The news of the outbreak of hepatitis C infections in the renal ward of Singapore General Hospital (SGH) that left 22 infected and 8 dead have left many Singaporeans reeling from shock. Many questions have been raised on why neither SGH nor the Ministry of Health (MOH) went public with the outbreak earlier.
In a statement released yesterday (7 Oct), MOH said that SGH had reported to it in late August that it had identified a cluster of 21 hepatitis C cases that were suspected of being linked. MOH also clarified that because there were no signs such as jaundice earlier to suggest that these were cases of acute viral hepatitis C, that the public had not been alerted. Further, a MOH spokesperson added that “it can be difficult to detect such asymptomatic hepatitis C based on blood tests alone, doctors usually look for a link to an event of relevant exposure…”
While the probable cause for infections is suspected to be a lapse in the use of multi-dose medication vials, the exact cause of the infections is still under investigation.
Timeline outlining actions taken since the first diagnosis of hepatitis C.
- “MOH told of hepatitis C cluster at Singapore General Hospital in late August” (The Straits Times, 8 October 2015)
- “Public not told earlier ‘as there were no signs of acute hepatitis C cases” (TODAYOnline, 8 October 2015)
- “Timeline on outbreak of hepatitis C infections at SGH” (TODAYOnline, 6 October 2015)
MOH told of hepatitis C cluster at Singapore General Hospital in late August
Ministry gives detailed timeline of events relating to the SGH cases
SINGAPORE - It was in late August that the Singapore General Hospital (SGH) reported to the Ministry of Health (MOH) it had identified a cluster of 21 hepatitis C cases and suspected they were linked.
On Sept 3, after reviewing SGH's report, Associate Professor Benjamin Ong, the director of medical services (DMS) at MOH, met SGH clinicians.
They told him tests showed the virus in the 21 cases was related. They also said they had taken enhanced control measures and noted there had been no further cases after June 24.
Dr Ong asked that the work be done expeditiously, and no later than two weeks.
The ministry on Wednesday (Oct 7) released this information, giving a detailed timeline in response to queries on why it had taken so long to inform the public of the cluster.
In mid-May, SGH had suspected that kidney patients might be contracting the liver infection while in hospital. Its tests showed the patients were infected from the same source, though that has not been found. Eight patients died, with four deaths thought to be linked to the hepatitis C infection.
MOH was notified of the 22nd case on Sept 21.
Following their meeting on Sept 3, this was the timeline of what next took place:
• On Sept 4, an MOH team visited the renal ward (Ward 64A and 67) and were taken through the processes by SGH.
• On Sept 7, an A*Star laboratory confirmed SGH's initial findings that the 21 cases were related.
• On Sept 9, SGH began screening all doctors and nurses who had taken care of the patients. Altogether, 76 staff members were screened and found negative for hepatitis C.
• The Medical Review Committee and Quality Assurance Review Committee also met in September.
• On Sept 18, Health Minister Gan Kim Yong was told about the cluster. He requested a briefing from SGH, who asked to see him on Sept 25 to give them time to complete their investigations and report. After the briefing, Mr Gan instructed that an independent review committee be set up, and for SGH to make public its preliminary findings.
• On Sept 28, the members of the Review Committee were appointed by Dr Ong, comprising clinicians from different disciplines.
• On Oct 6, SGH held its media briefing on the cluster.
The ministry said in its statement on Wednesday: "In the investigation, the primary consideration has been to try to get to the root cause of the issue as soon as possible, exploring all possible angles, to prevent recurrence. At the same time, the teams from SGH and MOH were mindful of the need to make public the cases as soon as preliminary investigations were completed."
It also said on Wednesday that it had previously been notified by the SGH laboratory of the cases as all acute hepatitis C infections must be reported within 72 hours.
However, as the patients did not have symptoms such as jaundice, the cases were not classified as acute and therefore were not flagged in its weekly infectious diseases bulletin. MOH said it had reclassified those cases and would update the bulletin.
The cause of the infections is still under investigation, with the use of multi-dose vials - in this case to deliver insulin - under suspicion.
At least one hospital, Mount Elizabeth Novena Hospital, is already starting to review its practices for multi-dose vials, said Dr Leong Hoe Nam of the Rophi Clinic there.
"I think all of us have a duty of care to review our practices, to make sure that we're doing things right," said Dr Leong.
Multi-dose vials hold more than one dose of medication and can be shared between two or three patients. Brand new needles and syringes are always used to extract the contents .