Thursday 8 October 2015

SGH Hepatitis C outbreak from April to June 2015

22 patients in SGH renal ward infected with hepatitis C; 4 patients have died
By Lee Min Kok, The Straits Times, 7 Oct 2015

The Singapore General Hospital (SGH) has apologised for an outbreak of the hepatitis C virus in one of its renal wards, which has led to 22 patients being infected with the virus.

Of the 22, four - who were also ill with other serious conditions - have since died.

At a media briefing on Tuesday (Oct 6) afternoon, the hospital said it had noted an increased frequency of hepatitis C virus infections (from an average of two to four infections per year to five in a few weeks) in early June in the ward.

It prompted SGH to step up urgent checks for the virus in patients with abnormal liver function test results staying in the same ward.

Investigations into the cause of the infections are ongoing, but initial checks have indicated that the source could be attributed to "intravenous (IV) injectable agents".

Independent Review Committee Report of the Hepatitis C outbreak at SGH

In a separate statement, the Ministry of Health (MOH) said it has set up an independent review committee, tasked to determine if SGH had taken all possible measures to identify the possible lapses, as well as remedy any weak points in the overall workflow with regard to infection control.

Health Minister Gan Kim Yong said: "I am gravely concerned and disappointed with the occurrence of the cluster of hepatitis C cases in SGH. My thoughts are with the affected patients and families.

"MOH takes this incident very seriously...I have decided to appoint an independent review committee to provide added assurance that there is an objective and critical review of the internal findings by SGH."

Hepatitis C, which causes chronic liver cancer, is mainly transmitted through blood-to-blood contact associated with IV drug use, poorly sterilised equipment and transfusions.

About 0.3 per cent of the general population in Singapore suffer from it.

SGH chief executive officer Ang Chong Lye said: "We would like to apologise unreservedly for the grief, pain and anguish this has caused our patients and their families.

"Patient safety is non-negotiable. What happens to our patients is always our responsibility. We will spare no effort in reviewing our processes and examining all possible sources of infection to prevent recurrence."

Prof Ang added that SGH is in touch with the affected patients and their families, and will "continue to provide full support and the appropriate care in managing their condition".

The 22 patients were admitted and stayed in the newly-renovated Ward 67 between April and June this year. Ward 64A, the original renal ward, was under renovation.

All were suffering from some form of renal disease, with the majority having undergone renal transplants.

Professor Fong Kok Yong, chairman of the SGH medical board, stressed that while there has been no conclusive evidence to what caused the infections, the hospital had taken "aggressive" steps to rectify any shortcomings detected during the ongoing investigations.

SGH has since taken added precautions to fortify its infection control measures, including "stopping long established and accepted practices in healthcare institutions" such as multi-dosing.

The hospital's renal care team, including doctors and nurses, have undergone hepatitis C screening. The screening will also be extended to other doctors who covered the ward during the affected period.

Meanwhile, SGH has been contacting patients who were admitted to Wards 64A and 67 from the start of the year to June for screening.

No new hepatitis C cases related to admission outside the affected April-June period have been identified.

Establish what happened, learn from experience, do better: PM Lee on SGH Hepatitis C cluster
Speaking at the official opening of Ng Teng Fong General Hospital on Saturday (Oct 10), PM Lee Hsien Loong says the healthcare system needs to be always open and transparent to maintain public confidence and trust.
By Olivia Siong, Channel NewsAsia, 10 Oct 2015

Prime Minister Lee Hsien Loong said on Saturday (Oct 10) that authorities always have to be open and transparent so as to maintain public confidence and trust in the healthcare system.

Healthcare authorities need to establish what happened, put things right and learn from experience when something goes wrong, he said at the official opening of Ng Teng Fong General Hospital.

Referring to the recent Hepatitis C cluster at a renal ward at Singapore General Hospital (SGH), PM Lee said: "When something like this happens our approach must always be first to put things right, to find out what's wrong, to put things right, to safeguard the health and well-being of patients."

"Establish what happened, learn from the experience to improve and do better in future. And we also always have to be open and transparent with the public and with the patients about what has happened," said Mr Lee. "Because we must maintain public confidence, and trust in the healthcare system."

Mr Lee said though he cannot say yet what happened in the case of the SGH Hepatitis C cluster, this is the approach the Health Ministry is taking in its investigation.

It was reported on Tuesday that 22 patients were diagnosed with the virus. Among them, four have died, possibly from the virus. The Ministry of Health said on the same day that it had convened an independent committee to provide an “objective, critical” review of the incident to prevent future occurrences, adding that the committee would take about two months to complete its work.

The cause of the infection cluster has not yet been uncovered. SGH had on Friday issued a timeline of actions it took after it discovered a spike in Hepatitis C infections in its renal ward.

As for the new Ng Teng Fong General Hospital and Jurong Community Hospital, the hospital's CEO Foo Hee Jug said the SGH incident while unfortunate is also a reminder to step up vigilance.

