: How long do you think it will take to reverse this practice of using them so freely without even thinking of the impacts, whether it be humans or animals?
Dr. Patrick: How long will it take to reverse? As I mentioned during my discussion, I'm not entirely pessimistic. I think that when you have the right educational programs and feedback loops in place, you can see a fairly dramatic change.
At the community level in human health, a lot of gains have been made in the last 10 or 20 years from serial efforts that have come through. We have to make similar gains in hospitals. It's time in our agri-food production, whether we ban things outright or not, that we begin to measure what we do and to seek improvement. So I'm not entirely pessimistic.
As to whether we can come down with draconian measures that instantly stop use, I think Dr. Conly has answered that quite well. There's a risk, if we move too quickly, that people may not engineer an adjustment in terms of how they manage things.
Dr. Conly: I'll respond by using the metaphor: It's like weight. It's a lot easier to put it on than it is to take it off. That adage applies to antibiotic resistance. You have to remember that these microbes are living, breathing organisms and they have a genetic profile. The theory of Darwinian evolution applies. Their cycling time is 20 minutes; for us it's 20 years, if you look at generational time. In fact, evolution can proceed in a matter of weeks in bacteria, compared to literally millions of years in humans. In fact, they can acquire these resistance genes. To lose them, it takes longer. So it can be reversed, but you need to pull away, and the speed of the reversal is much slower than the speed of acquisition.
You can think of that in evolutionary terms as well. It just takes longer. As you start to pull away, you see the antibiotic resistance plateau and then there will be a gradual decline. You want to be able to achieve what I consider to be, in the words of David Suzuki, "the appropriate ecological balance." We need antibiotics because they are life-saving, but we can't overuse them, just as we can't over deforest our forests because you get erosion and other complications. It's the same with antibiotics. They have to be used, but used judiciously. You have to try to achieve that ecological balance where you use them when you need them but not to the point of overuse so that you drive resistance. That's really the key.
Senator Chaput: The first critical step for the federal government would be what?
Dr. Conly: It is hard to say that there would be a first critical step because there are many facets. In fact, evidence from the WHO and elsewhere has shown that you need a multi-faceted, multi-modal type of program. From my perspective, and Dr. Patrick may have a different one, it would be to ask PHAC to organize an integrated federal-provincial trans-disciplinary committee or agency within the Public Health Agency to oversee efforts on antimicrobial use and resistance and surveillance because, in my mind, the first critical step that's lacking — and I've echoed it in my report repeatedly — is actionable, coordinated approach. We've had lots of plans and activity over the years, but it's somehow not coordinated. In my mind, that coordinated effort is the critical first step if I had to sum it up.
Dr. Patrick: I had an interesting conversation with a British foundation last week. These are the people that developed the longitude prize in the early 18th century for how you would know where you're at in longitude on the planet. I thought how appropriate, because they were asking what the priorities are with antibiotic resistance.
The first priority is to know where we are and to navigate. I agree entirely with my colleague: The most important thing the agency could do right now is help coordinate surveillance of resistance and use in all sectors in the country.
Senator Cordy: To follow up on that, "we should know where we are" is the whole issue of surveillance. We heard yesterday and today that CIPARS is collecting the data, but we're not getting it in a timely way. You gave the example of Newfoundland and Labrador, where surveillance has shown that per capita they are the highest users of antibiotics. It took four years to find that out. Yet when I think of the Public Health Agency, I think they were set up to react in a timely way. Why isn't this data being given out so that provinces, territories and Canadians can react in a timely way?
Dr. Patrick: I don't personally fault the agency. I've seen the analysts do a very timely job with pulling reports together that are extremely useful. Whatever restrictions they're under in terms of communications, however, that's the problem. Maybe that's the case when you're dealing with a political issue — it certainly needs to be vetted. But this is neutral information for action. As far as I can see, the main reason why this has not come out is it's been sitting on desks for a long time being vetted or somebody is deciding whether it's okay to release.
