THE independent review committee tasked to investigate the hepatitis C outbreak in the Singapore General Hospital's (SGH) renal ward in June, concluded that "a combination of multiple overlapping factors was the most likely explanation" for the cause.
The committee, led by Professor Leo Yee Sin, on Tuesday said the panel found that there were breaches in infection prevention and control practices in the two affected wards - 64A and 67 - in SGH.
It said there were deviations from standard procedures in administering intravenous protocols such as blood-taking, inefficient workflow in the affected wards, as well as evidence of contamination of medical equipment due to inadequate disinfection practices.
And these gaps increased the transmission risk of the hep C virus through intravenous procedures, the panel noted.
Another contributing factor was the high concentration of renal transplant patients in the affected wards.
Gaps in infection prevention and control may have been accentuated by the temporary move of the renal ward from 64A to 67, where the layout was different and the staff were unfamiliar with, the panel added.
It has recommended that SGH improve infection control by reviewing its existing standard operating procedures and practices to further reduce risk of contamination of medical equipment, to ensure compliance to standard precautions for infection control, as well as strengthen the monitoring and supervision framework of staff to ensure compliance.
The current national surveillance system works well for community outbreaks, while hospitals have robust frameworks to deal with common healthcare-associated infections, the committee said in its report submitted to the Ministry of Health (MOH) on Dec 5.
The committee also "found no evidence of deliberate delays by SGH or MOH staff in escalating the outbreak or in informing the minister of health".
But it found delays in the escalation processes within and from SGH to MOH and noted that the ministry did not have a division with clear responsibility to oversee outbreaks of unusual healthcare-associated infections.
It suggested MOH 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 for healthcare-associated infections, particularly unusual and unfamiliar ones.
SGH had announced on Oct 6 that 22 kidney patients had contracted hep C while receiving treatment in the hospital. To date, 25 patients in the hospital's renal ward have tested positive for hep C.