"We have gone around and we briefed our people that there must be an uncompromising adherence to infection control protocol and we remind people that it is really very important. So this is a good reminder for all of us to step up our vigilance. This is a good reminder that simple practices can actually lead to some of these infections that we have to be careful about," said the CEO of JurongHealth, Foo Hee Jug.

The hospital, which started its operations in June, said it already has processes in place which are equivalent to those in many other hospitals.

Independent panel to review SGH response to hepatitis C cases
The Straits Times, 10 Oct 2015

Whether Singapore General Hospital (SGH) was timely in reporting information will be one of the issues which the Independent Review Committee, tasked with investigating how hepatitis C infections there occurred, will examine.

Health Minister Gan Kim Yong, stressing the importance of transparency, said yesterday that the committee would critically look into the timeline of events provided by SGH to see whether there were gaps in the process.

These include "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".

On Tuesday, SGH made known that 22 kidney patients had contracted hepatitis C infections while receiving treatment in the hospital. It first suspected the cases were linked as early as mid-May though tests confirmed this only later.

It informed the Ministry of Health (MOH) in late August and briefed the minister on Sept 25.

On Wednesday, MOH released a sequence of events in response to media queries on why SGH took so long to make the information public.

In his statement, 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. We will share the findings of the Review Committee when they are ready."

MOH told of hepatitis C cluster at Singapore General Hospital in late August
Ministry gives detailed timeline of events relating to the SGH cases
By Seow Bei Yi and Linette Lai, The Straits Times, 8 Oct 2015

It was in late August that the Singapore General Hospital (SGH) reported to the Ministry of Health (MOH) it had identified a cluster of 21 hepatitis C cases and suspected they were linked.

On Sept 3, after reviewing SGH's report, Associate Professor Benjamin Ong, the director of medical services (DMS) at MOH, met SGH clinicians.

They told him tests showed the virus in the 21 cases was related. They also said they had taken enhanced control measures and noted there had been no further cases after June 24.

Dr Ong then asked for specific steps to be taken, including confirmation by the Agency for Science, Technology and Research (A*Star) of SGH's findings, screening for staff who had been exposed, and external representation on the committees being set up by the hospital to review its medical and patient safety processes.

Dr Ong asked that the work be done expeditiously, and no later than two weeks.

The ministry on Wednesday (Oct 7) released this information, giving a detailed timeline in response to queries on why it had taken so long to inform the public of the cluster.

In mid-May, SGH had suspected that kidney patients might be contracting the liver infection while in hospital. Its tests showed the patients were infected from the same source, though that has not been found. Eight patients died, with four deaths thought to be linked to the hepatitis C infection.

MOH was notified of the 22nd case on Sept 21.

Following their meeting on Sept 3, this was the timeline of what next took place:

• On Sept 4, an MOH team visited the renal ward (Ward 64A and 67) and were taken through the processes by SGH.

• On Sept 7, an A*Star laboratory confirmed SGH's initial findings that the 21 cases were related.

• On Sept 9, SGH began screening all doctors and nurses who had taken care of the patients. Altogether, 76 staff members were screened and found negative for hepatitis C.

• The Medical Review Committee and Quality Assurance Review Committee also met in September.

• On Sept 18, Health Minister Gan Kim Yong was told about the cluster. He requested a briefing from SGH, who asked to see him on Sept 25 to give them time to complete their investigations and report. After the briefing, Mr Gan instructed that an independent review committee be set up, and for SGH to make public its preliminary findings.

• On Sept 28, the members of the Review Committee were appointed by Dr Ong, comprising clinicians from different disciplines.

• On Oct 6, SGH held its media briefing on the cluster.

The ministry said in its statement on Wednesday: "In the investigation, the primary consideration has been to try to get to the root cause of the issue as soon as possible, exploring all possible angles, to prevent recurrence. At the same time, the teams from SGH and MOH were mindful of the need to make public the cases as soon as preliminary investigations were completed."

It also said on Wednesday that it had previously been notified by the SGH laboratory of the cases as all acute hepatitis C infections must be reported within 72 hours.

However, 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 said it had reclassified those cases and would update the bulletin.

The cause of the infections is still under investigation, with the use of multi-dose vials - in this case to deliver insulin - under suspicion.

At least one hospital, Mount Elizabeth Novena Hospital, is already starting to review its practices for multi-dose vials, said Dr Leong Hoe Nam of the Rophi Clinic there.

"I think all of us have a duty of care to review our practices, to make sure that we're doing things right," said Dr Leong.

Multi-dose vials hold more than one dose of medication and can be shared between two or three patients. Brand new needles and syringes are always used to extract the contents.

