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MOH informed of Hepatitis C infections by June, not late August

The report by Independent Review Committee (IRC) on the Hepatitis C outbreak at Singapore General Hospital's renal ward, which took place between April and June this year is finally out. The outbreak has so far been deemed to have 25 patients infected and claimed seven lives (eight if the suspected case is to be included).

The report highlighted that it was the practices by the renal ward, compounded with various factors which resulted in the outbreak. Apart from addressing the possible cause of the outbreak, the IRC also noted that the delay in the notification is attributed to SGH's poor process in identifying the Hepatitis C infection as an outbreak promptly.

What the official narrative and media reports have reiterated so far, is that Ministry of Health (MOH) and the Minister of Health, Gan Kim Yong were was only informed on 3 September and on 18 September respectively. The Minister only then instructed that an independent review committee be set up after his briefing with SGH and for the hospital to make public its preliminary findings on 6 October.

This stance has been used to justify the alarming delay in public notification of the Hepatitis C outbreak and the call out for patients to be examined for possible infection through their stay at the affected wards.

However, MOH had never denied that it had already acknowledged that it had been notified by the SGH laboratory of the cases as all acute Hepatitis C infections must be reported within 72 hours. Just that, the ministry claimed that as the patients did not have symptoms such as jaundice, the cases were not classified as acute and, therefore, were not flagged in its weekly infectious diseases bulletin.

MOH defended its classification of the infection on its website,  "However, at the point of reporting, the cases did not have symptoms such as jaundice nor history of exposure to suggest that they were acute." as an explanation of why MOH did not know about the Hepatitis C cluster in SGH earlier.

According to the timeline set out by the IRC, three separate departments from the MOH were being informed of the unusual number of Hepatitis C infection by early June.

It has been established as a fact that the Hospital Services Department (HSD) had been notified of the cluster of Hepatitis C transmission on 26 May, and both Communicable Diseases Division (MOH-CDD) and the Clinical Quality, Performance and Technology Division (MOH-CQPT) were informed by HSD on 4 June. HSD had requested for CDD's follow up on the matter.

By the time all three departments were informed, 7 cases at the hospital have been confirmed by the laboratory. For a comparison of magnitude, there were in total, 4 cases of Hepatitis C infection in 2014 and 2 cases in 2013. The 7 cases at that point of notification happened just within the span of two months from the same location and by late August, there have been 12.

While SGH might be faulted for not classifying the infection as a viral infection or not coming up with a full investigation over the outbreak to the satisfaction of MOH, but the truth is that departments within MOH were informed of the unusual number of outbreak way in early June. Why were alarm bells not ringing at this point for the departments and why did they not see this as a public health concern that the patients ought to be informed of a possible infection and arrange for screening?

A medical practitioner whom The Online Citizen (TOC) spoke to noted that the delay in screening would have an effect on the survivability of the infected, as the early the treatment, the higher chances that the patient would have to recover from the infection. A public acknowledgement of the Hepatitis C outbreak being the fault of the hospital would also be crucial for the patients as they would be able to go for immediate treatment without considering the cost of the treatment. It cost about USD$80,000 for a full 3-month treatment.

What followed the period of investigation by SGH is also bewildering, the parties involved were already in preparation to go public with the news of infection and to update MOH on the findings on 18 August.

The Director of Medical Services (DMS) was notified on 1 September and then briefed by the staff from SGH. Instead of going public with the information and arranging for the screening of patients who were from the affected wards. A*star was called to double check on the SGH lab results and more work were tasked to be done under the instructions of DMS. Coincidentally, the General Election 2015 was on-going during that period. However, IRC has assessed DMS's choice of action to be appropriate and necessary.

By the time of the public announcement was made by MOH and SGH about the Hepatitis C outbreak, four months have passed since the first notification to MOH and there had been 25 infections with seven deaths confirmed to be linked with the infections. Thousands of people who have passed through the wards were called back months after their treatment so as to be screened for possible infection of Hepatitis C.

It is interesting to read how the committee had SGH pinned for the delayed notification for not having a system to report possible outbreaks to MOH when SGH did report all the Hepatitis C cases to MOH according to standard procedures.

It is, however, hard to imagine how departments from MOH did not actively act upon information in regards to the Hepatitis cases as the number of cases within the short period in the same location would likely indicate an outbreak of sorts. And also to disregard the interest of the patients by not going public earlier with the information.

Apart from the investigation on the timeline of correspondence between SGH and MOH. There does not seem to be any investigation to why the individual departments did not raise the alarm on a possible outbreak to the Minister or DMS by June or July and to look into what consideration did the department heads adopt so as take the course of actions which resulted in the substantial delay in public announcement of the outbreak. Facts that could be revealed only by a committee of inquiry where individuals cannot be prosecuted for testimony provided in court.

But to no surprise, IRC wrote, "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.”

IRC concluded on the delay in notifications, "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."

And now, everyone is cleared of responsibility except for the staff heads and nurses in SGH.

The timeline in the annex G of the 79 page report by the IRC,

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