SINGAPORE - An independent committee has pointed to poor infection control practices at the Singapore General Hospital (SGH), which led to the hepatitis C outbreak in its wards earlier this year.
It also said the hospital was tardy in recognising the outbreak; its investigations were incomplete and it had delayed in escalating the incident, concluded the Independent Review Committee tasked to look into the spread of the hepatitis C virus in SGH's wards 64A and 67.
The outbreak affected 25 patients, eight of whom have died. The virus was directly responsible for, or contributed to, seven deaths.
The committee's report submitted to Health Minister Gan Kim Yong on Dec 5 and released yesterday also found gaps in the Ministry of Health's (MOH) infectious disease reporting system that needed to be tightened. Reports had trickled in to various departments in the ministry, but there was no one with oversight to see the big picture. This has since been changed.
The team headed by Professor Leo Yee Sin, the director of the Institute of Infectious Diseases and Epidemiology, found no evidence of deliberate reporting delays.
The committee looked at, and dismissed stealing of drugs, foul play and contaminated medical products as reasons for the hepatitis C outbreak. It concluded that the most likely cause was poor infection control.
Other factors that contributed to the outbreak include the high concentration of renal transplant patients, who were more susceptible to infection, in the affected awards. Also, the temporary relocation of the renal ward from Ward 64A to Ward 67 changed the workflow and increased the likelihood of the spread of the virus.
The committee had sent a team which made 18 visits to check SGH's practices, and found staff did not always adhere to established procedures, including hand hygiene, leading to the contamination of equipment, such as medical carts and trolleys, as well as surfaces, including walls. This was after the hospital had taken steps to tighten infection control to stop the spread of the virus.
Other factors that contributed to the outbreak include the high concentration of renal transplant patients, who were more susceptible to infection, in the affected awards. Also, the temporary relocation of the renal ward from Ward 64A to Ward 67 changed the workflow and increased the likelihood of the spread of the virus.
The committee had sent a team which made 18 visits to check SGH's practices, and found staff did not always adhere to established procedures, including hand hygiene, leading to the contamination of equipment, such as medical carts and trolleys, as well as surfaces, including walls. This was after the hospital had taken steps to tighten infection control to stop the spread of the virus.
The team found a spot of blood on the wall in the "clean" preparation room on Nov 2 that contained the hepatitis C virus. The virus can remain infective in the environment for several weeks and, in one reported case, up to a year.
The hospital also did not raise the problem to the ministry for more than three months. It started checking the high number of patients with hepatitis C in mid-May, but briefed the ministry's director of medical services Benjamin Ong only on Sept 3, after it had finished its investigations.
Even then, Associate Professor Ong found its investigations were "inadequate" in determining the severity and extent of the outbreak. He asked for an external party to review the seven deaths that had occurred then and for the SGH analysis to be verified by the Agency for Science, Technology and Research. He also suspended transplants at SGH.
He got the answers on Sept 17 and told the Health Minister the next day. The minister asked for a full briefing, after which he ordered that the matter be made public and an independent review committee be set up.
