SINGAPORE - Poor infection prevention and control measures at the Singapore General Hospital (SGH) were the main cause of the hepatitis C outbreak there earlier this year, the Independent Review Committee (IRC) that was tasked to look into has concluded.
It has ruled out other possibilities such as drug diversion, foul play or sabotage, and contaminated medical products.
In its report released on Tuesday (Dec 8), the committee found that some staff at SGH did not follow established standards for procedures such as blood taking, administering intravenous medication, and waste disposal.
This could have led to cross-contamination of equipment such as trolleys and surfaces.
All the patients in the affected wards had many exposures to intravenous medication or laboratory tests that required blood taking, which increased their risk of getting hepatitis C, which is a blood-borne virus.
The majority also had weakened immune systems following kidney transplants, which made them more susceptible to acute infections with extremely high quantities of the virus.
The IRC noted that while SGH has several commendable practices, such as consistent verification of patients' identity prior to performing procedures and clear structure for skills development of their nursing workforce, there were some gaps in infection prevention and control practices in the two wards (64A and 67) in SGH that suffered the outbreak.
The IRC, chaired by Professor Leo Yee Sing, director of the Institute of Infectious Diseases and Epidemiology, submitted its report to the Ministry of Health on Dec 5.