Panel to review if there were gaps in SGH’s handling of outbreak
Health Minister Gan Kim Yong. Photo: Wee Teck Hian
SINGAPORE— The independent review committee looking into the Singapore General Hospital (SGH) hepatitis C outbreak will examine whether there are gaps in the hospital’s handling of the matter, including the timeliness of its response and how crucial information is reported, Health Minister Gan Kim Yong said today (Oct 9).
Since the news broke on Tuesday, many have questioned the handling of the matter and why it took so long for the public to be informed.
“SGH has provided the sequence of events and the actions taken by the hospital between April and August 2015,” said Mr Gan in response to media queries on the sequence of events. “This is an important area that the independent review committee will be looking into critically to determine whether there are gaps in the process, including the timeliness of SGH’s response, how crucial information is reported, and whether there are areas that need to be tightened and improved upon, such as safety protocols and information flow.”
The committee is expected to take two months to complete its work. Adding that the committee’s findings will be made public when they are ready, Mr Gan said: “If there are gaps, we will close them. If there are weak areas, we will correct them. And if there are shortcomings, we will improve. It is important that we remain transparent.”
Meanwhile, the vast majority of the 678 patients who could have been exposed to the outbreak have been contacted to go for screenings, with 32 yet to be reached. In an update tonight, SGH said it has managed to contact 646 of these patients, of whom 585 have set appointments for their tests.
So far, 186 patients, as well as 202 out of 273 hospital employees who had worked at the renal ward 64A — or Ward 67 when the actual ward was undergoing renovations — have been screened. Results of the tests will be available after a week. The hepatitis C virus has an incubation period of between two weeks and six months.
The unprecedented viral outbreak, which was made public on Tuesday, is possibly due to a lapse in the use of multi-dose medication vials. The patients who are to be screened comprise those who had been admitted to the affected ward from January to June.
The outbreak has infected 22 patients, with the first case being detected on April 17. Eight of the 22 affected patients have died. Among these deaths, four were linked to the viral infection, while a fifth is under review. Two of the remaining 14 survivors are still hospitalised.
Meanwhile, 24 more people — bringing the total number to 181 — who did not stay in the renal ward during that period have made enquiries about the hepatitis C cluster. “The hospital reassured them that patients in other wards and visitors need not be screened as the hepatitis C virus is not air-borne,” said an SGH spokesperson.
The hospital today conducted a briefing and a media tour of its premises, with its staff showing how infection control is done, including measures such as a month-long orientation for new staff, surprise audits and regular walkabouts by senior management members who would gather feedback from frontline workers.
Every month, the renal, oncology and haematology units, as well as the Intensive Care Units and Immediate Care Areas are audited for infection control. Other units are checked annually. Hygiene practices are also conveyed through pamphlets, and posters put up throughout the hospital and on its shuttle buses. There are also various avenues for staff and patients to provide feedback. Still, SGH medical board chairman Professor Fong Kok Yong said, “no system is perfect”.
Apart from stopping the use of multidose vials throughout the hospital since June 23, SGH has also tightened its audit procedures for hand hygiene and environmental cleanliness, said Prof Fong. He added that his team was “quite confident” that environmental factors did not have a role in the outbreak.
MULTIDOSE VIALS UNDER SPOTLIGHT
Multidose vials, which typically hold several doses of liquid medication that may be shared by multiple patients, have come under scrutiny as a possible source of the viral outbreak.
Despite the World Health Organization’s advisory against the use of multidose vials where possible, a small number of drugs and vaccines are still administered through such vials “because there is no better alternative” in the market, said Tan Tock Seng Hospital’s (TTSH) medical board chairman Associate Professor Thomas Lew, who was also at the SGH briefing.
In TTSH for instance, 13 out of 700 types of “injectable agents” come in multidose vials. Of these, eight — including insulin — come in containers that are shared among multiple patients. Prof Lew said the hospital is reviewing the use of multidose vials following the outbreak.
In the aftermath of the outbreak, various hospitals said they have reminded staff on the need to adhere to medication administration protocols and infection control practices. The KK Women’s and Children’s Hospital said its staff have also been reminded of the “importance of observing sterility and correct aseptic techniques”. A Khoo Teck Puat Hospital spokesperson said that staff training on aseptic management and infection control strategies are being conducted and regular infection control audits are also carried out on the wards.
The National University Hospital (NUH) said its renal patients are routinely investigated for any symptomatic liver disease or abnormal liver function blood tests results. “We have not observed any unusual trends in (hepatitis C virus) infections,” it said.
NUH said that when the independent review committee’s findings are made available, it will review its practices and work closely with MOH to adopt any recommended changes.
Full timeline of actions taken by SGH to investigate hepatitis C cases:
• Apr: 1st case diagnosed
– HCV incubation period : 2 weeks to 6 months
– HCV carriage up to 20 years before symptoms
• May : Renal doctors noted increase in frequency
– Heightened awareness – More HCV RNA tests done
– Reinforcement of Infection Control
• June: Infection control team activated.
– Renal ward stopped use of multi-dose vial (9 Jun)
– Stopped use of multi-dose vial in all wards (24 Jun)
• July: Phylogenetic tests carried out for the first time in SGH lab
– Tests were done in 3 batches, as cases surfaced
– Some past Hep C positive cases were also tested as control group
– Results came out over period of 6 Jul to 6 Aug
– Evidence that this is a Cluster of cases
• Aug: Internal review by SGH senior clinicians
• Late Aug: Informed MOH of the cluster
• Sep 3: Director of Medical Services (DMS) recommends further investigation and verification
• Oct 6: SGH makes public the cluster of infections
– MOH announces the independent review committee
ADDITIONAL REPORTING BY VALERIE KOH