Senator Cordy: The government actually has to move and allow this information to get out faster is what it appears to be.
Dr. Patrick: Indeed. The agency should be encouraged to get it out as soon as it has made an intelligent report and there should be nothing holding it back from doing that.
Senator Cordy: Thank you. That makes sense to me.
The World Health Organization says that the antibiotic resistance is a global crisis. Yet in 2009, the government did away with the Canadian Committee on Antibiotic Resistance, which doesn't seem to make sense to me either. The committee that would actually be dealing with that was disbanded.
Dr. Conly, you said in your comments that since then there has been no path forward in terms of coordination or government agencies getting together. In 2011, the Canadian Medical Association Journal said that the federal government has not yet implemented initiatives to combat the growing problem of antibiotic-resistant infections.
I thought you said, Dr. Conly, that in fact we do have a national action plan; it's just not being acted upon. Is that correct?
Dr. Conly: Yes. The Canadian Committee on Antibiotic Resistance, in a meeting in 2002, in Ottawa, opened by the Deputy Minister of Health, created over the next ensuing two years a national action plan which was posted on the inactivated website for CCAR, but it has been lifted out and placed on the National Coordinating Centre for Infectious Diseases' website, where it is accessible. I can certainly send you the link to the national action plan.
What I commented on was that there was a leaked internal report that Paul Webster, an investigative reporter, found within the Public Health Agency in 2009 that commented on the pan-Canadian stakeholders. At the time that CCAR was being disbanded, there was a promise from the Public Health Agency that there would be the rise of a phoenix of a new trans-disciplinary committee that would oversee work on antibiotic resistance. That was in 2009. Fast-forward to 2014, no action.
This is where I develop a sharp tongue. You've hit a nerve on this one. I'm sorry. This inaction is completely unacceptable, in my opinion. Canada had been a leader, had been doing a great deal of work, but I don't know what has preoccupied them within the Public Health Agency. I know there have been a number of changes in the leadership, but at this point in time we have not seen an integrated trans-disciplinary group.
Many of the recommendations that are going to come forward are actually, according to the Webster report, highlighted in the 2009 report, which draws heavily on the national action plan.
Many times in the past, we've had excellent reports, excellent recommendations, excellent goalposts that have been set. Then the report goes onto a shelf, another report goes on top of it, and it continues to gather dust. So it is the inaction that draws sharp criticism and a sharp tongue from me. It is really a simple need to be able to create federal-provincial-territorial coordination. I believe that leadership should come from the Public Health Agency of Canada.
Look at what they've done in Sweden, where they've got the Strama program, or in Denmark, with the DANMAP program. Many of the Northern European countries Dr. Patrick spoke to have very good, active programs. From the late 1990s and the early part of the new millennium, there was active communication with them. That has virtually all dried up at this point in time.
If I have a singular complaint, it is the relative lack of actionable activity within the Public Health Agency on this file to coordinate those activities, notwithstanding the fact that the surveillance that is done within CIPARS and the surveillance on outpatient microbial use is excellent. The CNIS program is another excellent program. They are absolutely the highlights of the work that is being done, but overseeing a coordinated, active file just isn't happening, in my opinion.
Senator Cordy: Which is very frustrating because the World Health Organization says that it is a crisis and that Canada's taking no action and is not allowing information to get out from data being collected.
Thank you both very much. You've made a scientific issue easy to understand.
Senator Dyck: My question is going to centre around infection control and communities.
Dr. Patrick, in your presentation, you talked about how, based on the surveillance data, people under 50 weren't much of a problem, but elderly residents in long-term care facilities were living in a situation where there was a high incidence of antibiotic resistance of bacteria that are involved in bladder infections.
In Saskatoon, we're seeing an increase in the number of people who want to live together in communities. In the surveillance data, is there anything where you're targeting people who might live in communities in which, instead of one family, it might be ten families? For example, on a reserve, you might have families living in crowded conditions. Is there anything that indicates that crowded living or community living increases the risk of infection with antibiotic-resistant bacteria? Are there any recommendations with regard to education on how to prevent the infection of other people if you do have someone who has that type of infection?