The Ministry of Health (MOH) has been informed of a cluster of 22 cases of acute Hepatitis C Virus (HCV) amongst...
Posted by Ministry of Health on Tuesday, October 6, 2015

In early June 2015, we noted an increased frequency of newly-diagnosed hepatitis C virus infections in a renal ward. A...
Posted by Singapore General Hospital on Tuesday, October 6, 2015

SGH hep C outbreak: SGH's delay raises questions on info flow
By Salma Khalik, Senior Health Correspondent, The Straits Times, 9 Oct 2015

On Tuesday, Singapore General Hospital (SGH) called a press conference to inform the media and the public that 22 patients had been diagnosed with hepatitis C between April and June while they were in its renal ward. One was likely the index patient who brought the virus into the hospital. The other 21 must have been infected there.

The first case was diagnosed on April 17, and by the end of May, eight of its kidney patients were confirmed to have this virus, which could lead to liver disease.

Why did it take so long before the public was informed?

First, a bit of background.

Hepatitis C is a serious viral disease that can lead to liver failure, so it is obligatory for doctors and laboratories to inform the Ministry of Health (MOH) of all diagnoses within 72 hours. Such infections are also rare, with only six cases last year and two in 2013.

MOH explained that it lists only acute cases, that is, when someone has symptoms; and not chronic cases where they show up only in blood tests. This was why it had not reacted to the earlier reports of hepatitis C that it received from the SGH laboratory - they were classified as chronic. But the MOH now says that it will reclassify them as acute infections.

However, none of this explains SGH's slow reaction since the first case was diagnosed.

ST's Health Correspondent Salma Khalik asks why it took so long for Singapore General Hospital to react to the Hepatitis...
Posted by The Straits Times on Thursday, October 8, 2015

The hospital had told the media: "Full investigations and involvement of our infection control team started the moment we noticed a clustering of seven cases within four weeks, which is unusual."

According to MOH, SGH gets two to four cases of hepatitis C infections among its renal patients in one year. It took seven cases in one month to trigger alarm bells. A little slow, but these patients were seen by different doctors, making connecting the dots difficult.

Doctors knew something was wrong in mid-May. But its infection control team was activated only in June. If action had been taken earlier, could some patients have been saved from an infection that is expensive to treat and can be deadly?

Also, why did it take another four months and many more infections before the hospital informed MOH's Director of Medical Services (DMS) in late August?

It seems SGH has not learnt its lessons from the outbreak of severe acute respiratory syndrome (Sars).

In early April in 2003, the media heard rumours that some SGH staff had been infected with Sars. MOH was asked during the daily media briefing, and was told by the then DMS that there was no such thing. Senior SGH staff were present at that briefing.

The very next day, the ministry announced that 21 SGH staff were suspected to have contracted Sars.

It later transpired that SGH did not think there was any urgent need to inform the ministry about the cases, even as the number of its staff suspected to have contracted the deadly bug grew.

Yes, hospitals need some autonomy - but when there is a serious outbreak of disease, they must also be proactive and responsible in notifying the ministry.

Having more hepatitis C cases diagnosed in one month (seven) in one hospital than the whole country had in the previous year (six) should be classified as serious.

Singapore's highest medical authority should have been told of the big spike in numbers immediately.

Waiting until more than 20 patients were diagnosed before telling MOH in late August is tantamount to dereliction of duty.

After that, DMS Benjamin Ong met SGH doctors, roped in the Agency for Science, Technology and Research (A*Star) laboratory to verify that the cases came from the same source, and told Health Minister Gan Kim Yong about the outbreak on Sept 18.

In this case, it is fortunate that all the infections took place within SGH's ward 67. But what if the infections were occurring outside of the hospital?

What if the infections were taking place in every hospital, and no one told the ministry? The question on many minds is this: Is there a timeframe within which healthcare institutions must report such incidents to the ministry?

If there isn't, perhaps it is time to institute such a practice. Lapses in reporting undermine the country's ability to keep a lid on the spread of deadly diseases.

With Ebola, the Middle East respiratory syndrome and other emerging infectious diseases a constant threat, the MOH needs to strengthen its defence. Access to timely information is paramount.

Mystery of virus spread confounds medical experts
Transmission via dialysis machines ruled out; use of multi-dose vials under probe
By Salma Khalik, Senior Health Correspondent, The Straits Times, 7 Oct 2015

It is a virus that does not spread easily – and dies quickly.

That is why experts are still racking their brains over the source of the hepatitis C virus that infected at least 21 kidney patients at Singapore General Hospital (SGH).

The hepatitis C virus is generally transmitted by blood or blood products. It is not airborne and cannot be spread through social contact, sharing of utensils or drinking from the same glass, or through food or water.

Professor Fong Kok Yong, chairman of SGH's medical board, said the virus is "very fragile and dies quickly" when exposed. He added that the chance of the virus being spread through contaminated blood was "very minuscule".

Not only does the blood bank take great care, but also, not all the infected patients had a blood transfusion. Furthermore, they were from different blood groups, and would not be receiving blood from the same donor.

