Thursday 10 December 2015

Hepatitis C outbreak at Singapore General Hospital’s Renal Ward: Independent Review Committee Report, 5 December 2015

Probe points to lapses at Singapore General Hospital
Poor infection control led to outbreak; SGH also tardy in recognising and raising problem
By Salma Khalik, Senior Health Correspondent, The Straits Times, 9 Dec 2015

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.

SGH hep C outbreak: Lapses and gaps led to the spread which has been linked to the deaths of seven kidney patients.
Posted by The Straits Times on Tuesday, December 8, 2015

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.

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.

MOH has accepted the findings and recommendations of the Independent Review Committee (IRC) tasked to look into the...
Posted by Ministry of Health on Tuesday, December 8, 2015

SGH accepts the findings and recommendations of the Independent Review Committee (IRC), appointed by Ministry of Health,...
Posted by Singapore General Hospital on Tuesday, December 8, 2015

New task force to boost infection control in hospitals
By Salma Khalik, Senior Health Correspondent, The Straits Times, 9 Dec 2015

Health Minister Gan Kim Yong has set up a task force to strengthen infection control in all hospitals following the release of the report on the hepatitis C outbreak at Singapore General Hospital (SGH) in which 25 patients were infected and eight have died.

The task force is headed by the Ministry of Health's (MOH) new Minister of State Chee Hong Tat and will see how the surveillance and detection of infectious diseases, both in hospitals and in the community, can be enhanced.

"This is a very painful incident for all of us," Mr Gan told the media yesterday. "We must be determined to learn from this incident so that we can improve and be better."

Mr Gan added that SGH and the ministry will set up separate panels to assess what disciplinary action, if any, needs to be taken against any of the key people involved in the episode that he described as "painful".

The panel that will look at the actions of ministry staff will be headed by Ms Yong Ying I, Permanent Secretary of the Public Service Division, who previously held the post of permanent secretary in the Health Ministry.

The one for SGH will be set up by the SingHealth cluster to which the hospital belongs. The panel will include people from outside SingHealth, as well as from the civil service who "will understand the level of accountability", said Mr Gan.

He also said there is no need for a committee of inquiry into the incident as the report is very thorough.

He added: "I would like to take this opportunity to apologise to patients and their family members. I'm sorry for the lapses in the system".

Following the release of the Report by the hepatitis C Independent Review Committee appointed by the Ministry of Health,...
Posted by Singapore General Hospital on Tuesday, December 8, 2015

Hepatitis C outbreak: What caused it

Panel finds poor and inefficient work processes
Lapses were compounded by kidney patients' weakened immune systems and change of ward
By Linette Lai, The Straits Times, 9 Dec 2015

Lapses in infection control were behind the hepatitis C outbreak at Singapore General Hospital (SGH) earlier this year, an independent committee reviewing the incident has concluded.

The lapses were compounded by the fact that the kidney patients in the renal ward had weakened immune systems, making them more susceptible to infections.

In addition, the renal ward moved from Ward 64A to Ward 67 in April. The different layout in Ward 67 may have accentuated the gaps in infection control, the committee found.

Its conclusions followed two months of investigation into how the outbreak occurred and whether there were gaps in work processes at the hospital.

During its review, the committee found small blood stains on medical carts and trolleys used by hospital staff for procedures such as blood- taking and medication administration. Stains were also found on equipment such as an injection tray, as well as on the wall of the "clean" room in Ward 67 where medications were prepared.

One sample from the wall was taken on Nov 2 - well after the hospital had tightened its infection control measures - and tested positive for the hepatitis C virus.

The committee noted in its report: "The computerised medical carts and procedure trolleys can be possible sources of infection transmission as they are moved from patient to patient.

"During the demonstrations of procedures, it was observed that the computerised medical carts were not adequately cleaned after the procedures."

The committee also observed that staff pushed the carts and trolleys into the designated "clean area" of the preparation room after they were used in procedures, without cleaning them. This would have created opportunities for cross-contamination of clean supplies and medication.

Some ward staff were also seen to have removed the cap of a patient's intravenous cannula when injecting medication, rather than using a side port.

This would increase the risk of a patient's blood flowing out through the cannula, possibly leading to environmental contamination and transmission of infections.

Committee member Lim Seng Gee noted that these practices occurred after the staff were briefed on the inspections at the wards, and it was difficult to know what their practices were like during the hepatitis C outbreak itself.

"When we interviewed them, the practices seemed to be good, but of course that may not have been the case at the time when the outbreak was occurring. It's very difficult to know exactly what went on."

In the report, the committee also highlighted inefficient work processes, which it said could have been a contributing factor in the infection control lapses. This could have been exacerbated by the relocation of the renal ward from Ward 64A to Ward 67, where most of the infections occurred.

In Ward 64A, which has a more compact layout, the preparation room is in the centre of the ward.

In Ward 67, staff have to walk a longer distance between the place for preparing medications and procedures such as blood-taking, and patients' beds.

"The workflow process issues opened up potential for modified infection control practices among ward staff", the committee noted, as not everyone might have followed hygiene protocols.

Boosting infection control
The Straits Times, 9 Dec 2015

This is a summary of the Independent Review Committee's recommendations on infection control.

• Review how ward procedures are carried out to reduce the risk of contaminating the environment or cross-contaminating clean supplies.

• Set aside a clean area to prepare intravenous medication. Items used for invasive procedures are considered contaminated and should not be taken into the area.

• Avoid contaminating equipment or surfaces. Staff should be aware of precautionary measures they can take, such as using washable keyboard covers and not touching surfaces on medical carts with gloved hands.

• Medical equipment such as dialysis machines and computerised medical carts should be comprehensively cleaned.

• Nursing and housekeeping staff should be aware of their clearly designated roles and responsibilities when it comes to environmental cleaning.

• Consistently practise hand hygiene and proper use and handling of supplies for administering injections, such as syringes and needles.

• Improve the current framework for supervision and monitoring, to make sure staff comply with standard operating procedures.

• Extend the recommendations to all healthcare institutions and have the Health Ministry oversee the implementation.

How other possible sources of infection were ruled out
By Linette Lai, The Straits Times, 9 Dec 2015

Q: The Independent Review Committee has said poor infection control measures were behind the hepatitis C outbreak. How did it rule out other possible sources of infection?

A: Apart from poor infection control, the committee looked at three other possibilities - drug diversion, intentional harm and a contaminated batch of products.

First, there were no missing narcotics or other drugs with the potential for abuse in the affected wards.

About 319 nurses, doctors and renal coordinators who had come into contact with patients in the affected wards were screened for the virus to rule out drug diversion or intentional harm. All of them, including those who had left the hospital but returned for screening, tested negative.

The Criminal Investigation Department also looked into the possibility of intentional harm by a staff member, but found no evidence to support this hypothesis.

Lastly, 0.9 per cent saline solution was the only product used in common among all the infected patients. However, the review committee noted that this solution is widely used across hospitals, and that more cases of hepatitis C infection should have emerged had the batch of solution been contaminated.

It also sampled 10 random bottles of solution from Ward 67, none of which tested positive for the hepatitis C virus.

Q: What about the multi-dose vials that were suspected to be the cause of transmission of the virus?

A: The report said only 13 of the 25 cases were given medication from at least one vial.

The committee concluded that multi-dose medication alone cannot fully explain the transmission of hepatitis C to all 25 cases in the outbreak.

Q: Was the outbreak from a single source?

A: It seems likely. Detailed analysis by the Agency for Science, Technology and Research and the Duke-NUS Graduate Medical School found that the 25 cases were tightly clustered and closely linked.

The earliest infected case was likely to have been a kidney transplant patient who was not previously diagnosed with hepatitis C, and who was admitted to Ward 64A in early March, then re-admitted in mid-March.

Residual blood samples from mid-March showed that the patient had a high viral load, with at least one million copies of the virus in one millilitre of his blood. In contrast, people who are not infected by hepatitis C have "undetectable" viral loads.

It is not known where this earliest infected case acquired the hepatitis C infection.

Hepatitis C 'caused or contributed to deaths of seven kidney patients'
By Salma Khalik, Senior Health Correspondent, The Straits Times, 9 Dec 2015

A very large amount of hepatitis C virus in their bodies contributed to, and in some cases, directly caused the deaths of seven of the eight patients who died.

