SINGAPORE - Lapses at Singapore General Hospital (SGH) led to the hepatitis C infections in its wards earlier this year. There were gaps in infection prevention and control practices, failure to recognise the outbreak, inadequate investigations and delays in notifying the higher-ups within the hospital and the Health Ministry.

This was the conclusion of the Independent Review Committee that was tasked to look into the spread of hepatitis C virus (HCV) in SGH’s wards 64A and 67 that affected 25 patients.

The committee’s report submitted to Health Minister Gan Kim Yong on Dec 5 and released on Tuesday (Dec 8), also found gaps in the Ministry of Health’s (MOH) infectious diseases reporting system.

Reports had trickled in to various departments in the ministry, but there was no one with oversight who could see the big picture. This has since been changed.

However the team, headed by Professor Leo Yee Sin, the director of the Institute of Infectious Diseases and Epidemiology and which includes international experts, said it found no evidence of deliberate delays in reporting the outbreak to the Health Minister.

Related Story Interactive: How the hepatitis C outbreak was escalated to various parties

Of the 25 affected transplant and renal patients, eight have died. The committee said the hepatitis C virus infection “was a likely contributory factor to the death of seven cases”.

The committee looked at, and dismissed, stealing of drugs, foul play and contaminated medical products as causes of the outbreak. It concluded that the most likely cause was poor infection control.

It said the use of multi-dose vials, which SGH had said was the likely cause of the infection, may have contributed but was not the sole source of transmission as not all the affected patients had used them.

The committee had sent a team which made 18 visits to check SGH’s practices. The team found that staff did not always adhere to established procedures, including hand hygiene, leading to contaminated equipment such as medical carts and trolleys, and other surfaces.

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 virus. The virus can remain infective in the environment for several weeks, and in one reported case, up to a year.

Key recommendations from the committee:

For SGH:

- Review existing standard operating procedures (SOPs) and practices on infection control;

- Further reduce risk of contamination of medical equipment and contact surfaces, and ensure adequate environmental cleaning and disinfection;

- Ensure adherence to standard precautions for infection control;

- Strengthen monitoring and supervision of staff to ensure they comply with SOPs For MOH:

- Improve national notification and surveillance system for acute hepatitis C;

- Designate a team within MOH to carry out surveillance, identify and investigate potential outbreaks, and ensure adequate expertise for investigations;

- Strengthen the escalation and communication processes for healthcare-associated infections, especially unusual and unfamiliar ones;

- Clearer guidelines on the assessment of the significance and severity of such outbreaks

The hospital was also faulted for being slow to escalate the problem to the ministry and to SingHealth, the healthcare cluster to which it belongs.

It had started checking the high number of patients with hepatitis C in mid May, but only briefed the ministry’s Director of Medical Services Benjamin Ong, on Sept 3, after it had finished its investigations.

But even then, the committee said investigations were “inadequate” and “the severity and extent of the outbreak” was not clear until Prof Ong asked for additional analysis and investigations to be done.

Prof Ong received the answers on Sept 17 and informed the Minister the following day. The committee concluded that his decision to find out more before telling the minister was “professionally valid and appropriate”.

SGH, in a statement on Tuesday, apologised for the lapses and accepted the committee’s recommendations. Professor Ang Chong Lye, SGH’s chief executive officer, acknowledged that the hospital could have done better and escalated the matter earlier to SingHealth and MOH.

"I would like to apologise to the patients and their families who have been affected by the outbreak," he said in the press release, adding that it has been "a hard and humbling lesson but we will learn from this".

Prof Ang said SGH will work closely with the SingHealth Infection Control Audit Taskforce to conduct cross-institution audits to reinforce the standards of infection control

practices. SingHealth has also appointed a Report Implementation Committee to follow up on the Independent Review Committee recommendations.

He added: "We are determined to regain the trust of Singaporeans, whom we have been most privileged to serve."