The hospital had at first suspected that the virus was spread through a dialysis machine, which kidney failure patients use to clean their blood of toxins.

But by the end of May, investigations had shown that this was not the source of transmission as the patients had used different machines, and other patients using those machines were not infected.

The hospital then turned to the use of multi-dose vials, possibly those containing insulin, which some diabetic patients need.

These vials contain more than one dose and are often shared between two and three patients.

SGH's chief nurse, Dr Tracy Ayre, said the protocol is for the user, either a doctor or a nurse, to swab the rubber top of the vial before injecting a new needle into the vial to extract the required amount of liquid.

She said: "You use a new needle, new syringe for every patient, for every episode."

With one vial shared by about three patients, in order to infect more than 20 patients, a fairly large number of vials would need to be contaminated.

When posed this question, Professor Ang Chong Lye, SGH's chief executive officer, replied: "That's why we couldn't confirm that it is from multi-dosing. We took that extra precaution to stop multi- dosing.

"But we cannot pinpoint for sure that that is the ultimate cause."

Asked if it had ruled out foul play, SGH said: "Since investigations are ongoing, we cannot rule out any possibility."

Hopefully, the new review committee set up by the Health Ministry can shed more light.

Hepatitis C generally does not kill quickly
By Linette Lai, The Straits Times, 7 Oct 2015

A liver specialist is surprised that at least four people are suspected to have died within months of being infected with hepatitis C.

This is not a virus that kills quickly, Dr Desmond Wai told The Straits Times about the deaths linked to the virus at the Singapore General Hospital.

In his experience, even those with a weakened immune system - such as kidney failure patients - would take at least five to 10 years to develop severe liver damage.

The only exception, he said, is a rare and aggressive strain of the virus known as fibrosing cholestatic hepatitis C.

If someone who has a severely weakened immune system is infected with this particular strain, he could become critically ill in a matter of weeks.

"But this is very rare," he stressed. "In more than 20 years of practice, I've seen only two cases."

He added: "For someone healthy like you or me, hepatitis C... would take approximately 20 years to cause severe liver damage."

Even for someone who is ill and whose immune system has been compromised, said Dr Wai, the serious problems take as long as five to 10 years to emerge.

Such problems include liver cirrhosis - or scarring of the liver - liver cancer or liver failure.

Hepatitis C affects an estimated 0.3 per cent of the Singapore population. It is usually transmitted through infected blood and other body fluids.

The virus takes between two weeks and six months to incubate before people begin showing symptoms, such as fatigue, fever and weight loss.

The majority of people do not show symptoms and may not even know that they are infected.

Around 20 per cent of people infected with the virus will be able to get rid of it on their own without the need for medical intervention, said Dr Wai. Of the remaining group, nine in 10 people can be cured using antiviral medication.

He highlighted the example of one of his patients who contracted acute hepatitis C after a kidney transplant in China.

"I've seen her for more than a year and she's very stable, there's minimum damage to her liver," he said.

On average, Dr Wai sees one hepatitis C case every two months.

"Frankly speaking, this disease does not kill," he said. "We need to wait for more information from the Ministry of Health before we know what is going on."

SGH screening staff, patients who may have been exposed
Those who passed through affected wards from January to June being checked for virus
By Linette Lai, The Straits Times, 7 Oct 2015

The Singapore General Hospital (SGH) is in the midst of screening all other staff and patients who might have been exposed to hepatitis C.

On Tuesday (Oct 6), the hospital revealed that 22 patients who were hospitalised for kidney problems between April and June had the disease. Eight of them have since died, with four of the deaths linked to the viral infection.

Another three died of unrelated causes, while one more death is pending investigation.

A total of 411 patients who passed through the affected wards between January and June this year are being screened. The number does not include the 22 patients who have already been diagnosed.

Those whose screening results do not reveal any abnormality will continue to be monitored by the hospital for a period of six months - the maximum known incubation period for the hepatitis C virus.

SGH has also screened all other patients who tested positive for abnormal liver function. Abnormal liver function can be caused by a hepatitis C infection.

However, no new hepatitis C cases related to admission outside the high-risk period of April to June this year were identified following these tests.

The hospital is also screening 42 doctors - including renal doctors, transplant surgeons and interventional radiologists - as well as 51 nurses who were directly involved in caring for the affected patients.

All staff have tested negative so far, said Professor Fong Kok Yong, who is chairman of SGH's medical board. He added that the hospital will also be recalling doctors who were formerly caring for the patients but have now been posted elsewhere.

The Health Ministry has also convened an independent review committee to scrutinise SGH's internal investigations and findings.

This committee will look for gaps or potential weaknesses in the current infection control system, as well as recommend safeguards that can be introduced, said Health Minister Gan Kim Yong yesterday.

"Our first priority is to extend our help and support for our patients, to ensure that their conditions are managed... and also provide support for the family members," he said.

"And our second priority is to look at how we can strengthen our precautionary measures and safeguards to ensure that this doesn't happen again."