Professor Lim Seng Gee, a senior liver specialist at the National University Hospital (NUH), and a member of the Independent Review Committee, said these patients had an "extremely high" number of viruses in their blood.

All were kidney transplant patients with low immunity because of the immunosuppression drugs they need to take so their bodies do not reject the foreign kidney. One of the patients received the transplant within the past year.

The drug they need to take paralyses the body's immune cells, so the virus can replicate freely in their blood, resulting in much more than what would be found in a normal hepatitis C patient.

Prof Lim said that the amount of viruses they had "goes beyond the upper limit of detection of the kit".

He added that just one drop of their blood would have had at least 5,000,000 viruses.

This was also the reason for the easy transmission of the disease as just a tiny speck would carry a huge number of viruses.

All 25 patients who had the virus had stayed longer in hospital than patients who did not get infected, suggesting that their longer stay exposed them to greater risk. Twenty of them had received a transplant.

The report by the committee found that the primary causes of the eight deaths were infections of the lungs, blood and their transplanted kidneys, as well as end stage kidney failure.

There was definitely no link between one of the deaths and the hepatitis C virus.

Asked if any of the seven patients could still be alive today if they had not been infected by the hepatitis C virus, Prof Lim said: "I think one can always speculate that's the case."

He said that they suffered from jaundice and severe liver dysfunction, which are caused by the hepatitis C virus.

Professor Leo Yee Sin, director of the Institute of Infectious Diseases and Epidemiology at Tan Tock Seng Hospital, and chairman of the review committee, said that the hepatitis C virus "can lead to rapid death in the immunosuppressed", who could suffer from "jaundice, liver failure and death within weeks".

Prof Lim said: "In some of the cases, there were no other co-morbid factors, there was just basically hepatitis C, there was liver failure and it was fairly straightforward."

He added that in all seven, "hepatitis C was definitely a contributing factor, or we certainly could not exclude it as a contributing factor".

Hepatitis C outbreak: Why the delay

SGH's investigation, tests took longer than expected
Its tests and investigation led to minister being told of outbreak only 4 months later
By Tan Weizhen, The Straits Times, 9 Dec 2015

When it first noticed a rise in hepatitis C virus infections, the Singapore General Hospital tried to seek out the source - and barked up the wrong tree at first.

Then, as cases multiplied, its Infection Control Unit took almost two months to carry out lab tests to establish that they were related.

Its report, when it was submitted to the director of medical services (DMS), was deemed inadequate.

This series of delays and events meant the Health Minister was told of the hepatitis C outbreak only four months afterwards.

It all started between late April and end-May, when the SGH Renal Unit noticed that hepatitis C infections were rising and started investigating the dialysis centre. By the end of the month, it realised that was not the 

The Renal Unit then turned to the Infection Control Unit in early June to conduct more investigations, noted the Independent Review Committee in a report yesterday.

In a briefing yesterday, the committee chairman, Professor Leo Yee Sin, said: "The committee felt that the recognition of the outbreak by the SGH Renal Unit was delayed. SGH took action to investigate the dialysis centre in mid- May; however, they escalated the information and request to the infection control team only in the early part of June."

The SGH Molecular Laboratory then started doing what was called a phylogenetic test to ascertain if the infections were related, which took longer than anticipated.

"As this was the first time that the laboratory had to do such a test, the test could only be completed in end-July," said the report.

The Clinical Quality, Performance and Technology Division at the Ministry of Health (MOH), which had been alerted to the increase in hepatitis C cases by then, instructed SGH to report the incident as a Serious Reportable Event on June 23.

However, "SGH did not do so, nor explain why", the report said.

Meanwhile, the issue was not flagged to top MOH officials, while other MOH divisions that inquired were told that the matter was being investigated.

In late July, the tests were completed, confirming that the first 20 cases were related.

The month of August was spent finalising findings and reports from SGH's nursing, hepatology and infection control units in preparation for briefing MOH.

The committee further found that as neither SGH nor MOH raised the issue with the director of medical services, Associate Professor Benjamin Ong, during this period, he was told by MOH only on Sept 1, and eventually briefed by SGH only on Sept 3.

Prof Ong was not satisfied that the report presented the full picture on the severity and extent of the outbreak. He asked for several things to be done next, including having third-party experts to chair SGH's review committees, the lab tests to be verified by an A*Star laboratory, and an MOH team to be walked through SGH's processes. Transplant operations were also halted.

"These additional steps would have provided information on the severity of the outbreak. Their absence led to the DMS needing to ask SGH... to complete the necessary work in order for him to better assess the situation," said the report.

On Sept 25, SGH briefed Health Minister Gan Kim Yong, who instructed that the matter be made public.

Prof Leo also pointed out the "unusual" nature of the outbreak, which made it hard to detect.

"Because it's so unusual, it highlights gaps in the system. First of all, the infection is not easily being picked up by any regular surveillance system and this is a global issue, it's not just a Singapore issue."

She said the existing frameworks, which were built for community outbreaks and common outbreaks in the hospital setting, are "just not catered to this unusual outbreak".

Reporting procedures failed to catch 'unusual' outbreak
By Tan Weizhen, The Straits Times, 9 Dec 2015

While there are solid reporting procedures in place for well-known infectious diseases and epidemics, these were not effective in catching an "unusual and unfamiliar" outbreak like the hepatitis C virus (HCV) infections that occurred earlier this year at the Singapore General Hospital (SGH), an independent review committee found.

The national surveillance system was built to pick up communicable diseases in the community and infections contracted by patients in hospital during treatment for other medical or surgical conditions, noted the report released yesterday.

But HCV is not detected easily, because of characteristics such as its lack of obvious symptoms. Unlike, say, airborne diseases or those spread by close contact, it is harder to establish how it was transmitted, noted the committee.

"Some characteristics of HCV make it difficult to be detected by the current system. In addition, not all cases of HCV infections were reported by the doctors and laboratories," said the report.

Nonetheless, the committee found that there was no evidence of deliberate delays by SGH or Ministry of Health (MOH) staff in reporting the outbreak or informing the Minister for Health.

Mr Gan Kim Yong was notified only in mid-September, nearly four months after the initial cluster of four cases was discovered.

"There's no evidence to suggest that the escalation of the matter from DMS (director of medical services) to minister was deliberately delayed," said chairman Leo Yee Sin in a briefing yesterday.

What the committee did find, however, was that reporting processes and clarity of roles were lacking both at MOH and SGH.

Professor Leo said: "MOH CQPT (Clinical Quality, Performance & Technology Division) oversees the hospital-associated indicators but the division was not set up specifically to look into outbreak investigation."

As for the roles and responsibilities within the hospital's own senior management, the panel felt it was not clear what the roles were and whose responsibility it was in the event of an outbreak.

Yesterday, Mr Gan said MOH would set up a task force, led by Minister of State for Health Chee Hong Tat, to enhance the processes for handling infectious disease outbreaks. The task force will enhance the surveillance, detection and response to such outbreaks.

Improving responses and procedures
The Straits Times, 9 Dec 2015

Here are the recommendations by the Independent Review Committee to enhance Singapore's response to outbreak detection and reporting protocol, among other things.

1 The national surveillance system for acute hepatitis C virus infections should be fine-tuned, adapting from international best practices. This should pick up infections occurring in both the hospitals and community.

2 Early incident reporting procedures within the hospital, public healthcare cluster, and to the Ministry of Health (MOH) should be established. Guidelines could include instances where the hospital needs to identify exposed patients who could have caught infections.

3 Hospitals should develop clear structures and frameworks to investigate and manage infections patients get while in hospital. They should enhance capabilities if required, for instance, by hiring epidemiologists and infection control practitioners.

4 MOH should have an overall plan to strengthen capabilities for investigating outbreaks nationally.

5 Reporting procedures within MOH need to be reviewed, so the senior management can be made aware of risks in a more timely manner.

6 MOH should set up a team to adopt a broader set of responsibilities and functions across institutions and settings. The team should have the capabilities to investigate outbreaks, from knowing when there is one to being able to mobilise the operational expertise to deal with it.

