Singapore

Hospital apologises for four deaths and 22 infections in hep C outbreak

Four die, 22 infected in hep C outbreak at SGH. Hospital apologises, says investigation underway

It should not have happened.

Especially in this day and age where screening is supposed to be more vigilant, doctors say.

Yet, there was an outbreak of the hepatitis C virus in the renal ward of the Singapore General Hospital (SGH) that led to 22 patients being infected.

Among them, eight have died. In four of those cases, hep C is suspected to have contributed to the deaths. Three of the others did not die of the disease, while one other fatality is being checked for the hep C virus, the hospital revealed at a press conference yesterday.

(Above) A sample of a multi-dose vial.

Initial findings pointed towards intravenous (IV) injectable agents as the source of the infection. These are stored in multi-dose vials.

In normal practice, fresh syringes and needles are used to administer doses to different patients. Those which are used have to be disposed safely.

Following the investigation, the hospital took precautionary steps by stopping the use of these multi-dose vials - first within the ward itself and then hospital-wide.

The infection is impossible if everyone follows the protocol, said Dr Desmond Wai. The gastroenterologist at Mount Elizabeth Novena Specialist Centre explained: "Multi-dose medicine has been used for a long time; it is quite common for medicine to come in large quantities."

But he stopped short of calling it possible sabotage.

"MOH (Ministry of Health) has appointed external experts to investigate. We should listen to them as they will be objective. If the breaking of protocol was indeed the cause, then the committee needs to explain to us how it could have happened," he said.

It all began in early June, when SGH discovered an increased number of hep C virus infections in its renal ward.

The hospital stepped up checks for the virus in patients with abnormal liver function tests in the same ward and found 22 patients infected. (See timeline on facing page.)

Of the 22 infected, the youngest is 24, and the rest are between 50 and 60.

All have some form of kidney disease and most had past history of end-stage renal failure and/or renal transplant done. They were admitted at the newly renovated Ward 67 between April and June.

Nine underwent kidney transplants within the past year and 10 had transplants more than a year ago. There were also three non-transplant renal patients among the 22.

Nearly half had recent high-dose immunosuppression therapy for transplant rejection.

The hospital said four of those who died had multiple co-morbidities (presence of one or more additional disorders or diseases co-occurring with a primary disease or disorder) and severe sepsis and the hospital was "not able to rule out the possibility that hep C virus infection could have been a contributing factor".

POLICIES IN PLACE

Another three deaths were "thoroughly evaluated" and "no link to the hep C virus infection has been established".

Group chief nurse at SingHealth, Dr Tracy Carol Ayre said: "There are policies in place that govern how intravenous drugs or drugs in general are prepared, diluted and administered and that includes your infection control practices, hand hygiene, new syringe, new needle, swabbing of the bungs."

Speaking to The New Paper, Dr Jarrod Lee, a gastroenterologist at Mount Elizabeth Novena Centre, said that although such an infection is not common within a hospital setting because of the stringent guidance and protocol, "this does not change the fact that this group of renal patients remains at high risk for hep C infection, especially when they are going through hemodialysis. Hepatitis C is transmitted via blood."

He added: "To be fair, the time it happened and the period it took for SGH to pick it up and carry out investigations was quite fast."

MINISTER CONCERNED

But Health Minister Gan Kim Yong still expressed his concerns with the occurrence of the hep C cases in SGH .

He has appointed an independent review committee to "ensure an objective and thorough review of the incident so that we can also identify possible weaknesses in our infection control system".

"The committee will take about two months to complete this work. When the review is completed, we will share the outcome with the public as well as with our healthcare clusters," he said.

SGH CEO, Professor Ang Chong Lye, apologised "unreservedly for the grief, pain and anguish this has caused our patients and families".

He added that SGH is in touch with the affected patients and their families, and will "continue to provide full support and the appropriate care in managing their condition".

Doctors in private practice said the apology from the management of the hospital yesterday was "indeed a big deal".