Mr Gan said the committee would take about two months to complete its work, following which it would share the results with the public as well as the various healthcare clusters.

"We hope that SGH as well as all our healthcare institutions will learn from this incident and work hard to continue to improve our patient safety," Mr Gan said.

I am gravely concerned and disappointed with the occurrence of the cluster of hepatitis C cases in SGH. My thoughts are with the affected patients and families.

Screening for those in affected wards
The Straits Times, 7 Oct 2015

SGH will be contacting patients who were admitted to wards 64A and 67 between January and June to be screened for hepatitis C.

It is also setting up an appointments hotline for patients who think that they might have been affected.

Only those who were admitted to the two affected wards during the stated time period should contact the hospital.

These patients may call 6321-3356, leave a message via SMS to 8799-2736, or e-mail They should provide their name and NRIC number when doing so.

Infections dash hopes of kidney transplant patients
By Salma Khalik, Senior Health Correspondent and Linette Lai, The Straits Times, 8 Oct 2015

Last year, 57 people got a kidney transplant, with 40 getting the organ from a living donor. The transplants came with the hope of many years of good-quality life.

But for 19 transplant patients who spent time at Singapore General Hospital's (SGH) renal ward, this hope took a hit as they were infected with hepatitis C - which could lead to liver diseases.

Of these, nine got their new kidneys only within the past year.

The infected patients were aged 24 to 70, with the majority in their 50s and 60s.

At least five, possibly more, of these 19 transplant patients have died in the past six months, with hepatitis C a possible contributory factor in some of the deaths.

The fact that they had a kidney transplant could have worked against them.

One reason they succumbed so quickly could be because of their compromised immune system.

According to SGH, "nearly half had recent high-dose immunosuppression therapy" to help them overcome their body's rejection of the new organ.

Liver specialist Mark Fernandes of GutCare Clinic said severe hepatitis infection is more likely to strike patients with a weakened immune system.

Known to doctors as "rapidly progressive fibrosing cholestatic hepatitis", it can cause liver failure within a matter of months, he said. Once the liver fails, secondary problems such as bacterial infections or sepsis quickly set in.

"The only way we know to treat this is to reduce the amount of immunosuppressants given to the patient," Dr Fernandes said. "Even then, the outcome is not good."

However, he stressed that this particular form of hepatitis infection is rare, and that hepatitis C usually takes years to inflict severe damage on a person's liver.

"For the average Joe, it could take 20 to 30 years," he said.

Even in a sick person with a weakened immune system, a non-aggressive form of the infection would take at least one or two years to cause serious problems.

According to Professor Fong Kok Yong, chairman of SGH's medical board, the majority of patients whose deaths might be linked to the hepatitis C infection died of sepsis or blood poisoning.

He added that many patients were in hospital for infections, such as pneumonia and infection of the urinary tract.

The hospital has promised to pay for all the treatment these patients need to overcome this infection. Antiviral medicine, which can cure up to 90 per cent of otherwise healthy patients, can be very expensive, with newer drugs costing $90,000.

Professor Ang Chong Lye, SGH's chief executive officer, said all the infected patients have been referred to liver specialists who will work together with their kidney doctors to treat them.

SGH hep C outbreak: Multi-dose vials come under scrutiny
Even before hepatitis C outbreak at SGH, many local institutions had reduced usage, say doctors
By Linette Lai and Seow Bei Yi, The Straits Times, 9 Oct 2015

Doctors say many local healthcare institutions have been cutting down on the use of multi-dose vials, even before the hepatitis C outbreak at the Singapore General Hospital (SGH) was revealed.

This is because of the risk of infection that arises from using such vials, said infectious disease specialist Leong Hoe Nam of the Rophi Clinic at Mount Elizabeth Novena Hospital.

Typically, these small glass or plastic bottles hold several doses of liquid medication that can be shared by two or three patients.

A brand-new needle and syringe are usually used to extract the contents for each patient, so as to avoid contamination. The rubber stopper on top of each vial is usually also disinfected with an alcohol solution before use.

The vials have recently come under scrutiny as a possible source of the hepatitis C viral outbreak in a renal ward at SGH, where 22 kidney patients were diagnosed with the disease. Eight of them have since died, with four deaths possibly linked to hepatitis C.

Over the past decade, said Dr Leong, doctors have been using more single-dose vials instead, containing smaller quantities of medication. Otherwise, they use multi-dose vials kept for the same patient.

"Both single-dose and multi-dose injection medication vials are used in our public hospitals," said the Health Ministry in a statement on Wednesday night.

"Our public hospitals utilise multi-dose vials where the preparation is specifically formulated for such use, and governed by safety protocols."

Dr Ben Ng, a senior consultant at Arden Endocrinology Specialist Clinic, maintains that if the guidelines are followed, the risk of contamination is low.

He added that hospitals are likely to use them out of cost and practicality concerns.