Dr. Patrick: Before answering, I want to stress that this age concentration was in specific reference to drug-resistant urinary tract infections, so distribution will be different.
I don't want to speak against having people live in communities. There are so many other benefits to a social animal living in community — getting good nutrition, being more active, that sort of thing — but there are certainly elements of community design that are important.
It's not just a culture of hand-washing or coughing into the sleeve, but some things have been shown to play a prominent role. On-reserve, for example, if you have more people in a dwelling, a priority is to have excellent ventilation, good air turnover. You can actually track the distribution of the spread of tuberculosis in First Nations communities by the numbers of individuals inhabiting the same airspace and by the rate of air turnover. So there's an engineering solution. We don't want to be too crowded, obviously, but living in communities is a good thing for humans.
When it comes down to long-term care facilities, good ventilation and good cleanliness is important, but some of the problem has been driven by the fact that we're a little bit understaffed. An elderly person gets a little confused, and the solution seems to be to give them an antibiotic.
It's important that Dr. Conly and I are also educating health care providers because there are other approaches. Fully 50 to 75 per cent of people who are a little bit confused and might get an antibiotic are better in 24 hours if they simply get hydrated orally by a good drink. So we have to make sure that our standards of care follow a logical approach and that we're avoiding overtreatment, as well as keeping things clean.
Senator Dyck: As a follow-up, is there an indication of any dangers in pediatric care? Typically — and I don't know if this is right or not — you think of newborns or young children as not having the same sort of resistance to infections. Is there anything that we need to consider amongst babies or young children?
Dr. Conly: The only comment I would make corresponds to your question about infection control in a community. It's important that we have adequate funding for infection-control practitioners. They're an important element in any hospital, any community-living environment, such as a nursing home, any type of institutional environment. That would apply to the pediatric setting as well. If you've got that type of setting — a pediatric rehabilitation centre or something — any time you have a group of those individuals together, the role of the infection-control practitioner is extremely important. They bridge the gap between the hospital, the institutional environment and public health. So they're a very important liaison. I can't stress enough the importance of the infection-control professional and their role in helping with that surveillance and, importantly, education in terms of the components of good hygiene and surveillance within that setting, bridging between the hospital, the institution and the community. It's almost a continuum of care, hygiene and good surveillance along that spectrum.
Senator Dyck: To put it in a realistic situation, let's say that within my family I had a child who was infected with one of those antibiotic-resistant bacteria, and I was concerned about it spreading to me or to other children. Is anything out there available to the general public that would say, "If this has happened to you, here is what you should be aware of, and here is what you need to do. If you're immunocompromised, maybe you need to consider the following." Is that type of information available?
Dr. Patrick: There are guidelines for the public. It's important to remember that these organisms are particularly risky for people who are vulnerable — newborns, people who are really sick in the hospital. There are a large number of these bugs being carried around in the community, and people aren't running into huge problems with them. Where you see problems with skin and soft tissue infection from resistant bugs tends to be in places where people can't get clean that easily, people who don't have shower facilities to use every day or two. The common denominator is usually hygiene, so just the idea that we promote reasonably good standards of hygiene is really a good societal defence.
There are rare circumstances where you've got a particularly worrisome organism, and the public health officer for a region can give specific instructions. Thankfully, that's a rare thing. This isn't something that we have to tackle at the community level with stringent measures yet.
Dr. Conly: Senator Dyck, thank you for that question. That's a very pertinent and real example. We run into it on an almost daily basis.
I will reiterate again that that's where the infection-control professional and the relationship between public health and institutional infection control come in. We have often worked hand in glove with our public health colleagues to develop guidelines so that as someone with an antibiotic-resistant germ is transitioning from a hospital into a community, the major focus is on hand-washing, good general hygiene and keeping those who might be vulnerable in the household away from an individual until their health returns.
