Review Committee finds fault with SGH’s practices on Hepatitis C outbreak

Photo – The Straits Times, Tan Weizhen

The report by the Independent Review Committee (IRC) has found that sloppy practices, including poor infection control, led to the Hepatitis C outbreak in Singapore General Hospital’s (SGH) renal wards 64A and 67 where 25 patients were infected between the period of April and June 2015.

The report by the review committee was submitted to the Ministry of Health (MOH) on 5 December and has been accepted by the ministry.

The independent review committee headed by Professor Leo Yee Sin, the director of the Institute of Infectious Diseases and Epidemiology, was announced by MOH on 6 October to review the report by SGH submitted to the ministry on 24 September. The review committee was convened on 28 September by the Minister of Health, Gan Kim Yong.

The review committee concluded in its report that a combination of overlapping factors was the most likely explanation for the outbreak. Immuno-compromised kidney transplant patients were highly susceptible, and the introduction of the virus led to acute infections with extremely high quantities of the virus in those patients.

Multiple exposures of the infected patients to intravenous medication and/or blood tests exacerbated the risk of virus spreading through the gaps in infection control practices. Lapses in disinfection protocol and the prevention of environmental contamination, as well as the new working environment in which the staff were operating (after they had been shifted from one ward to another) also potentially facilitated the transmission of Hep C in the two affected wards.

The review committee also found fault with SGH’s detection procedures, as it did not recognise the outbreak in a timely manner. “While SGH commenced investigations into the HCV cluster from mid-May, and implemented enhanced infection control measures from early June 2015 onwards which were instrumental in slowing the spread of infection, the IRC is of the view that the outbreak was not investigated and managed optimally,” said the report.

“The absence of an established framework for unusual and unfamiliar events resulted in delays in escalating the matter from SGH to SingHealth, from SGH to MOH, and within MOH.” – Review committee

The committee went on further to absolve MOH’s role in the incident by stating that there is no division within MOH which has clear responsibility to deal with outbreaks of unusual Health Associated Infections (HAIs) and how this hindered MOH’s ability to respond in a timely way to the unexpected event.

MOH own press release also states, “MOH notes that the IRC had found no evidence that SGH or MOH staff deliberately delayed escalating the outbreak or in informing the Minister for Health. The IRC agreed that the decision of the DMS on 3 September to ask SGH to complete key pieces of investigation was professionally appropriate and valid.”

The committee also wrote, “Overall, while there were gaps in identification, management and reporting of the outbreak, there was no evidence to suggest that escalation to DMS and subsequent notification of the Minister had been deliberately delayed.”

MOH and SGH only held a press conference on 6 October to publicly announce that there had been a Hepatitis C outbreak in the renal ward after the months have passed since the initial detection of the first few infections in May/June.

Of the 25 affected transplant and renal patients, eight have died. The committee said the HCV infection was a likely contributory factor to the death of seven cases instead of the initial five said cases.

The executive summary of the report can be found below.

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