"Cost is by far the biggest issue," said Dr Ng. "From a practical standpoint, these vials are useful to patient care as there is a huge variation in the dose needed by different people in certain illnesses such as diabetes."

According to a 2008 report by the United States Centres for Disease Control and Prevention, some 40,000 patients at an endoscopy clinic were potentially exposed to the hepatitis C virus. This was likely the result of reusing syringes and medication vials intended for one-time use.

Some hospitals are taking no chances. Dr Kelvin Loh, senior vice- president of Parkway Hospitals Singapore, said the group has "stringent clinical guidelines in place" that follow globally accepted standards.

"These include safe processes for the use of multi-dose vials," said Dr Loh, who oversees hospitals in the Parkway group such as Gleneagles and Mount Elizabeth. "Nevertheless, we have rechecked the integrity of our processes and continue to remain vigilant."

TTSH ‘strengthening overall system, vigilance’ in wake of SGH Hepatitis C cluster
Tan Tock Seng Hospital also demonstrated its safe practices for multi-dosing, which was raised as a possible cause of the virus spread at the Singapore General Hospital.
By Justin Ong, Channel NewsAsia, 9 Oct 2015

Tan Tock Seng Hospital (TTSH), one of Singapore's largest hospitals, on Fri (Oct 9) said it was strengthening its injection practices in light of the Hepatitis C cluster at Singapore General Hospital (SGH).

Multi-dosing – injection by attaching needles to a shared vial – was identified by SGH as apossible cause of the virus spread, which infected 22 patients and possibly killed four in the hospital’s renal ward. The Ministry of Health (MOH) has said it is not yet conclusive that multi-dosing is the cause of the infections and an independent review committee's probe into the incident is expected to take two months.

However Associate Professor Thomas Lew, chairman of TTSH’s medical board, said: “We are reviewing our processes, looking at guidelines provided to ensure we are in compliance with best practices … and strengthening our overall system and vigilance.”

This would be done by “constant repetition of key messages” such as safe injection practices for both single and multi-dosing, said Prof Lew, who spoke during a media tour of TTSH and SGH organised by MOH to demonstrate patient safety and infection control measures.

Prof Lew said that out of 700 types of injectable drugs at TTSH, 13 are multi-dose. “These 13 are not commonly administered, not available in single dose, and there are no alternatives based on current manufactured supply,” he stated.

Eight of these 13 multi-dose drugs can be used by different patients while the rest are for a single patient only.

“This is consistent all over Singapore. We are not practising something unique here,” said Prof Lew.

TTSH also explained safety procedures behind its use of haemodialysis machines, which are another potential mode of transmission for the Hepatitis C virus (HCV).

Each machine’s dialysers and bloodlines are single-use and discarded after each patient has gone through haemodialysis, said the hospital. Before TTSH starts patients on dialysis, they are also screened for blood-borne viruses like Hepatitis C and HIV, on top of being screened every six months as per national protocol.


Earlier, SGH – which has halted the practice of multi-dosing following the Hepatitis C cluster – demonstrated its haemodialysis procedure in a simulation room.

The chairman of SGH's medical board, Prof Fong Kok Yong, also outlined the hospital’s infection control programmes for staff such as e-learning, training courses up to twice a year, and monthly audits of high-risk wards.

When asked why SGH only released information about the Hepatitis C cluster in October, four months after doctors noticed a spike in infections, Prof Fong reiterated that Hepatitis C has a “long incubation period of up to six months” and that it is a blood-borne virus.

“If it were airborne like SARS or MERS, the moment there is a case, everybody jumps, isolates the patient and it’s a reportable disease,” he said. “For blood-borne viruses, if you don’t do a test, you don’t even know such a thing has occurred.”

Added Prof Fong: “The first thing we did was to ensure it’s not airborne, that there was no danger to people around them (the infected patients) and we implemented whatever infection control practices we have as what we did in the stopping use of multi dosing.”

“There was no danger to other patients. We knew how it’s being transmitted and we took action to further ensure there was no further chance of spreading to anyone else,” he said.

“I’d like the independent review committee to make a thorough investigation. We are fully cooperative, whatever they ask we have provided them and they have a free hand to look at whatever they need to look at.”

In an update on Friday evening, SGH said it has contacted 646 out of the 678 patients who were admitted to Wards 64A and 67 from January to June. A total of 585 have confirmed their appointments for screening and 186 have been screened to date. Additionally, 202 out of 273 staff have been screened for the virus. Those tested will be informed when the results are available in a week.

Hepatitis: SGH offers emotional support for patients, families
By Carolyn Khew, The Straits Times, 12 Oct 2015

Patients and families affected by the hepatitis C outbreak at the Singapore General Hospital (SGH) are being given emotional support, said the hospital.

SGH said that doctors and medical social workers have already spoken to them, or will be contacting them, to address their concerns, and to offer psychological and emotional support.

