Dr. Marc Ouellette:
Okay, wonderful. Thank you very much.
I would like to thank the committee for inviting me to speak to you on how the Government of Canada is supporting Lyme-disease-related research across the country.
First of all, I would like to say how impressed I am by the deliberations you have had so far in the committee on this very important bill. As you know, the Canadian Institutes of Health Research, or CIHR, to use the acronym, is the Government of Canada health research funding agency with a mandate to support the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products, and a strengthened Canadian health care system.
Preparing for and responding to existing and emerging global threats to health has been identified as one of the five research priorities in CIHR's 2009-14 strategic plan. This includes the areas of microbial threats and the environment and health, which relates directly to our topic today.
Within CIHR, the Institute of Infection and Immunity for which I'm currently the scientific director supports research and helps build capacity in the areas of infectious disease and the body's immune system. In addition to supporting research, the Institute of Infection and Immunity plays an important role in infectious disease issues in Canada, including helping coordinate Canada's rapid research response to infectious disease outbreaks, especially those caused by new and emerging pathogens.
Since its inception in 2000, CIHR has invested close to $7 million in Lyme disease research. This includes an investment of approximately $600,000 in 2012-13 alone.
These investments have supported research examining the dissemination and replication of the bacteria Borrelia burgdoferi, which is known to be the causative agent of Lyme disease. CIHR's investments also allowed researchers to examine protective practices against ticks and tick-borne diseases.
For example, CIHR is currently supporting the work of Dr. George Chaconas, a Canada Research Chair at the University of Calgary, who is investigating how the genetic information in the bacteria that causes Lyme disease is passed on from generation to generation.
Part of Dr. Chaconas' research focuses on identifying the proteins expressed on the surface of the bacteria that interact with proteins of the human immune system as part of the disease-causing process. This research will help provide a better understanding of the complex processes of this very unusual disease-causing organism, and may well lead to the development of drugs to either block or treat infection associated with Lyme disease.
Over the past decade, Dr. Chaconas' research has been recognized internationally. His CIHR-funded research has resulted in the publication of over 30 peer-reviewed scientific articles and allowed him to collaborate with the best Lyme diseases researchers in the United States. In 2011 Dr. Chaconas received the Canadian Society of Microbiologists' Murray Award for Career Achievement for his microbiology research in the area of Lyme disease.
CIHR is also supporting the work of Dr. Tara Moriarty from the University of Toronto. Dr. Moriarty developed a new microscopic technique for studying the dissemination mechanism of Borrelia burgdorferi in real time. This technique facilitates the work she's currently conducting with engineers at the University of Toronto to design novel devices to screen inhibitors of Lyme bacteria in the bloodstream. This will help further our knowledge of the vascular dissemination of the bacteria, a key step to better understanding the progression of Lyme disease in humans. In 2011 Dr. Moriarty received the Bhagirath Singh Early Career Award in Infection and Immunity, which facilitated the expansion of her research program into new areas related to susceptibility to Lyme disease infection and dissemination.
As you can see, research conducted in Canada has significantly contributed to global knowledge surrounding the bacteria responsible for Lyme disease. Thanks to researchers' efforts, we have a better understanding of how this bacteria replicates, how it spreads in the bloodstream, how it evades destruction by the immune system, and how gene expression is regulated.
Advances in imaging technology now allow the visualization of the Lyme disease bacterium in the living host. Understanding how this organism survives, functions, and causes disease will help us develop innovative treatments for those who suffer from Lyme disease.
In conclusion, Mr. Chair, let me assure you that CIHR will continue building Lyme disease research capacity in the country, and promoting international research collaborations to address the impact of Lyme disease on the health of Canadians and the global population, and ultimately, find a cure to this disease.
Thank you very much for your attention. I'll be pleased to answer any of your questions after my colleague from the Public Health Agency of Canada has his turn at speaking.
Mr. Steven Sternthal (Acting Director General, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Infectious Diseases Prevention and Control Branch, Public Health Agency of Canada):
Thank you, Mr. Chair and members of the committee, for the opportunity to contribute to your deliberations on Bill C-442.
I am pleased to be here today to address the work under way in the Public Health Agency of Canada to reduce Lyme disease across the country.