Hepatitis C outbreak: What next

SGH apologises for lapses, says it will work to close gaps
By Linette Lai, The Straits Times, 9 Dec 2015

The Singapore General Hospital (SGH) has apologised for the lapses that led to the hepatitis C outbreak in its renal wards, stressing that it is working to close the gaps identified in the independent review committee's report.

"My colleagues and I deeply regret what happened," said SGH chief executive Ang Chong Lye. "I would like to apologise to the patients and their families who have been affected by the outbreak.

"It has been a hard and humbling lesson but we will learn from this, improve and work tirelessly to ensure that our patients are always safe in our care. We are determined to regain the trust of Singaporeans, whom we have been most privileged to serve."

The hospital's parent organisation, SingHealth, has set up a task force to conduct audits on infection control practices across its various institutions.

It has also appointed a separate committee to implement the recommendations of the independent review committee, which was convened by the Ministry of Health (MOH) to investigate the outbreak.

The recommendations include refreshing standard operating procedures for infection control, as well as improving surveillance and outbreak response systems.

Professor Ang admitted that the hospital could have reacted more quickly to the outbreak.

"SGH has reflected on our response and approach, and acknowledges that we could have done better and escalated the matter earlier to SingHealth and MOH."

Professor Fong Kok Yong, chairman of SGH's medical board, said in the same press statement: "We have learnt from this outbreak that a more robust alert and escalation system at the hospital has to be in place, with clear definition of roles and individual accountability.

"We will leave no stone unturned to enhance patient safety, and do all we can to prevent the recurrence of such an unfortunate event."

Prof Fong also said the hospital will work with MOH to implement the recommendations in the committee's report, including building a framework across institutions to detect, investigate and manage uncommon infections such as hepatitis C.

Twenty-five patients who were admitted to Ward 64A or Ward 67 in SGH between January and September this year were diagnosed with hepatitis C infections.

Of the 25, eight have since died. The virus was proven to be either a direct or contributing factor in seven of the deaths.

Hygiene lapses a serious cause for concern
Infection control still found lacking despite action taken earlier; staff need to know why following protocols matters
By Salma Khalik, Senior Health Correspondent, The Straits Times, 9 Dec 2015

The most disconcerting part about the hepatitis C outbreak in Singapore General Hospital (SGH) wards is not so much that it happened. That is unfortunate and regrettable, even tragic, given the seven deaths that were possibly caused by the virus.

What is troubling is that, having discovered the spread of the virus, and having taken steps in June to tighten infection control in the affected wards, a team sent in by the Independent Review Committee to check on the processes still found lapses in infection control.

These checks were made between Oct 15 and Nov 11 - about four months after the hospital took steps to prevent the continued spread of the virus.

Yet on Nov 2, a spot of blood on the wall of the preparation room - which has to be super clean as it is where medicine is prepared for intravenous use - had traces of the hepatitis C virus (HCV).

And all this happened in a renal ward with transplant patients - where greater care is expected because their immune systems have been compromised and they are at greater risk of catching infections than other patients.The team found that staff did not clean medical carts and trolleys properly before pushing them into the preparation room, and stains were found on them, as well as on other surfaces. It also found hand hygiene wanting.

These lapses raise the inevitable question: If the staff do not exercise proper care in a renal ward, how do they behave in a normal ward? And does this happen in other hospitals?

The hepatitis C infection was spotted because it is not that common. And because transplant patients have lower immunity, the infection showed up quite quickly.

But if protocols are not followed, patients in normal wards can contract a whole range of viral, fungal or bacterial infections, with no one being the wiser.

Acquired infections occur all the time in hospitals. Hospitals try to combat them by improving hygiene among staff and visitors.

Disinfectants are placed throughout hospital buildings so anyone can disinfect their hands and staff are told to wash their hands properly between patients, and to change their gloves with each new patient.

These precautions are of no use if the staff caring for patients are not scrupulous in practising good hygiene. While it is too late to change what might have happened, now is a good time for all hospitals to review their practices, and not assume such lapses occur only at SGH.

Part of this review must include explaining the dangers of certain practices, because expecting staff to follow instructions without explaining why they need to do so is a recipe for failure.

One failing the team found was staff removing the cap of the intravenous tube - which is faster than using the side port. But the report said doing so exposes the patient to contaminants entering the bloodstream. It also allows bugs from the patient to enter the environment.

But this is not obvious to the layman, and possibly even to some healthcare staff.

Explaining, or better still, showing how such contamination can occur will make everyone realise that the bosses are not "being difficult" when they make staff follow protocol, and that this is something that ensures the safety of patients.

This cannot just be a one-off exercise today. It must be done with every new batch of employees.

Only when concrete steps are taken to ensure that such mistakes do not happen again can we say that we have learnt from events at SGH, and that the healthcare system has been strengthened as a result.

Enact positive change for the long term
Looking for newer and better ways of doing things would do more to restore confidence than pledges to intensify checks
By Salma Khalik, Senior Health Correspondent, The Straits Times, 10 Dec 2015

The hepatitis C outbreak at the Singapore General Hospital (SGH) has been a blow not only to the patients affected, but also to all of Singapore.

The revelation that unhygienic practices at one of the country's two tertiary hospitals resulted in 25 infected patients and possibly seven deaths, affects the image of the whole healthcare system.

That this happened in a renal ward makes it so much worse, as such wards house patients at the highest risk of infection.

Singapore has been promoting itself as a medical hub, citing its safe blood and hygiene practices.

Patients pay more to come here, instead of seeking cheaper medical services in neighbouring countries, because they trust the Singapore brand.

Now, that brand has taken a hit.

Inevitably, people will wonder: If it can happen at one of Singapore's largest and oldest hospitals, can it happen elsewhere, too?

That's a pity as, overall, healthcare here is very good.

Singapore has highly qualified and experienced doctors and nurses, who do care very much for the patients they look after.

This must also be true of the doctors and nurses working in SGH's renal wards, 64A and 67, where the infections took place.

Singapore's chief nursing officer, Ms Tan Soh Chin, said on the Ministry of Health's Facebook page the day after the report by the independent review committee (IRC) was released:

"In the next few days and weeks, it will be a very tough and difficult period for nursing and especially CN Tracy (Dr Tracy Ayre, SGH's chief nursing officer) and her team in SGH."

Certainly, the spotlight will be on Singapore's 38,000 nurses and 12,000 doctors.

Is this fair? Of course not.

Unfortunately, the doctors and nurses at SGH's Ward 64A and Ward 67 were found to have poor hygiene practices and were not adhering to protocols set up by the hospital to avoid just such an outbreak.

They deviated from protocol and caused the infection, and so, they are guilty. Or are they?

Singapore faces a shortage of doctors and nurses. This is a known fact and has been the case for some years.

Having protocols is well and good. But to be fair to our nurses, there is only so much they can do when they are told they have to uphold these standards all the time, while we are also demanding that they have to take care of so many patients, and do it all within a set amount of time.

We need to ask: How realistic are the demands we make on healthcare workers?

They are not superhuman. They get tired too.

When people are tired and rushed off their feet, things can go wrong.

Unfortunately, in a hospital, when things go wrong, they can go wrong very badly - as in this case.

And yes, Singapore and SGH must now ensure that this does not recur. Infection control must be strengthened.

But how it is done is equally important.

There is little point in putting in many more layers of prevention, making it even more difficult for staff, unless these measures are really necessary and possible to be carried out in the real working environment.

The IRC pointed out that the layout of Ward 67 - where the bulk of the infections occurred - added to the work of staff as the preparation room was at one end of a long corridor, and not centrally located as it was in Ward 64A.

Enhancing the environment to reduce unnecessary work would be a good start.

Another possibility is to streamline some of the work. Medical carts and trolleys have to be properly cleaned between patients, and before they are pushed into the "clean" preparation room. A cursory wipe with antiseptic is obviously not enough.

But is it absolutely necessary for a nurse to do it?

Perhaps it might be better that such trolleys, once used, be pushed into a cleaning room where housekeeping staff can do a thorough job. Meanwhile, nurses can use a fresh trolley for the next patient.