Last week, SGH revealed that 22 kidney patients had con-tracted hepatitis C infections while receiving treatment in the hospital.

Although the hospital first suspected that cases were related as early as mid-May, tests confirmed this only later.

Eight of the patients have died, and five deaths could be linked to the infection.

Update of Hepatitis C clusterWe are deeply concerned about the well-being of our patients and their families from the...
Posted by Singapore General Hospital on Monday, October 12, 2015

In a statement, SGH said that it has been in touch with the 14 affected patients and their families, as well as the next of kin of the eight patients who died.

Eight family conferences have been held, with nine more scheduled for the next few days, while another five are being arranged, it said.

A spokesman said: "We understand that they are anxious about their condition and treatment.

"Many of them have been our patients for a long time and are close to our care team."

The hospital has also contacted 646 out of 678 patients for screening. These patients were admitted to wards 64A and 67 from January to June.

Of the 585 who have confirmed their appointments for screening, 244 patients have been screened and will be notified of their results this week.

A total of 223 out of 284 staff have also been screened, added SGH.

The Ministry of Health (MOH) was informed about the incident in late August, and Health Minister Gan Kim Yong was briefed on Sept 25.

Questions have been raised as to why SGH took so long to inform the public about the hepatitis C cluster, prompting the hospital to give a detailed timeline of the events last Wednesday.

The Health Ministry has since launched a separate investigation of the matter.

The Independent Review Committee will be investi-gating how the hepatitis C in-fections occurred, and look into the timeline of events provided by the hospital to see whether there were any gaps in the process.

SingHealth chief tells staff to 'keep strong', stresses mission of care
By Salma Khalik, Senior Health Correspondent, The Straits Times, 13 Oct 2015

Shortly after Singapore General Hospital (SGH) revealed that 22 patients had been diagnosed with the potentially deadly hepatitis C virus, SingHealth chief Ivy Ng sent a cluster-wide message to staff to "keep strong".

She told them last Wednesday: "Despite our very best efforts, we can still fail our patients; hurt them when we mean to heal them; and trigger understandable distrust in the public whom we only seek to serve."

SGH was alerted to an infection in its renal ward in mid-May, as an unusual number of its kidney patients were diagnosed with hepatitis C, which can lead to liver failure. Typically, it has two to four such cases a year among renal patients. It started to react when seven cases turned up within four weeks. Since then, eight patients have died, with up to five deaths linked to theirbeing infected with the hepatitis C virus.

Professor Ng quoted from a note sent by a chief executive officer of another health cluster, who said SGH had "good surveillance and reporting" and "open disclosure and strong accountability".

The unnamed CEO also said: "It shows that you have a strong patient safety and learning culture."

A separate memorandum to staff last Thursday from SGH's CEO, medical board chairman and chief nurse said they wanted to address the question of why it took the hospital four months to inform the Ministry of Health of the infections.

The delay was because it was not an airborne virus (which is spread easily); SGH did not want to "cause unnecessary alarm" as "that would not be responsible". They told staff: "We took action immediately in early June, when we noticed the clustering of seven cases within four weeks, which is unusual."

SGH had told the media it started internal investigations in mid-May, although its infectious control team was not activated till early June.

Eight patients were diagnosed with the virus by the end of May, 10 more were diagnosed in June, two in July, and one each in August and last month.

SGH told the media that all the infections occurred between April and the time it stopped the use of multi-dose vials some time in June. A multi-dose vial contains more than one dose of medicine.

It is confident that it has arrested the spread of the virus.

Prof Ng told staff that the hospital had stopped using multi-dose vials "except where unavoidable".

"We need to commit ourselves to an obsessive adherence to our strict protocols for infection control. Thousands of patients entrust their care to us. We cannot fail them."

Update of Hepatitis C cluster - 14 OctAs at 6pm, 14 October, SGH has screened 441 patients out of 678 patients, of...
Posted by Singapore General Hospital on Wednesday, October 14, 2015

Hepatitis C: Panel to also review MOH response
Gan: SGH, MOH processes will be scrutinised in thorough check
By Salma Khalik, Senior Health Correspondent , The Sunday Times, 18 Oct 2015

The independent committee looking into the spread of hepatitis C in Singapore General Hospital (SGH) has had its job expanded to include a review of the Ministry of Health's (MOH) actions in the matter.

Announcing this yesterday, Health Minister Gan Kim Yong said: "The committee will also look at the processes in both SGH and the MOH to identify whether there are any gaps and areas that we can improve upon so that we can strengthen our system.

"I have also assured the committee that SGH and MOH will extend our full support so as to facilitate the review and to ensure that it is a very thorough review."

At least 21 kidney patients caught the hepatitis C virus while warded at the hospital's renal ward 67 between April and June. One more patient has the virus, but could be the index case that brought the virus to the ward. Their ages range from 24 to 70.

Eight of the patients have died, and five of the deaths could be linked to the infection.

