Hep C outbreak at SGH: Health Minister apologises
Independent review committee points to safety lapses at Singapore General Hospital and gaps in Ministry of Health's infectious diseases reporting system. It ruled out foul play in the case in which 25 patients were infected with hepatitis C, with five deaths possibly linked to it
The Health Minister made a rare apology yesterday.
Mr Gan Kim Yong spoke after an independent review committee (IRC) into the hepatitis C infection at Singapore General Hospital pointed to lapses at SGH and gaps in the Ministry of Health's (MOH) infectious diseases reporting system.
"I would also like to take this opportunity to apologise to our patients and their family members, and I'm sorry for the lapses in the system," he told reporters after the IRC's announcement yesterday.
Twenty-five people were infected by the virus between April and August this year at SGH. Eight of the patients died and five of the deaths could be linked to the infection.
The IRC said there were gaps at SGH in infection prevention and control practices, in the failure to recognise the outbreak, inadequate investigations and delays in notifying the higher-ups within the hospital and at the Health Ministry. (See report on right.)
The committee also said that at the ministry, reports had trickled in to various departments, but there was no one with oversight who could see the big picture.
The team, headed by Professor Leo Yee Sin, the director of the Institute of Infectious Diseases and Epidemiology and which includes international experts, said it also found no evidence of deliberate delays in reporting the outbreak to the Health Minister.
The Minister was told on Sept 18, a week after the General Election.
SGH CEO Professor Ang Chong Lye also apologised.
He said: "My colleagues and I deeply regret what happened.
"I would like to apologise to the patients and their families who have been affected by the outbreak.
"We will learn from this, improve and work tirelessly to ensure that our patients are always safe in our care."
Mr Gan also announced yesterday that his ministry, SGH and SingHealth will each appoint a human resource panel to determine who will be accountable for the outbreak.
The panels will be looking separately into the roles, responsibilities and actions of all key staff involved and assess if disciplinary action need to be taken.
Mr Gan also said that MOH will be setting up a taskforce, led by Minister of State for Health Chee Hong Tat, to "look into enhancing our surveillance and detection and response to infectious disease outbreaks in the community and hospitals".
Mr Gan said his ministry has designated its Communicable Diseases Division to be responsible overall for infectious diseases in both the community and within hospitals.
What went wrong
1. Bad hygiene practices by Singapore General Hospital (SGH) staff at the renal wards resulted in contaminated equipment such as medical carts and trolleys, and other surfaces.
Blood specks with the hepatitis C virus (HCV), which can survive for up to a year, were found on the wall in the "clean" preparation room.
Independent review committee (IRC) member Professor Lim Seng Gee, who heads the hepatology services at the National University Hospital (NUH), said a drop of blood, which is around 50 microlitres, will contain at least five million of HCV.
"So you can imagine the high level of virus in that blood sample," he said.
2. There was inefficient workflow and disorganisation in the two affected wards after patients were moved en bloc from Ward 64A to Ward 67 to facilitate renovation there. The Ward 64A staff were not familiar with the layout of Ward 67.
3. There was a high concentration of renal transplant patients in the affected wards, who were at risk because of their suppressed immune system, making them more susceptible to infection.
4. Although SGH recognised that there was something amiss in May, it was slow to escalate the problem to SingHealth, the healthcare cluster to which it belongs, and the Ministry of Health (MOH).
Asked if SGH should have escalated the matter when there were only four cases, Prof Lim said: "It's always easy in retrospect to say they should have done this... but imagine the clinicians handling cases of jaundice and hepatitis C in rapid succession. I think you need to keep in mind the ministry did not have a strategy to deal with this. It was a two-pronged problem."
5. At MOH itself, there was also no single division with clear oversight and responsibility over outbreaks of unusual infections within hospital settings.
Police have ruled out foul play and have submitted their findings to the Attorney-General's Chambers and the IRC.
- Review infection control standard operating procedures (SOPs) and practices to reduce risk of contamination and ensure clean and disinfected environment.
- Ensure the hospital follows closely to standard precautions for infection control laid out by the US Centers for Disease Control and Prevention (CDC) and adapt them to local context.
- Strengthen monitoring and supervision to make staff comply with practices.
- Strengthen national notification and surveillance system for acute hepatitis C virus.
- Have only one dedicated team or division within the ministry to carry out surveillance and outbreak investigation.
- Remind healthcare professionals to remain vigilant to unusual medical events.
- Strengthen the escalation and communication processes for healthcare associated infections, especially unusual ones within and between medical hospitals, public healthcare clusters and MOH.
Both MOH and SGH have accepted the findings and recommendations of the IRC.