I'll begin by addressing the agency's role and how it applies to Lyme disease.
The agency aims to promote better overall health of Canadians by preventing and controlling infectious diseases. We undertake primary public health functions, such as health promotion, surveillance, and risk assessment. These inform evidence-based approaches to prevent and control the spread of infectious diseases.
As part of its public health leadership role, the agency coordinates the national surveillance on Lyme disease as one of the most rapidly emerging infectious diseases in North America. I know that was part of your deliberations late last week.
The spread of Lyme disease is driven, in part, by climate change, as the tick vector spreads northwards from endemic areas of the United States. Moving into Canada, it is impacting our most densely populated regions. Based on the lessons learned in the United States, we anticipate the disease will affect over 10,000 Canadians per year by the 2020s.
To date, we have seen cases increase from 128, in 2009, when Lyme disease became a nationally notifiable disease, to an estimate of over 500, in 2013. That's a fourfold increase in just over five years.
However, this national snapshot only reflects a portion of all cases in Canada. This is because some people do not seek treatment for milder symptoms. Others do seek medical help, but may be misdiagnosed because their doctors are not always aware of the range of symptoms, or even that Lyme disease is in Canada. Agency risk models estimate the true number of infections to be at least three times higher than what has been reported today.
To support physicians in diagnosing Lyme disease, laboratory diagnostic testing is available across Canada in various public health laboratories. Like the United States, we use a two-tier test that must be requisitioned by a physician: the ELISA, to screen; and the western blot, to confirm Lyme disease.
The following are just a few facts about the testing in Canada.
Last year, almost 40,000 ELISA tests were administered by provincial and national laboratories. Of this total, approximately 3,000 tested positive or inconclusive, and were sent on to have essentially the second part of the screening and testing, the western blot, for confirmation of Lyme disease, by either our National Microbiology Laboratory in Winnipeg, or by public health laboratories in Ontario and British Columbia.
Following a thorough review of this surveillance information, available domestic and international research, stakeholder views, and existing public health messaging on this important topic, the agency has put in place an action plan to prevent and control Lyme disease in Canada. The action plan identifies three pillars for concrete action: engagement, education, and awareness; surveillance, prevention, and control; and research and diagnosis.
The first pillar includes a comprehensive public awareness plan that focuses on educating health care professionals and the public about Lyme disease.
Raising awareness among health professionals is one of our main goals: informing them that Lyme disease is here, educating them on symptoms, and encouraging them to properly diagnose and report cases.
This year, we have already reached an estimated 200,000 health professionals with awareness posters published in medical journals beginning in March. We have also presented to clinicians at a variety of venues across Canada in recent months.
We are also using every means available to get the message out to the general public. From social media, to Google AdWords, to partnering with organizations like The Weather Network, we are telling Canadians that Lyme disease is here, how to recognize it, and how to protect themselves from it. These public messages will continue throughout the summer period, which really is the Lyme disease season in Canada.
The agency has also worked with provincial and territorial public health authorities, as part of the Pan-Canadian Public Health Network, to develop a coordinated, vector-borne disease communications strategy, and public awareness tools targeting Lyme disease.
We hope that by the end of this year's tick season Lyme disease will be a household term.
I would now like to address the second pillar, which focuses on innovative ways to conduct surveillance and encourage preventive behaviour.
Efforts made in Lyme disease surveillance are starting to show some results. This year the majority of provinces are providing detailed case information, which will help identify new areas where Lyme disease is endemic and assist provinces in tailoring their preventive strategies.
The information will also provide a clear picture of the signs and symptoms of Lyme disease, information that is key for clinicians to properly diagnose it.
The final pillar focuses on increasing lab capacity, testing new diagnostic methods and carrying out research to generate new insights into effective diagnosis and treatment.
Under this pillar the agency is increasing testing capacity and quality by using state-of-the-art laboratory equipment. We recognize the challenges with current testing, particularly around detecting early Lyme disease, as the human body takes some time to develop antibodies to the bacteria.
The agency is committed to improving diagnostic testing. New methods are being evaluated and any that outperform current methods, the two-step method, will of course be adopted.
In the meantime we continue to recommend doctors diagnose patients on the basis of a full, wholesome, clinical assessment.