"What's encouraging here is that the higher-ups at the hospital is taking ownership of the issue and this gives me the confidence that the hospitals are taking on the responsibility of patient safety," Dr Lee said.

"The committee will take about two months to complete this work. When the review is completed, we will share the outcome with the public as well as with our healthcare clusters." - Health Minister Gan Kim Yong (above)

HOW SGH TOOK ACTION

What happened?

In June, as soon as the Singapore General Hospital (SGH) was aware of the cluster of cases of hepatitis C virus infection in Ward 67, it stepped up checks for the hep C virus infection in patients in the ward with abnormal liver function test results and started thorough investigations. To date, 22 patients who were hospitalised between April and June have been diagnosed with the infection.

How many patients died from the infection?

Four. They had multiple co-morbidities and severe sepsis, the presence of harmful bacteria and their toxins in tissues, typically through infection of a wound. SGH was unable to rule out the hep C virus infection as a contributing factor. A fifth fatality is being reviewed.

What could be the source of the infection?

While SGH is still investigating all possible sources, it believed, from initial findings, that the infection could have been spread through the use of "intravenous injectable agents", which can be medicine kept in multi-dose vials.

Is the ward contaminated?

As hep C virus infection is not airborne like SARS (severe acute respiratory syndrome), cleaning up the facility is irrelevant in this context. Nonetheless, SGH has tightened its infection control practices by conducting an additional round of environmental cleaning. It is also screening the care team providing direct care to renal patients, including doctors and nurses. Other doctors who covered the ward during the period are also screened.

Do family members of those affected have a case against the hospital?

Lawyers say family members can explore that option, but it is not so simple to establish negligence. Mr Steven Lam from Templars Law said the courts will look at whether there was a breach of duty. In this case, it means whether it was foreseeable that medical staff could have reasonably known that the hep C virus was floating around.

What steps are the hospital taking?

SGH has been conducting investigations ever since the first seven cases appeared. The infection control team was called in to review and examine the hospital processes and all possible sources of infection.

After investigations showed that one of the sources could have been intravenous injectable agents, SGH stopped multi-dosing, a long accepted practice, first within the affected ward and later throughout the hospital. All patients with abnormal liver function test were also screened.

All about hepatitis C

WHAT IS HEPATITIS C?

It is a liver disease caused by the hepatitis C virus (HCV).

The virus is blood-borne, and the most common modes of infection are through unsafe injection practices, inadequate sterilisation of medical equipment, and transfusion of unscreened blood and blood products.

Many who are chronically infected develop liver cirrhosis (scarring of the liver) or liver cancer.

However, HCV is rarely associated with acutely life-threatening diseases.

WHAT ARE THE SYMPTOMS?

Hepatitis C infection usually causes no symptoms in the acute stage, although a small number may see the following symptoms in the first three months after being exposed to the virus: Fatigue, nausea or poor appetite, stomachache, dark-coloured urine, jaundice, fever, and muscle and joint pains.

At the chronic stage, symptoms include: Bleeding and bruising easily, itchy skin, fluid accumulation in stomach, swelling in legs, weight loss, spider-like blood vessels on skin and confusion.

HOW IS IT TRANSMITTED?

The hepatitis C virus is transmitted mainly by blood-borne routes, although it can also be spread through other body fluids like semen.

The hepatitis C virus infection is not airborne.

HOW IS IT TREATED?

There is no vaccine for hepatitis C, but treatment is available to prevent the onset of complications, such as cirrhosis, which typically take years to occur if left untreated for a prolonged period.

Anti-viral medicine can cure 90 per cent of those infected, according to the World Health Organisation.

Source: SingHealth, WHO

SGH: GET SCREENED

SGH is encouraging all patients admitted to Wards 64A and 67 from January to June this year to come for screening.

Patients who are unsure if they are affected may either call 6321-3356 or leave a message via sms to 8799-2736. They can also e-mail check@sgh.com.sg with their names and NRIC numbers.

Singapore General Hospitalhepatitis CoutbreakDeathHep CMulti-dose vialsUncategorised