When the news was announced earlier this month, it raised questions that have yet to be answered: how the virus was spread, could SGH have reacted faster, and why it took so long to release the information about the infections.

The hospital suspects the cause of transmission to be improper use of multi-dose vials, but has not been able to confirm this.

SGH was alerted to a possible outbreak of hepatitis C some time in May when seven renal patients tested positive for this virus within a four-week period. Typically, between two and four renal patients would have this virus in a year.

SGH told MOH about this only at end-August, briefed Mr Gan on Sept 25, and went public on Oct 6. Only last week did it start counselling for infected patients, who are mostly kidney transplant recipients, and their families.

SGH is in the process of recalling patients who stayed in wards 64A and 67 between January and June. No new cases have been found, after about 770 patients and staff were screened as of last Friday.

MOH has set up the independent committee of seven doctors headed by Professor Leo Yee Sin, clinical director of the Communicable Disease Centre at Tan Tock Seng Hospital, to find out how the bug was spread and to remedy any weakness in SGH's infection control.

The committee has requested the help of more experts, including those from outside Singapore.

Speaking on the sidelines of the SingHealth President's Challenge 2015 Finale Event yesterday, Mr Gan said he supports the request as this would "ensure that the review will be a very thorough one".

"One of the key objectives of the Review Committee is also to identify areas where we can strengthen and where we can improve, so that we will learn from this experience and prevent similar incidents from happening in the future," he said.

He promised that MOH and SGH "will adopt an open attitude" as this is the only way to learn from the incident.

Hepatitis C probe under way: Panel
The Straits Times, 21 Oct 2015

The independent review committee looking into the hepatitis C cluster at Singapore General Hospital (SGH) said yesterday its work is under way and that it has met three times since its appointment on Oct 6.

Investigation work has begun. This includes ward visits, interviews and reviewing the movement and care of the patients, and SGH records.

The panel members have been split into three teams - epidemiology, quality assurance and infection control, and case review - to undertake the review more efficiently and effectively.

Two international experts were brought in yesterday to provide advice on analyses, interpretation and report of findings.

Dr Scott Dewey Holmberg is from the US Centers for Disease Control and Prevention (CDC). He is chief of the epidemiology and surveillance branch at the division of viral hepatitis at the National Centre for HIV, Hepatitis, STD and TB Prevention. Professor Trish Perl is a senior epidemiologist for Johns Hopkins Health System. She is a professor in the departments of medicine (infectious diseases) and pathology at Johns Hopkins University School of Medicine and in epidemiology at the Bloomberg School of Public Health.

Dr Holmberg will be assisted by Dr Amanda Beaudoin, a CDC veterinary medical officer, while Prof Perl will be assisted by Ms JoEllen Harris, programme director of epidemiology and infection prevention at Johns Hopkins Health Systems.

SGH files police report on hepatitis C cluster
By Lester Hio, The Straits Times, 21 Oct 2015

The Singapore General Hospital (SGH) filed a police report yesterday, two weeks after it revealed that 22 kidney patients had contracted hepatitis C infections while receiving treatment in the hospital.

In response to media queries, SGH said: "After initial internal investigation, we are still unable to determine the cause of the cluster of infection."

Currently, an independent review committee appointed by the Ministry of Health is looking into the cluster with the help of international advisers.

"The police report has been filed so that the police may ascertain if there was any foul play," SGH said.

Update of Hepatitis C cluster - 20 OctAs at 6pm, 20 October, we have screened 593 patients, of which the results of 512...
Posted by Singapore General Hospital on Tuesday, October 20, 2015

On Oct 6, SGH revealed that 22 kidney patients had contracted hepatitis C infections. Eight have died, with five of the deaths possibly linked to the infection.

In a statement last night, Health Minister Gan Kim Yong noted that with the help of international advisers, the review committee will look into the cause of the cluster of hepatitis C infection at SGH and identify gaps or weak points that need to be improved.

Even as the committee continues its work independently, "we are not excluding any probable cause", he said, hence the police report.

Lawyer Amolat Singh noted that police investigations can be carried out only if there is a complainant.

"By being the complainant, SGH gives the police the basis to conduct a criminal investigation," he said. "It shows SGH wants to get to the bottom of this and rule out any possibility of sabotage or foul play."

As of yesterday, SGH had screened 593 patients for the hepatitis C virus. Of the patients, 512 tested negative while the remaining 81 results are pending.

A total of 296 staff members have been screened, with 294 of them having tested negative and the results pending for two.

Meanwhile, two international advisers have been appointed to the independent review committee.

They are Dr Scott Dewey Holmberg from the US Centers for Disease Control and Prevention, and Professor Trish Perl from Johns Hopkins University.

Professor Leo Yee Sin, who chairs the committee, said: "We anticipate the inquiry and investigation processes to be challenging. The international experts will work closely with the local team to provide their inputs, as well as to be actively involved in the investigation processes."

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