LAPSES in infection prevention and control practices played a key role in causing the hepatitis C (hep C) outbreak in the renal ward of the Singapore General Hospital (SGH) between April and June.
Of the 25 patients who contracted the illness, eight died. The independent committee tasked to investigate the case said the hep C virus likely caused the deaths of seven of them.
These were some of the findings in the report submitted by the committee to the Ministry of Health (MOH) last Saturday.
The committee found deviations from standard procedures in administering intravenous protocols such as blood-taking.
There was inefficient workflow in the affected wards, as well as evidence of contamination of medical equipment due to inadequate disinfection practices.
These gaps increased the transmission risk of the hep C virus through intravenous procedures, it noted.
The outbreak was localised in wards 64A and 67, where most of the patients were immunocompromised and had multiple exposures to intravenous medications and laboratory tests; these factors contributed to the outbreak, the panel found.
Ward 64A was the original renal transplant ward, but had to be closed for renovation. The patients were moved to ward 67 on April 6, and returned to ward 64A on Aug 28. This transfer of patients from ward 64A to 67 meant that hospital staff were unfamiliar with the layout and workflow in the new area.
The panel, led by professor Leo Yee Sin, on Tuesday said a combination of these "multiple overlapping factors" led to the outbreak.
Hep C is an infection of the liver and is spread through blood-to-blood contact.
On Oct 6, SGH announced that 22 kidney patients had tested positive for the hep C virus while receiving treatment there; three more cases were identified subsequently, bringing the total number to 25.
Earlier in the day, the police said in a statement that it found no evidence of intentional harm or foul play.
The report also ruled out possibilities of drug diversion and contaminated medical products as likely sources of the outbreak.
The committee noted that the "current national surveillance system works well for community outbreaks and that hospitals have robust frameworks to deal with common healthcare-associated infections (HAIs)".
The hep C virus is not easily picked up through regular surveillance because of its unique characteristics, noted Prof Leo, who added that the existing HAI framework did not cater to unusual HAI outbreaks.
The panel added that it "found no evidence of deliberate delays by SGH or MOH staff in escalating the outbreak or in informing the Minister of Health".
But it said SGH failed to recognise the outbreak earlier. Within the organisation, there was also a lack of clarity on the roles and responsibilities for the management of unusual HAI outbreaks. There were delays in the escalation processes within and from the hospital to MOH.
On the ministry's part, the panel noted that it did not have a division with clear responsibility and capabilities to oversee outbreaks of unusual HAIs.
It said that MOH needed to improve the national notification and surveillance system for acute hep C virus, designate a team within the ministry to carry out surveillance and to strengthen the escalation and communication processes among stakeholders for HAIs, particularly unusual and unfamiliar ones.
Health Minister Gan Kim Yong on Tuesday apologised to the affected patients and their family members for the lapses in the system, adding that he will set up a taskforce to be led by Minister of State for Health, Chee Hong Tat.
"It will look into enhancing our surveillance and detection and response to infectious disease outbreaks in the community and hospitals," he said, adding that more details will be shared in time to come.
Taking the committee's recommendation for a specific division to be set up within MOH to handle infectious outbreaks, Mr Gan said his ministry has designated its communicable diseases division to be responsible for infectious diseases within the community and in hospitals.
SGH, MOH and SingHealth will each appoint a human resource panel to look into the roles, responsibilities and actions of all key staff involved in the process, to determine who will be accountable and to assess whether disciplinary action will be taken, he said.
SingHealth's panel will include representatives from the civil service, while MOH's panel will be chaired by permanent secretary of the public service division, Yong Ying-I.
Mr Gan said the panel's findings will be shared with the healthcare community, "so all of us can learn and improve".
In a separate statement, SGH chief executive Ang Chong Lye apologised for the outbreak and said the hospital was determined "to regain the trust of Singaporeans".
"SGH takes a very serious view of what happened and will look into the areas identified by the committee on top of the enhanced practices and additional measures we have taken since June 2015. Our patients' safety and well-being are our highest priority," said Prof Ang, adding that the hospital has met with the affected patients and their families to provide them with full support.
Saying that SGH could have done better and escalated the matter earlier to SingHealth and MOH, Prof Ang said the hospital will work closely with the SingHealth infection control audit taskforce to conduct cross-institution audits to reinforce the standards of infection control practices.
SingHealth, the parent organisation of SGH, has appointed a report implementation committee to follow up on the panel's suggestions. Both SingHealth committees are led by Prof Tan Kok Hian, SingHealth's group director of academic medicine.
Said Fong Kok Yong, chairman of the medical board at SingHealth: "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. SGH will work with MOH to implement the committee's recommendations. We will leave no stone unturned to enhance patient safety, and do all we can to prevent recurrence of such an unfortunate event."