This would mean having a far larger supply of such trolleys - but surely that is a minor investment for such a major benefit.

Looking for newer and better ways of doing things would do more to restore confidence than hospitals saying they will intensify checks and monitoring systems.

Simply doing even more of the same is unlikely to reassure the public and win confidence.

After all, SGH had already been strengthening its infection control before the checks by the IRC. And still, there were notable lapses.

Shortage of staff is something the healthcare system will continue to face in the foreseeable future. We need robust systems that work around this problem.

No doubt, there will be some finger-pointing following this unfortunate incident. But we need to go beyond that, to make sure that something positive emerges from the episode in the long term.

Hospitals reminded to report acute hepatitis C cases quickly
Experts say hospitals should not wait to finish their investigations or try to solve problem by themselves
By Tan Weizhen and Linette Lai, The Straits Times, 10 Dec 2015

The Ministry of Health yesterday sent a reminder to hospitals, stressing that they must report acute hepatitis C cases within 72 hours. Its reminder came a day after the Singapore General Hospital was criticised for not reporting its hepatitis C outbreak quickly enough.

Meanwhile, experts said such incidents should be reported sooner rather than later, instead of hospitals waiting to finish their investigations or trying to solve the problem all by themselves.

"The MOH would like to remind all hospitals that acute hepatitis C is a notifiable disease under the Infectious Diseases Act. Notifications must be made within 72 hours," said the circular signed by Dr Jeffery Cutter, director of the Communicable Diseases Division (CDD), on behalf of the director of medical services.

It said a separate notification has been sent to clinical laboratories.

The call for quick reporting was echoed by others, too, including a member of the Independent Review Committee that examined the SGH outbreak.

"When you have a sniff that there's an outbreak, maybe we should activate the new unit in the ministry (CDD) that deals with outbreaks so that we can get together, the ministry plus the hospital, draw in experts, draw in resources to understand what was the source of the outbreak and how to deal with it in a more expedient manner," said Professor Lim Seng Gee, a senior consultant of the gastroenterology and hepatology division at the National University Hospital, at a briefing on Tuesday.

He also said that, in the future, any hospitals facing such unusual outbreaks should draw on the MOH's resources to deal with it.

But would hospitals turn to the ministry quickly enough?

One health expert suggested that since SingHealth and the National Healthcare Group had been formed, there had been a slight disconnect between the ministry and the healthcare clusters as most clinically trained staff had moved from the MOH to these clusters.

Healthcare consultant Jeremy Lim, former chief executive of Fortis Hospital who was also involved in making policy at MOH, said: "Ministries are typically designed as policy units rather than operators and the different knowledge and expertise might lead to governance challenges."

Dr Lim added that the episode could present an opportunity to strengthen the healthcare system to respond to future threats.

"We need many more doctors and nurses to be specially trained in the management of infectious diseases and public health," he said, while acknowledging that not many healthcare professionals would wish to be bogged down by compliance issues.

Infectious diseases physician Leong Hoe Nam concurred.

"For too long we have ignored infection control, and perhaps even paid lip service to the dangers of infectious diseases spread. We need to put more manpower and resources into infection control related work, to recognise, identify, notify and contain. Doctors who are infection control trained are already in short supply and there is high demand for them in Singapore. They have to do their regular work and yet do outbreak investigations - this is too much."

He also asked for a closer watch on other possible outbreaks.

"It calls to question if we should be monitoring other diseases too, besides hepatitis C. For instance, chickenpox, measles, norovirus, rotavirus in the hospitals. Perhaps they are not too threatening to life - but they are capable of causing outbreak situations."

However, Ang Mo Kio MP Koh Poh Koon, who was a colorectal surgeon before he entered politics this year, called for people not to overreact, saying: "In the larger context, it is an unusual occurrence; it is a rare incident in the long history of Singapore's healthcare system."

What matters more to patients is the hospitals' long-term performance, he said.

GPC wants clearer steps to detect, report outbreaks
By Chong Zi Liang, The Straits Times, 10 Dec 2015

The Government Parliamentary Committee (GPC) for Health has called for a clearer protocol in detecting and reporting incidents like the hepatitis C outbreak in Singapore General Hospital (SGH).

Its chairman, Dr Chia Shi-Lu, said yesterday that the GPC welcomed the recommendations of the independent review committee that looked into the spread of the virus in SGH's wards 64A and 67. The outbreak affected 25 patients, eight of whom have died.

The GPC also supports the measures the committee recommended to improve infection control practices at hospitals, added Dr Chia, an orthopaedic surgeon at SGH.

He urged hospitals to adopt a more cautious approach even if it was not easy to determine the precise conditions that warrant raising the alarm. "It may be difficult to define alert or red lines for reporting, but in the light of this event, a more conservative perspective with low thresholds would be desirable," he said.

Dr Chia noted with concern that the exact cause of the outbreak is still unknown, but "this is not entirely unusual as for other similar cases elsewhere, it is often difficult to pinpoint the cause".

However, as the outbreak ceased after procedures at the hospital were tightened, it was most likely that a significant cause was related to its lapses in infection control practices, he said.

A task force, headed by Minister of State for Health Chee Hong Tat, has been formed to boost infection control in all hospitals, following the release of the committee's report on Tuesday.

Dr Chia, an MP for Tanjong Pagar GRC, said his GPC is awaiting more details from the Health Ministry on the framework to strengthen the handling of such matters. It will then study the proposed measures and give its feedback.

MacPherson MP Tin Pei Ling, who is also a member of the GPC for Health, said the focus should be on minimising the risk of a similar outbreak happening again.

Jurong GRC MP Tan Wu Meng, another GPC member, said early recognition is crucial for diagnosing uncommon hospital-associated infections and outbreaks, and for calling in extra resources earlier.

"Modern hospitals today generate enormous amounts of data, lots of clinical observations of symptoms, physical check-ups, blood tests, and so on. But this data can be spread out over multiple departments - some digital, some on paper," he added.

"The future of outbreak surveillance should involve better use of electronic medical records, with inter-operable databases and big data analytics to help human experts pick up problems sooner."

Call for regular audits and clear rules at hospitals
By Linette Lai and Tan Weizhen, The Straits Times, 10 Dec 2015

Hospitals should have regular audits and make rules as easy to follow as possible, say those in the industry, and not just have good infection control protocols.

These measures, which could range from conducting surprise spot checks to making sure that sinks are conveniently located, would help to reduce the risk of transmitting infections.

The topic has come under the spotlight after an independent review committee found that poor infection control caused the hepatitis C outbreak at the Singapore General Hospital (SGH) earlier this year.

Some 25 kidney patients who were admitted to the hospital between January and September this year were diagnosed with the blood-borne virus. Eight of them have since died.

Regular audits, suggested Dr Desmond Wai, of Mount Elizabeth Novena Specialist Centre, are a way of helping staff be more aware of what they are doing.

"It's like driving - if you know there's a speed camera up ahead, you will slow down," the gastroenterologist said.

Hospitals, he added, should try to make following the standard protocol as easy as possible for all healthcare staff. "For example, you need to think about the workflow so that the clean and dirty areas never overlap," he said. "The flow between them should be one-way only."

In response to queries yesterday, a Ministry of Health (MOH) spokesman said that it carries out biennial inspections of all hospitals to ensure they comply with regulations.

"Since we were informed of the outbreak, MOH has reminded all healthcare institutions and providers of the need to strictly comply with clinical protocols and guidelines, including infection prevention and control safeguards," the spokesman said.

Comparing the hepatitis C outbreak with the severe acute respiratory syndrome (Sars) crisis in 2003, healthcare consultant Jeremy Lim said that it shows that people tend to be more alert when they are at personal risk.

"During Sars, healthcare professionals here were more vigilant because they were personally much more at risk," said Dr Lim, who also teaches at the National University of Singapore's Saw Swee Hock School of Public Health.

"For a lot of hospital-acquired infections, the patients are more at risk because they are immuno-compromised."

Experts also said that, as far as possible, hospitals should try to make sure the staff on duty are able to adequately handle patient loads to reduce the risk of accidents.

"When we are in a rush, we are tempted to take shortcuts," Dr Wai pointed out.