We actually do have guidelines. Public health can visit. There are guide sheets available. In most jurisdictions across Canada, that is available, but it then goes back to understanding that we require the infrastructure to adequately fund our public health and infection control professionals to be able to provide that expert advice, consultation and education to those individuals.
Senator Enverga: Going back to vaccines, do you think that these drug companies are not developing new medicines because of cultural or political issues that maybe the government could work on?
Dr. Patrick: I do not see a big problem with the vaccine pipeline. We see a fair amount of development of vaccines. Some of these organisms would be nice to prevent by vaccines. There is still some good research going on. The specific industrial failure, and I would also call it essentially a market failure, is that of antibiotic production. There simply is not enough money in sales of antibiotics, the way we want to use them going forward, to make it worthwhile for shareholders to underwrite the cost of discovery.
That means that we have to be imaginative. The free market can do an awful lot, but in all probability it will not give us antibiotics. If it did, we'd probably have the same problem that we had in the 1940s and 1950s: We've got this so let's take it out the door by the truckload and sell it where we can to everybody. We obviously can't do that with antibiotics.
The Chair: I want to come back to a couple of things and ask you a general question.
I believe it was you, Dr. Patrick, who made the comment, as you were giving us all that wonderful information about the elderly, that there was relatively low resistance in youth to a particular bacteria, perhaps E. coli, but a 70 per cent resistance in the elderly. Could you clarify that for me?
Dr. Patrick: Yes. We have both referred to E. coli, which is the most common organism causing 80 per cent of urinary tract infections. It is also true of a couple of others that contribute. The existence is much higher in the elderly, in particular those in long-term care. It's logical because this is a population in whom progressively more antibiotics are being used, not only to treat urinary tract infections but also to treat respiratory infections. If I use a quinolone-type drug to treat a respiratory infection, I will cause resistance to quinolone-type drugs in urinary tract infections as well. Vast over-treatment, on reflex, in many long-term care facilities is a big contributor to that problem.
The Chair: I thought that might be it, but I wanted it clarified because on its own it was an interesting observation.
Dr. Conly, I totally agree with your comment about the urgency on antibiotic resistance in terms of the seriousness. Looking at it in general terms, it would be hard to imagine a more potentially serious human health issue than resistance to antibiotics and the opportunities that would give to the microflora in terms of taking us on as part of that biodome you've been referring to.
Since the understanding of the possibility of dealing with bacteria, we have had a much greater awareness of it in the medical profession and the general population. It reached a point in the 1950s and into the 1960s where it was apparent that bacteria were being transferred on food in food-chain distributions. Governments spent a lot of money in different countries looking at how to deal with that. One of the solutions that arose at the time was nuclear radiation, and Canada in the 1970s and 1980s was a world leader in the technology.
It didn't go anywhere because of the universal fear of the term "nuclear" among the public. Food distributors were not interested in providing food on which there was a symbol that said the food had been irradiated. The promise at the time was that for meats and packaged foods, irradiation using this technology would eliminate 100 per cent of the microorganisms that were of concern.
Fast forward 40 to 50 years and not only do we have bacteria being transferred on food products but also we have had, as everyone in this room knows, many serious outbreaks in parts of North America with regard to food-borne pathogens. We now have this tremendous issue of antibiotic resistance, which you have made more compelling with your articulate and knowledgeable presentations on the seriousness of this, and the idea that these types of organisms are possibly being transferred in food.
My question is: From your perspective, is nuclear radiation technology really something that could provide a practical application on this issue in today's world?
Dr. Patrick: Food irradiation works to eliminate bacterial carriage. I would not use the term "nuclear irradiation" because we're not using radioisotopes to do it. Essentially, we use a form of ionizing radiation that will kill bacteria and leave no residue or isotopes around.