We recognize that laboratory technologies have evolved and will continue to do so in the future. The agency's national microbiology laboratory, in collaboration with the Canadian Public Health Laboratory Network and other stakeholders, will be updating our laboratory diagnostic guidelines in the near future.
However in doing so the agency faces a challenge. We can update the guidelines to reflect the current available evidence, but new evidence is needed to inform new diagnostic and new treatment methods. Therefore the agency is committed to continuing to work with medical professionals, patient advocacy groups such as the Canadian Lyme Disease Foundation and the Canadian Institutes of Health Research, and my colleagues on the video conference today to identify and address research gaps.
In closing, I would like to restate that the goal of the agency is to mitigate the impact of Lyme disease on Canadians. Through our collective efforts, Canadians will become more aware of the disease, how to recognize its symptoms, and the benefits from early treatment.
Together, we can reduce the severity of Lyme disease in Canada.
Thank you for your attention.
Mr. Steven Sternthal:
That's correct. So the current two-step testing focuses on one strain of the Borrelia, and is not as sensitive to picking up the many other bacteria that, of course, are carried by ticks. There's no question that there are multiple strains of Borrelia and multiple different bacteria that can be carried by a tick in wildlife. So we certainly concur that the association between this particular Borrelia strain with Lyme disease is quite well established, and the two-step testing has so far demonstrated the best way for us to minimize the false positives.
With regard to the tests available in the United States, they have been looked at very closely in the recent past. We'll continue to look at them, of course, because we do want, as I said, to bring the best methodologies forward in terms of the diagnostic testing.
There are really two issues that have been identified. One of them is around the interpretive criteria that the laboratory technical staff apply in interpreting the results. We feel that currently there's the potential for too many false positives in the way in which those criteria are implemented in the United States. So we're very much mindful of the limitations of the current testing. As a result, the agency, through our laboratory in Winnipeg, will in fact be investing in assessing those methodologies, the current ones in the U.S. and other ones that come online in the near future elsewhere, even in Europe. We'd love to cross the globe to find those tests, as we would also, ourselves in-house, help develop testing in the future. So it's very much on our radar. That's why it's one of the three key pillars of the action plan.
If we don't have a good diagnosis, it's very hard to provide early care and treatment. That's why we end up focusing clinicians on really diagnosing the person, and whether or not the person has been in an area of the country where they could have been exposed to ticks. They will look at how they're presenting. Of course, they'll need to rule out other health conditions that may also have some similar symptoms.
So we do appreciate that more work is needed to provide guidance to physicians and laboratories in that area.
Ms. Eve Adams (Mississauga—Brampton South, CPC):
Thanks very much for joining us here today.
Just following up on Ms. Davies' comments, the earlier witnesses were not as concerned about false positives and that we were overstating the incidence of Lyme disease. Rather, they were very concerned about all of these false negatives, where people had apparently taken the test and were told, categorically, that they didn't have Lyme disease. They travelled to the United States. They went through exhaustive tests there. They were told categorically there that, yes, they do have Lyme disease. They returned and their physicians continued to say to them that they didn't have Lyme disease. So that was the frustration and the challenge they raised.
Also, this is also what we've really been hearing from constituents over time. I'm certainly not a physician, and I don't mean to put an overabundant weight on these anecdotal representations. However, it's quite clear that these people are in pain. They are suffering. It's person after person coming forward saying he or she is not able to be diagnosed with Lyme disease.
I suppose part of our collaborative approach here, in working with all parties, is to really raise awareness about Lyme disease across the country, so that physicians are aware and are testing for this, and that they too take it into consideration. Some of our witnesses have indicated that no matter how they explained it, their physicians would say, no, you simply don't have Lyme disease.
So is there an approach for all these false negatives, or what is the best understanding at this point?
Dr. Marc Ouellette:
Very well. Thank you for the question.
Obviously, when comparing ourselves with the U.S., right off the bat, we have to multiply any investments by a factor of 10. Consequently, where we have spent $7 million, they have spent at least $70 million. In addition, the U.S. spends twice as much on research per capita than Canada does. Basically, then, after multiplying the amount by 10 and then 2, we are talking about 20 times what we invest in Canada.