His sentiments are shared by former nurse Elizabeth Chan, who remembers how, as a young nurse in the 1970s, she once dashed to deliver a baby with her bare hands - only to get a literal slap on the wrist from her mentor. "She told me: 'The baby won't fall; put on your gloves!'" recalled Ms Chan, 69, who used to be a hospital nurse and is now a senior nurse educator.

"I think it's easier to make mistakes or miss out some steps when you're in a hurry."

Hepatitis C: Before the next outbreak threatens...
By Jeremy Lim, Published The Straits Times, 10 Dec 2015

Singapore General Hospital (SGH) staff woke up yesterday to the sobering headlines that "lapses" at their hospital were responsible for the hepatitis C outbreak that led to 25 infections among its patients and contributed to seven deaths.

In a hard-hitting report, the independent review committee (IRC), while noting SGH had "several commendable practices", found it wanting in select infection prevention and control practices. The Ministry of Health (MOH) and SingHealth, SGH's parent cluster, have announced immediate measures to strengthen processes and also potential disciplinary action against individuals.

Newly appointed Minister of State for Health Chee Hong Tat will lead a task force to examine national-level gaps and make improvements to the surveillance and outbreak response systems.

As the dust settles and the investigations and actions move into the next phase, it is worth pausing to reflect after two months of intense investigations. As with any crisis, there are three prongs to the response - treat the affected, hold those responsible accountable and strengthen the system.

The families who have lost loved ones deserve more than apologies, no matter how sincere and heartfelt, and compensation, which should be worked out on a case-by-case basis. Likewise for the 25 infected patients. It is good that SGH has taken responsibility, but let us not forget the many healthcare professionals impacted by this. None of us want our patients to suffer adverse events or outcomes, least of all that it be wrought by our own hands. It has been a terribly difficult period for all affected and we need to support the doctors and nurses emotionally devastated by what has occurred.

Individual clinician failings aside, hospital leaders and system planners have responsibility for what MOH cautiously worded in its media release as "delayed recognition of the HCV (hepatitis C virus) outbreak by SGH, and delayed escalation from SGH to SingHealth, from SGH to MOH, and within MOH". These delays may have cost lives as MOH tacitly acknowledged, as it noted that measures by SGH to tighten infection control processes from June were "instrumental in containing the spread of infection".

There is a delicate balance to strike, as those responsible must be taken to task but, at the same time, Singapore cannot lose forever the wealth of experience those involved have gained through this painful episode. We also cannot be so ruthless that talented clinicians and healthcare managers shun key positions in the ministry and public hospitals.

Mr Chee has an unenviable task. Perhaps with the benefit of hindsight, the design of our current national outbreak surveillance system is naive, premised on too many individual actions - doctors have to be alert enough to spot notifiable diseases and report them, ministry officials have to make sense of disparate data points and "join the dots" to form a coherent picture and effect the right escalations in a timely fashion. And this is only for the known diseases; what about the "unknown unknowns"? Singapore is a global city and we live with constant risk of exposure to novel diseases brought in by travellers. We are also a potential target for terrorists who not only terrorise with bombs and guns but also germs, chemicals and radiation.

A chain is only as strong as its weakest link, and in this instance, not even a chain, but a net is called for. What could this look like? Technology-enabled human actions could help.

"Big data" is taking the world by storm, famously allowing the retailer Target to correctly identify a pregnant shopper and even her due date.

In healthcare, the Global Public Health Intelligence Network (GPHIN), a cooperative effort initially between only Canada and the World Health Organisation, scans, on average 3,000 newspapers and other communications globally every day for potential indicators of outbreaks, and then aggregates these findings for a team of analysts to consider and issue alerts as appropriate. The utility of the GPHIN was first demonstrated with Sars in 2003 and more recently, GPHIN was credited with being the first to issue an alert about Middle East respiratory syndrome coronavirus .

Today, it also tracks potential chemical and radio-nuclear hazards. Various other data sources, including social media, online searches and even physicians' use of clinical databases are being used and while each on its own is limited, collectively they may provide powerful and timely insights less reliant on human interpretation and action.

In the movie A Beautiful Mind, there is a scene where actor Russell Crowe, playing the brilliant mathematician John Nash, stares at a window filled with complex equations. He stares intently and suddenly, the truth springs out at him. This is dramatic effect appropriate for the movies, but in the real world, we need data mere mortals can make sense of and use for effective decisions.

A network of data sources synthesised as above, coupled with strengthened notification processes by doctors and laboratories, could provide the MOH with rich information to identify early outbreaks, whether they be related to raw fish or hospitals.

The human element nonetheless remains vital and Singapore needs to ensure some of our best and brightest physicians interested in infectious diseases and public health opt for careers in the Ministry of Health. "All hands on deck" are also needed, given the modest numbers of infectious diseases and public health specialists nationwide, and we need to work out how to leverage on the deep knowledge and expertise in both the public and private sectors.

Singapore has suffered a major blow to our healthcare system but we can pick up the pieces, learn and become stronger. We will have to, as the breadth of diseases and complexity will only increase. It is a matter of time before the next outbreak threatens. Will we be ready?

The writer is a partner in the health and life sciences practice of Oliver Wyman, a management consulting firm.

Task force to study best practices in disease control in wake of SGH hepatitis C outbreak
It will plug gaps raised by review committee in the wake of hepatitis C outbreak at SGH
By Salma Khalik, Senior Health Correspondent, The Straits Times, 10 Dec 2015

Singapore will turn to the international arena to draw on "best practices" that can strengthen its ability to respond to infectious disease outbreaks, both in hospitals and the community.

Minister of State for Health Chee Hong Tat will lead a task force, to be set up shortly, to plug gaps highlighted by the Independent Review Committee, which analysed the hepatitis C outbreak at the Singapore General Hospital (SGH). The outbreak, first detected in mid-May but reported to the Ministry of Health (MOH) only in September, affected 25 renal patients and may have caused the deaths of seven.

In its report released on Tuesday, the committee found that lapses at SGH had led to the outbreak. These included gaps in infection prevention and control practices, failure to recognise the outbreak, inadequate investigations and delays in notifying the higher authorities in the hospital and ministry.

The committee noted that a contributing factor was the nature of hepatitis C, a liver infection that does not have obvious symptoms.

Mr Chee said that while Singapore has an effective surveillance system for community outbreaks, the panel had highlighted "gaps in how we detect and respond to uncommon and unusual infections".

This will be the focus of the task force, announced by Health Minister Gan Kim Yong on Tuesday. It is expected to complete its work by the middle of next year. Mr Chee said: "We will learn from international best practices to adapt to our local context, and work closely with healthcare institutions and medical professionals to improve our systems and processes."

MOH said yesterday it had reminded all healthcare institutions and providers to comply strictly with clinical protocols and guidelines. It has also strengthened its own capabilities to detect potential outbreaks, including designating the Communicable Diseases Division to oversee the surveillance of all infectious diseases, and all related information such as notifications and reports.

MOH has also revised its notification criteria for acute hepatitis C infections to be in line with international best practices.

As experts and MPs weighed in on the issue - with many noting the importance of sticking to existing protocols - the opposition Workers' Party suggested that a retired and respected medical professional be appointed as a joint head of the task force.

'Difficult period' ahead, but nurses urged to stay strong
By Linette Lai, The Straits Times, 10 Dec 2015

Nurses have been urged to "stay united and strong" in the wake of the recent hepatitis C outbreak at Singapore General Hospital (SGH).

In a Facebook note yesterday, the Health Ministry's chief nursing officer, Ms Tan Soh Chin, also urged her colleagues to take a look at infection control practices in their institutions and stressed the importance of sticking to them.

"I would like to encourage all of you to stay positive and be open to acknowledge there are areas for improvement," she wrote in the note, which was shared by the Ministry of Health (MOH).

She also stressed the importance of "patient safety and strict adherence to infection control protocols and measures".

The IRC report on the Hepatitis C cluster at SGH’s renal ward is a timely reminder of the critical role that our...
Posted by Ministry of Health on Tuesday, December 8, 2015

On Tuesday, the independent review committee charged with investigating the outbreak released its report, which found that poor infection control was the main reason for the infections.

