Wednesday, October 14, 2015

Hepatitus C at SGH

4 dead after 22 infected in SGH hepatitis C outbreak
Here is a timeline of how events unfolded.April 17 to May 14: Five cases of Hepatitis C infections detected
May 15: SGH conducted internal investigations on dialysis centre
May 25 to 27: 6th and 7th cases detected
May 29: Dialysis centre cleared as potential source of infection
May 30: 8th case detected
June 2: Infection control team activated; 9th case detected
June 10: Renal ward stop using multi-dose vials
June 11 to 16: 10th, 11th, 12th, 13th and 14th cases detected
June 23: Use of multi-dose vials stopped hospital-wide; 15th case detected
June 25 to 26: 16th, 17th and 18th cases detected
July 7 to 15: 19th and 20th cases detected
Aug 11: 21st case detected
Late August: SGH informs Ministry of Health (MOH) of “unusually large cluster” of Hepatitis C patients
Sept 18: 22nd case detected
Late September: SGH submits final report to MOH
Oct 6: SGH makes public the infections, says it will start contacting staff and more than 400 patients who had gone to the ward, to ask them to go for screening. The MOH announces setting up of independent review committee.


OCTOBER 6, 2015

SINGAPORE — The renal ward at the Singapore General Hospital has seen a hepatitis C virus outbreak that is suspected, after preliminary investigations, to be linked to the misuse of multi-dose vials, or medication containers from which multiple dosages are extracted. So far, the outbreak has affected 22 patients, of which four have died, possibly because of the infection.

Three other deaths among this pool of patients, who were admitted to Ward 67 between April and June, have been determined by a Medical Review Committee set up by SGH to be unrelated to the outbreak while an eighth death is undergoing a review. The actual renal ward, 64A, was undergoing renovations in those three months.

Of the 14 surviving patients, 12 have been discharged. Four have been treated for hepatitis C.

This unprecedented lapse by a restructured hospital was made public today (Oct 6) as investigators start recalling 411 patients who stayed in either of the two wards between January and June for screenings for the virus. These checks have started for the 42 doctors and 51 nurses who were attached to the ward in the same period.

Hepatitis C, which is virus transmitted by blood, usually presents no symptoms and has an incubation period of up to six months. Antiviral medicines can cure approximately 90 per cent of infected persons, according to the World Health Organization.

At a press conference this afternoon, SGH chief executive officer Ang Chong Lye was asked about the delay in making public the outbreak — the hospital started investigating a possible outbreak in early June and informed the Ministry of Health (MOH) in late-August. He replied: “Investigation work took a while.” He added that the hospital will “take responsibility” for the treatment costs affected patients incur, which could go up to S$90,000 for a course of anti-viral drugs.

Healthcare professionals interviewed felt the timeframe was reasonable, given the “silent” nature of the viral infection and the fact that it takes time to verify the facts. Nevertheless, some of them felt that the public could have been informed earlier.

Speaking to reporters after the press conference, Health Minister Gan Kim Yong apologised to patients and their family for the incident. “The priority now is to ensure patients are taken care of,” he said. “The hospital has assured that they’ll provide the necessary support as well as appropriate care for the patients, going forward. The hospital has also introduced additional precautionary measures, even when investigations are ongoing.”

Mr Gan added that his ministry has set up an independent review committee to “identify gaps and possible weaknesses in the infection control system, as well as additional safeguards if necessary”. The committee, headed by Tan Tock Seng Hospital’s Prof Leo Yee Sin, will deliver its report in two months’ time.

At the press conference today, SGH gave details of the outbreak and what remedial actions it has taken, as well as further steps being taken. Red flags went up at SGH after the fifth case of hepatitis C virus infection in the renal ward between April 17 and May 14 — the norm is three to four cases each month. On May 15, the hospital started investigations of the dialysis centre — all 22 patients had some form of renal disease, and many had end-stage kidney failure, a kidney transplant, or both.

The dialysis centre was ruled out as a possible source on May 29 because three of the seven patients affected by then were not on dialysis. SGH activated its infection control team on June 2 and stopped the use of multi-dose medication vials at its renal ward eight days later, and hospital-wide on June 23. SGH has also set up a medical review and quality assurance committees to review processes and identify reasons behind the outbreak.

The multi-dose vials believed to be linked to the outbreak hold medication such as insulin or vaccines, which is shared among patients.

SGH stressed that there are protocols for using these vials, which are also used in other hospitals here. For instance, a new needle and syringe must be used to extract the medication from the vial. A fresh needle is then used to administer the drugs intravenously. The hospital admitted, however, that shortcuts could have been taken, leading to contamination of the shared medication.

“As far as transmission goes, (hepatitis C) is a blood-borne transmission. Top on our list is the use of multi-dose vials. Many of these (medications) don’t come in a single unit,” said Professor Fong Kok Yong, chairman of the hospital’s medical board. The hospital has conducted in-house phylogenetic studies to analyse the virus, and also sent samples to the Centers for Disease Control and Prevention in Atlanta, United States for further analysis. These tests are expected to trace the origin of the virus to the first infected patient.

SGH was tight-lipped about the identities of the affected patients and would only say they were between the ages of 24 and 70. The four patients whose deaths are suspected to be linked to the hepatitis C virus infection suffered from various conditions including pneumonia and fungal infections and severe sepsis.

The MOH said it has kept public hospitals informed of the hepatitis C outbreak in SGH. It also sent a circular to all public healthcare institutions and voluntary welfare organisations renal dialysis providers to “remind and request that all practitioners comply with infection prevention and control protocols during the administration of injections from medication vials here”.


SGH hep C outbreak: SGH's delay raises questions on info flow

First, a bit of background.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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