We are discussing Lyme disease, but you should know that Lyme is the name of a small town in Connecticut. The disease has been rampant in the U.S. for much longer. A body of research has been built over time. And because of temperature changes, the carrier, meaning the tick, migrated north. So now the disease is endemic in Canada. Right now, the U.S. contributes more per capita to Lyme disease research than Canada does.
As far as international efforts go, there are many, and that applies to a number of areas including vaccines, HIV, Hepatitis C and antibiotic resistance. But, apart from the interaction between the researchers themselves, the level of collaboration between CIHR and the U.S. government is rather low, in terms of Lyme disease efforts.
Mr. Robbin Lindsay:
That's a very good question.
We have been doing research looking at the different strains of Borrelia burgdorferi, or genotypes, as they're called. There are minor differences in either the DNA of the organism or the amino acid. We know that there's a range of these different genotypes. We know from work done in the U.S. that there are differences in the rate of whether the strains will disseminate or not and maybe just cause a localized infection, depending on those genotypes.
The easiest source to find those isolates, to look at these genotypes, is to look at the ticks. When we do active surveillance for ticks or we go out in the field and collect ticks, either actively ourselves or through our passive system, we have these ticks that we can look at, the different strains, and we realize when we're looking at an analysis of those genotypes that we have many of the same genotypes that are present in the U.S. It's not surprising, because we feel that these ticks that we see in Canada come through the U.S. and establish populations here. I guess they are transplanted American ticks, in a way. So it's not surprising.
But we are finding that looking at those genotypes in populations that actually do establish, we are seeing some unique differences. We do realize that yes, we have differences in genotypes that come here, and those genotypes may present a disease in a different way, and we're starting to get a better understanding of that. But what we lack at the present time is an understanding of which strains are infecting individuals. So we can look at the ticks, but we don't know how the strains that are present in the ticks are going to present. We need to doing further research looking at the actual strains that are infecting individuals to get a better handle on here's what comes into Canada on an annual basis, here's what is infecting individuals, and here's the clinical presentation to put that whole piece together. Also, we need to look at how our diagnostic tests perform when these individuals are infected with a particular genotype. That's one of the missing elements that we need to do further research on.
Ms. Libby Davies:
There are a number of things here.
The first one, which is lines 12 to 14, is a fairly substantive change, because the original bill speaks about convening a conference, but in this amendment it says “or otherwise engage with the provincial and territorial ministers”. I think the problem here is that it sets up the possibility that there wouldn't be a conference and that there would be individual consultations. I believe that Ms. May has an alternate wording that includes both.
Because the main point here is that we don't want the stakeholders to be left out. If you remember, the witnesses were pretty adamant that whatever happened, they have to be at the table. I think that by having the words “or otherwise engage”, it leaves it such that there could be separate provincial-territorial consultations and there wouldn't necessarily be a conference.
That's one problem. I'm hoping that Ms. May might have some wording that she has worked on to kind of bridge the gap.
The other one that I think is a problem is the last one on G-3, where it says “management of Lyme disease, and the sharing of best practices throughout Canada”.
Now, it's good that the government amendment has taken out the words “current” in regard to “practices”, because, again, the witnesses sure didn't like that. But the government amendment does leave out the words “national standard of care”, and I'd like to move a subamendment that we insert these into the wording, so that it will also include “the management of Lyme disease, and the sharing of best practices throughout Canada, including a recommended national standard of care”. It's basically what it says in the bill before us.
Are there any thoughts or comments on amendment G-9?
(Amendment agreed to)
The Chair: Shall the title carry as amended carry?
Some hon. members: Agreed.
The Chair: Now we've basically gone through the bill, front to back, and then again, so now we have three more points here that I have to ask. Now we're on the entire bill.
Shall the bill carry as amended?
Some hon. members: Agreed.
The Chair: Now for the report. Shall I report the bill as amended to the House?
Some hon. members: Agreed.
The Chair: Shall the committee order a reprint of the bill?
Some hon. members: Agreed.
The Chair: That covers what we needed to do, and we're five minutes ahead of our plan, so we'll consider Bill C-442 dealt with and we'll report it back in due course.
Ms. May has a short comment, and then we're going to go in camera.