Twenty-five kidney patients who stayed in Wards 64A or 67 between January and September this year came down with the virus, eight of whom died.

Ms Tan also wrote that SGH chief nurse Tracy Carol Ayre and her team "have been working tirelessly to strengthen and tighten the infection control practices and standards for many months".

"In the next few days and weeks, it will be a very tough and difficult period for nursing and especially chief nurse Tracy and her team in SGH."

"We are confident that chief nurse Tracy and team will regain and restore the trust and confidence of their patients and families," she added.

Netizens who commented on the post were generally encouraging, with several calling for more stringent checks on the healthcare system and staff's adherence to standard operating procedures.

"This is a very unfortunate event," wrote one. "The independent review committee has found lapses, hope the healthcare professionals can quickly put in place remedies."

Infectious disease expert Leong Hoe Nam of Mount Elizabeth Novena Hospital noted that the SGH renal department is one of the most established in Singapore, and that many of its staff have worked there for several years.

"They are certainly not short of experience," he said. The hepatitis C incident, he added, "is a reminder to everyone - not just SGH - that we need to be vigilant in all infection control".

Dear Sisters and Brothers of the Healthcare Services Sector,We know how much all of you have put in throughout all...
Posted by Chan Chun Sing on Thursday, December 10, 2015

Unusual factors in SGH hepatitis C outbreak
An infectious diseases expert assesses the independent review committee's report to highlight what was done well, and the need to empower healthcare workers to do their job better
By Paul Ananth Tambyah, Published The Straits Times, 12 Dec 2015

The independent review committee (IRC) report on the recent outbreak of hepatitis C at the Singapore General Hospital (SGH) has 81 pages of detailed facts, figures, assertions and conclusions. It would be good, first of all, to review what we know about hepatitis C viral outbreaks globally.

Unlike hepatitis A and E, which are spread by contaminated food and water, hepatitis B and C are spread exclusively by blood and body fluids. Hepatitis B is being brought under control globally with successful vaccination programmes in which Singapore was a leader and pioneer. Hepatitis C has no licensed vaccine but, in recent years, there have been a number of drugs which have been remarkably successful in curing the disease. However, these drugs are very expensive and can cost in excess of US$80,000 (S$112,400) for a three-month course.

Patients with acute hepatitis C usually do not have any symptoms at all, although occasionally patients will have jaundice (yellowing of the skin) and other signs of liver disease. As a result, most outbreaks, even in major academic medical centres internationally, were not detected for months.

A rare complication of hepatitis C that was previously reported to occur infrequently in transplant patients (1.5 per cent of kidney transplant patients in one large study), called fibrosing cholestatic hepatitis (FCH), can lead to rapid progression to liver failure and death.

Surprisingly, this occurred in many of the transplant patients in the recent SGH outbreak, which probably accelerated its detection and reporting. Dozens of previous hepatitis C outbreaks in hospitals worldwide have almost never resulted in fatalities. This is one of the many unusual features of the SGH outbreak.

Hepatitis C is most efficiently spread through unsafe injection practices, inadequately screened blood transfusions, by sexual contact and by contamination when administering injections. Hepatitis C cannot be spread by casual contact and unless the skin is broken, there is no risk of an individual contracting hepatitis C. It cannot be spread by ordinary interactions or by simply handling objects in an environment where people with hepatitis C live, work or are taken care of.

Hepatitis C is also not even that easily spread through broken skin. When a healthcare worker sustains a sharp injury from a hepatitis C-infected patient, the documented rates of infection range from 0.2 to 5 per cent.

Hepatitis C is rare in the general Singapore population, with less than 0.5 per cent of the population estimated to be positive. However, there are certain groups in Singapore who have much higher infection rates. A study this year of 170 illicit drug users in Singapore found that while none of them was HIV-infected (as most did not share needles), nearly 40 per cent were hepatitis C-positive. This could be because they often shared drug paraphernalia and the hepatitis C virus can survive much longer outside the body than HIV.

A 2006 report stated that 46 per cent of Singapore patients with haemophilia (a blood disorder that requires frequent blood and clotting factor transfusions) and 28 per cent of Singapore patients on haemodialysis ("blood dialysis") were hepatitis C-positive.

In contrast, only 5 per cent of Singapore patients on peritoneal dialysis ("water dialysis") were found to be hepatitis C-positive; this again emphasises the importance of blood and injections in the spread of the virus.


Singapore has had a comprehensive surveillance system for hepatitis C for years. All cases of viral hepatitis B and C are required by law under the Infectious Diseases Act to be notified to the Ministry of Health (MOH) within 72 hours.

According to a report published in the local Epidemiology News Bulletin last year, all these notifications are individually reviewed by an MOH public health officer, who decides if the cases meet the current case definition of acute hepatitis C. Cases meeting the definition are then investigated to determine the source of the infection.

According to that report, the rate of acute hepatitis C infection dropped from 10.1 per cent of all viral hepatitis cases notified in the years 2005-2007 to 2.4 per cent in the years 2008-2013. This was due mainly to successful efforts to curtail the illicit injection of subutex (a drug used to treat opiate addiction) by Singaporean substance abusers.

In addition, under the Private Hospitals and Medical Clinics Act (PHMC), all dialysis providers are required to routinely test patients for HIV, hepatitis B and hepatitis C.

The National Organ Transplant Unit of the MOH also does passive surveillance of viral infections after transplantation to ensure that there are no outbreaks such as the tragic cases of dengue in transplantation in 2003.

In addition, the regulations under the PHMC cover serious reportable events, including infections post-transplant. These mandate reporting within two working days.

MOH also routinely keeps track of selected hospital-acquired infections, in particular hospital- acquired methicillin-resistant Staphylococcus aureus (MRSA) infections as a marker of the quality of infection control programmes. It would be interesting to know if the devastating general "infection control lapses" which are being blamed for the SGH hepatitis C outbreak were also reflected in increased MRSA rates in the affected wards.

As the above survey of MOH surveillance measures suggests, an existing system is in place to monitor hospital-acquired infections. However, the implementation of these systems in the different hospitals and healthcare facilities needs to be strengthened and made both practical and effective.


The US Centres for Disease Control and Prevention (CDC) published a report this year in the journal Hepatology of all the outbreaks of hepatitis C reported in developed countries. There were 46 healthcare-associated outbreaks of hepatitis C from 1990 to 2012. Seven were caused by hepatitis C-infected surgeons, seven by incidents in anaesthesia due mainly to reuse of syringes or multi-dose vials, 24 were caused by breaches in infection control (predominantly related to haemodialysis, reuse of syringes, multidose vials or the older spring-loaded blood-sugar testing devices), and eight were deliberate acts of drug diversion by healthcare workers tampering with narcotic solutions.

Tampering occurs when someone with access to controlled drugs (narcotics) injects himself and then re-enters a vial of narcotic drugs using the same syringe or needle. If that person is hepatitis C-infected, there is a high risk that the virus can be spread to patients who are on these powerful painkillers for legitimate reasons.

Alternatively, tampering occurs when an illicit drug user taps a nearby saline solution to "top up" a vial of narcotics after helping himself to some of the drug. The vial will then look like it is still full of the narcotic on visual inspection when, in reality, it may have only half the concentration of the drug.

There are a series of steps which needs to be taken to elucidate which of these is the cause of an outbreak and these are illustrated in Annex A of the Independent Review Committee Report.

They include defining cases, doing a case control study to identify risk factors for infection and testing the hypotheses generated. The one step not listed in the Annex A list that was also not done by the SGH infection control team was a broad sweep to determine the extent of the infection by making a public call for those potentially infected to come forward for testing and treatment.

For some reason, that was delayed and the SGH leadership is now paying the price for that delay.

Its case control study was, however, well done and it showed that patients in the affected wards who were infected were nearly three times more likely than non-infected patients to receive an intravenous fluid injection. This is consistent with other outbreaks in developed countries where contaminated fluids have spread the virus.


Finally, most modern outbreak investigations use DNA/RNA-fingerprinting or molecular epidemiology to link viruses or bacteria isolated from outbreaks.

This is another striking feature of the SGH outbreak - the isolates were almost identical, which strongly suggests a single point source outbreak (such as repeated contamination of saline solutions from the same index case). A general breakdown in hospital hygiene would usually result in a multiplicity of strains reflecting the different viruses present in different patients in the wards or hospital at the time.