You're quite right: The public perception about the danger of that is out-of-keeping with what the technology is. It probably will be the consumer who will drive the use.
I spoke recently with a provider of this service, which is a specialty niche in B.C. Their markets are essentially for immunocompromised people who are at high risk of getting infections. It's a potential answer if the problem becomes grave. Personally, I'd rather prevent the problem by not having it emerge to such a large situation in the first place. Maybe that's my public health bent.
There is another thing that should be on the table. H.G. Wells was right. The microbes are our friends. They took out the Martians at the end of War of the Worlds, but we were immune because we'd been living with them for millennia. Most of them do good things for us along the way. There's abundant evidence that children who sample the environment a little more, for example if they have a puppy, may be healthier in some ways and less likely to get asthma. We don't want to create bubble children in a bubble society, if possible.
In the extreme, it is a solution, but I'd say we'd be better off preventing the problem if we can.
Dr. Conly: I would just respond by saying yes, it may be part of the solution. I would like to thank you, senator, for raising that.
When I was on sabbatical with the WHO, I lived in Switzerland for a year. They irradiate their milk and it sits unrefrigerated on the shelf; and it tasted fine.
I believe it is part of the solution. There is a consumer phobia, as you very nicely outlined, about the use of ionizing radiation on food. One other item comes into play with that consumer phobia: Some people believe that if it has been irradiated, it does not taste as good.
This takes us to back to the issue of wine, beer and cheeses — many of those bacteria are our friends, such as the probiotics and lactobacilli. We want those because they actually help with the tastes we like. Some people like unpasteurized cheese, and they eat it despite the risk of getting Brucella and Bang's disease because it tastes better. People have told me that I haven't had cheese until I've had cheese that is unpasteurized.
You have to be very careful about this because you're affecting humans' taste buds. In high-production areas where you've got meats and other things, in particular large production facilities, irradiation may have a role. You've hit on a good point that needs to be explored as to where it might be used, but it's certainly not a solution for everything because our food would become tasteless.
The Chair: Absolutely. I was bringing it into your multidimensional approach to these issues. I know a fair amount about this. The Whiteshell Nuclear Research Establishment in Manitoba was a leader in this technology. It was closed down because of the public fear. At that time, societies were going to require a nuclear symbol on any food packages. In today's world, with ionizing radiation, the way you've phrased it, Dr. Patrick, it might be possible to use a different symbol that would have a different kind of connotation, but I think it is a potential weapon for us.
On the issue of raw foods, there are people who jump off of very high places as well, and there is a certain thrill in life and perhaps therefore a satisfaction in foods to know that you are on the edge of a serious risk by dealing with it.
Dr. Patrick, in your inference to Dr. Conly with regard to Alberta and British Columbia earlier, you entered into another unintended consequence that we heard about yesterday, and that is the unintended consequence of public policy. The policy issues that your very humorous comment fell against in terms of British Columbia and Alberta was certainly not lost on us in terms of what you were referring to.
You have been extraordinary in your ability to cover the range of aspects of this very important issue. I can tell you that it's likely that the ears on this committee were very receptive to your very strong urgings. This is the fourth phase of a study in which some of the issues you have raised are those that we have urged very clearly in different ways and on different aspects in earlier reports — the collection of information, the urgency of doing that in real time, the urgency of analyzing that and the urgency of getting it back through the health profession in real time. We are, as a committee, astounded that in the electronic age we are not where many of us think we might be, and you have given us additional dimensions in all of that.
I'm particularly interested in urging this upon you because you have both referred to the need to identify pragmatic recommendations that can actually be acted upon and work. That is what we are seized of as a committee, ultimately making recommendations that can be implemented and will lead to change. After you leave here, if at any time prior to the windup of our study this spring you have one of those "aha" moments, would you please communicate directly to our clerk? We would be most appreciative.
I would like to thank my colleagues for their insightful questions, and I thank you again for the outstanding contribution you have made to us through your responses today.
(The committee adjourned.)