The IRC had a difficult job attempting to do a high-profile investigation in a short period of time. It is unclear if the committee had the benefit of information available only to law enforcement about who had access to various fluids. This highlights some of the problems in trying to prevent future occurrences.

The investigation by the SGH infection control team led to the tightening of procedures and the effective end of the outbreak soon after it was recognised.

The IRC report, however, highlighted structural issues which may have led to contamination of intravenous fluids by busy or distracted ward staff and which need to be addressed urgently.

In conclusion, this was a very unusual outbreak with a virulent virus and many lessons learnt for the Singapore clinical and public health communities.

I hope that the reaction will not be more bureaucracy but rather strengthening of existing surveillance systems and empowering healthcare workers at all levels to do what we are called to do - look after sick patients without doing them any harm, as the medical adage goes: Primum non nocere, first do no harm.

The writer is an infectious diseases physician and lecturer who trained in the United States and Singapore. He was also a Singapore Democratic Party candidate in the last general election.

Gaps in healthcare system may be fixed with new laws
That is one way, says task force leader; but time needed to study areas for improvement
By Linette Lai, The Straits Times, 12 Dec 2015

New laws could be a way to plug the gaps in the healthcare system revealed by the hepatitis C outbreak, Minister of State for Health Chee Hong Tat said yesterday.

However, Mr Chee stressed that it is too early to provide details as the task force set up to strengthen infection control in all hospitals starts work only early next week.

"The measures that we are going to put in place could also include legislative requirements that would have to be complied with by all healthcare institutions," he said.

"But we just formed the task force, and I think we do need a bit of time to first understand our system (and) see where are the areas for improvement," he added.

He spoke to reporters to give more details of the eight-member task force established to boost the healthcare system's ability to detect and respond to disease outbreaks.

Led by Mr Chee, the task force has experts in infectious diseases, systems engineering and data science. It will likely look at best practices in places like the United States, Britain and Hong Kong, and is expected to complete its work by mid-next year.

Currently, most measures to prevent and control infectious diseases in Singapore come under the Infectious Diseases Act in force since 1977. It includes provisions for the director of medical services of the Ministry of Health (MOH) to get patient information from doctors to investigate an outbreak, and to fine or jail those who lie about donating infected blood, for example.

On Tuesday, the independent review committee (IRC) tasked with investigating the hepatitis C outbreak at the Singapore General Hospital (SGH) concluded that poor infection control practices, and a slow response, were to blame. It also found lapses in the detection and response system for disease outbreaks here.

A total of 25 kidney patients admitted to the affected SGH wards between January and September this year were diagnosed with hepatitis C. Eight have since died.

Yesterday, Mr Chee said that while the task force was formed specifically to implement IRC recommendations, it will look at the healthcare system from a "holistic point of view". "We intend to take the opportunity to see how we can do a thorough systems-level review, and identify where are the areas for improvement, and take concrete steps to address the gaps."

Apart from learning from international best practices, local medical professionals will be asked for feedback on how to enhance the system.

Dr Chia Shi-Lu, who chairs the Government Parliamentary Committee for Health, had previously called for a clearer protocol in detecting and reporting incidents such as the hepatitis C outbreak.

He told The Straits Times last night: "I think the important thing is to have a robust framework for (dealing with) infectious diseases that can be audited and is enforceable.

"Whether or not it needs to be legislated is open for debate."

Good controls exist already: Experts

What hospitals need to do is to instil 'a culture among staff of keeping patients safe'
By Linette Lai and Tan Weizhen, The Straits Times, 17 Dec 2015

Singapore already has good infection control measures in place - it just needs to make sure that people stick to them, world experts say.

Ways to do that include building a culture that ensures sticking to strict hygiene practice, led and reinforced by the chief executive officers or chief nurses of hospitals.

"There are many standard infection control measures with which healthcare facilities in Singapore are familiar," said Professor David Heymann, chairman of Public Health England, an executive healthcare agency in Britain.

"What is needed is to ensure adherence all the time; hence there is a need for regular internal and external audits."

Sir Liam Donaldson, former chief medical officer at England's Department of Health and now chair of World Alliance for Patient Safety, World Health Organisation, agreed.

He said: "I'll be surprised if Singapore isn't already familiar with international best practices of infection control. The challenge is if there is a culture of carelessness, lack of leadership.

"The board, the CEO and the chief nurse should be instilling a culture among the staff of keeping the patients safe. The big question now is, could this happen in any other Singapore hospital?"

The topic came under the spotlight after the committee investigating the hepatitis C outbreak at the Singapore General Hospital (SGH) concluded that poor infection control practices and a slow response time were to blame.

Last week, Minister of State for Health Chee Hong Tat named the eight members of a task force which will work to plug these gaps. It is expected to finish its work by the middle of next year.

Professor Seto Wing Hong, who is director of WHO's Collaborating Centre for Infection Control in Hong Kong, said Singapore should also pay closer attention to the health organisation's guidelines.

The committee reviewing the outbreak suggested that SGH adhere to infection control precautions under the US Centres for Disease Control and Prevention guidelines.

However, Prof Seto pointed out that while infections are broadly similar, these guidelines are formulated for the United States context.

Both he and Sir Liam added that Singapore needs to speed up its reporting process.

"If there is even one case of hepatitis C infection, that should be the trigger for action," Sir Liam said.

Changi General Hospital chief nurse Paulin Koh, who was on the review committee, said improving staff education could help improve infection control in hospitals.

"Understanding the rationale for the prescribed infection control protocols should help staff to remain vigilant at all times, and to appreciate the importance of adhering strictly to (such measures)," she said.

Going forward, the latest advances in medical innovations should be used to track such infections. For instance, other countries have started to explore the genetic fingerprinting of infections, which will help to track the way they spread, said Sir Liam.

* Hepatitis C saga: 16 penalised, systems strengthened

Sanctions include financial penalties; new response team to deal with disease outbreaks
By Salma Khalik, Senior Health Correspondent, The Straits Times, 18 Mar 2016

A total of 16 senior staff have been disciplined for their role in the hepatitis C infections linked to eight deaths at Singapore General Hospital (SGH) last year and a national response team has been set up to deal with disease outbreaks in the future.

Responding to the outbreak that exposed gaps in the system, both SGH and the Ministry of Health (MOH) have acted to strengthen their processes while pulling up senior staff who were found wanting when the infections flared up last year.

Four senior MOH officials - holding director-level or equivalent roles - were punished, said the ministry yesterday, adding that "disciplinary sanctions include warnings, stern warnings and financial penalties".

They had failed to intervene early and to ensure that the disease notification system was effective. "Those with higher level of responsibilities have received heavier penalties," said an MOH spokesman.

At SGH, where 25 patients were infected - including 20 who had received kidney transplants and were more vulnerable - the sanctions cut wider.

"For 12 staff in leadership positions, including senior SGH management, the disciplinary sanctions meted out include stern warnings and financial penalties for gaps in their roles in managing the outbreak or in infection control," the hospital said.

Following the Report of the Independent Review Committee’s (IRC’s) investigation, our priority has been to continue to...
Posted by Singapore General Hospital on Thursday, March 17, 2016

Both MOH and SGH declined to name those who were disciplined.

SGH became aware of the outbreak in its renal ward in May last year, but it was September by the time it informed the ministry's director of medical services.

In December, an independent review committee set up by MOH ascribed the outbreak to "multiple overlapping factors, including gaps in infection control procedures and protocols".

It also pointed out that there was no designated division within MOH to deal with an unusual healthcare-associated infection like hepatitis C, which led to delays in recognising it. To plug these gaps, MOH has set up a National Outbreak Response Team from March 1, to help healthcare institutions deal with disease outbreaks.

The reporting procedures for infectious diseases will also be simplified. Doctors can call an MOH hotline directly to flag urgent cases.

Also, instead of making two reports, doctors need to notify the ministry just once, without waiting for laboratory confirmation. MOH will follow up with the laboratories on is own to match results.

SGH, too, has initiated a wide- ranging review of its systems.

Potentially contaminated surfaces are being regularly disinfected. There are enhanced training programmes in place for staff, whose practices are also being closely monitored. Needleless connectors are being used hospital-wide.

SGH has also engaged international consultants to review clinical processes at its renal unit.

Disciplinary action taken against the MOH senior officials and SGH staff holding leadership positions included stern warnings and financial penalties.
Posted by The Straits Times on Thursday, March 17, 2016

* Focus now to review systems to enhance infection control

The Ministry of Health (MOH) and Singapore General Hospital (SGH) are deeply sorry for the hepatitis C outbreak at SGH's renal ward last year.

Affected patients remain our primary concern and will continue to receive hepatitis C treatment, counselling and support from SGH.

Senior health correspondent Salma Khalik's commentary suggests that MOH and SingHealth are intent on protecting officials and doctors, and have not viewed the outbreak seriously enough ("Name those responsible for hep C infections at SGH"; last Saturday).

This is not the case.

As the commentary itself noted, MOH set up an independent review committee to investigate the causes of the outbreak and recommend areas for improvement.

The independent review committee produced a thorough report that was released publicly.

The independent human resource (HR) panels that SingHealth and MOH established to look into disciplinary matters took into account the independent review committee's conclusions that the outbreak was due to gaps in infection prevention and control practices at SGH's renal ward, and that there were delays in escalation processes.

The SingHealth HR panel decided that the junior and front-line staff involved would be required to undergo retraining and competency assessment to improve infection prevention and control practices.

The panels decided instead to hold senior officers at SGH responsible for the failure to enforce a strong infection control regime and incident escalation protocols, and those at MOH for gaps, such as weaknesses in the national notification and surveillance system for unusual healthcare-associated infections such as acute hepatitis C.

The deliberations and recommendations of the independent human resource panels for SGH and MOH were carefully considered and approved by the SingHealth board of directors and the Public Service Commission, respectively.

We have made public the detailed findings of the independent review committee and announced the outcome of the disciplinary process.

Looking ahead, the focus for MOH and SGH is to review our systems and processes to enhance infection control and strengthen detection and response to infectious diseases.

Revealing the names of the officers would not contribute to fixing the gaps in infection controls and reporting practices.

Healthcare institutions have instead tried to foster a culture that encourages continual learning and improvement.

In deciding what to disclose, we have to bear in mind the longer-term impact on our healthcare system and healthcare workers, and strike a balance.

Lim Bee Khim (Ms)
Corporate Communications
Ministry of Health
ST Forum, 22 Mar 2016

Hep C outbreak at SGH: Staff confidentiality has no part to play when there is a serious breach of patient care, writes ST's senior health correspondent Salma Khalik.
Posted by The Straits Times on Friday, March 18, 2016

"There is some, albeit unhealthy, satisfaction in seeing public servants being named and shamed. But we must not confuse...
Posted by The Straits Times on Tuesday, March 22, 2016

Don't conflate accountability with naming and shaming

Senior health correspondent Salma Khalik argues for the identities of the 12 Singapore General Hospital (SGH) and four Ministry of Health (MOH) staff who were disciplined to be released ("Name those responsible for hep C infections at SGH"; last Saturday).

The commentary makes several pertinent arguments that support the case for revealing their identities. But there are also equally valid, if not stronger, considerations that buttress doing otherwise.

A key element to be considered is the principle of causality.

The comparison made between the hepatitis C outbreak at SGH and the case of an SAF serviceman who died after a training session involving smoke grenades is not quite appropriate.

In the SAF case, it involved a single and quick episode where two officers were clearly responsible for the training session that preceded the tragic death.

In contrast, the hepatitis C outbreak lasted several months and involved quite a few patients who were cared for by dozens, if not hundreds, of healthcare professionals.

Many other staff in supporting roles, such as housekeepers and porters, could also have contributed to the outbreak.

Establishing direct causality and, hence, an individual's direct responsibility for the mortality and morbidity that arose from the outbreak is, therefore, very difficult, if not impossible. Is it then fair to name the 12?

The commentary concludes that doctors and ministry officials must be held accountable, and that public confidence in the system will be "badly eroded" if it is perceived that they get "special protection".

Modern hospital care is team-based, involving many more professionals and staff than just doctors.

There is no evidence to suggest that the 12 SGH staff who were disciplined were all doctors and, hence, enjoying "special protection".

The SGH press release stated that the 12 were in leadership positions and included senior management.

Senior positions in hospitals are typically filled by people from different professional backgrounds. It would be reasonable to think that the 12 may include doctors, as well as nurses, allied health and "lay" managers. Why just single out doctors?

There is some, albeit unhealthy, satisfaction in seeing public servants being named and shamed.

But we must not confuse or conflate accountability with naming and shaming.

It is noteworthy that both SGH and MOH have stated clearly that only senior people were disciplined.

It would be more expedient to punish junior staff if the principle of accountability was not paramount.

Wong Chiang Yin (Dr)
ST Forum, 23 Mar 2016

“The greatest penalty is not these disciplinary measures. ... For everyone involved, we will carry with us the pain and...
Posted by Channel NewsAsia on Monday, April 4, 2016

* Parliament: Revealing names in hep C saga 'could breed blame culture'

Health Minister says encouraging learning culture more beneficial in the long run
By Linette Lai, The Straits Times, 5 Apr 2016

Health Minister Gan Kim Yong said yesterday that naming the people responsible for last year's hepatitis C outbreak at the Singapore General Hospital will not help patients in the long run. The reason is that it could create a "blame culture" in healthcare institutions.

He told Parliament that it is more beneficial "to encourage a learning culture to make our hospitals as safe as possible for the patients".

"In deciding what to disclose, we have to bear in mind the longer-term impact on our healthcare system and healthcare workers, and strike a careful balance," he said.

Mr Gan made the point in his reply to Non-Constituency MP Leon Perera, who asked for the names of those disciplined over the outbreak, as well as details of the penalties they received.

Last year, 25 kidney patients admitted to SGH between January and September were diagnosed with hepatitis C infections. Eight of them died.

The independent review committee tasked with investigating the outbreak concluded that poor infection control practices and a slow response were to blame.

Sixteen senior staff - 12 from SGH and four from the Health Ministry - were punished.

The penalties meted out included "warnings, stern warnings and financial penalties".

Mr Gan did not elaborate on the specifics but said the warnings would remain on the staff members' service records.

Stern warnings would also have a negative bearing on their careers, including promotion and awards.

"But the greatest penalty is not these disciplinary measures," Mr Gan said.

"For everyone involved, including those who had provided direct care to the affected patients, we will carry with us the pain and regret of this incident for a long time to come."

The tragedy has also led SGH to strengthen its infection control practices, including the cleaning of potentially contaminated surfaces.

It has also stepped up staff training and education, and engaged international consultants to review its clinical processes.

Mr Gan listed these moves in his reply to Ms Cheng Li Hui (Tampines GRC) who asked about preventive measures taken to avoid a similar incident from happening again.

"We are also sharing the lessons learnt from this outbreak with all hospitals, and working with them to ensure their infection control, risk management and escalation protocols are in place," he said.

Meanwhile, a task force is looking at ways to strengthen the national healthcare system's ability to detect and respond to infectious disease outbreaks.

Set up last year by the Health Ministry, it is headed by Minister of State for Health Chee Hong Tat, and will complete its review by the middle of the year.

Independent Review Committee (IRC) Report of the Hepatitis C cluster in the Singapore General Hospital’s Renal Ward
MOH Accepts Findings of the Independent Review Committee
SGH accepts IRC's findings, apologises and takes steps to regain trust

SGH Hepatitis C outbreak
MOH sets up taskforce to enhance detection and response to infectious disease outbreaks
MOH sets up taskforce on strengthening outbreak detection and response
"SWAT Team" to tackle outbreaks of infectious diseases in Singapore

Hepatitis C Outbreak at Singapore General Hospital – Update on Follow-up Actions by MOH -17 Mar 2016
Update by SGH Following Report of the Independent Review Committee’s Investigation into the Hepatitis C Cluster -17 Mar 2016

Taskforce On Strengthening Outbreak Detection And Response Completes Its Review - 8 Jul 2016

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