4 dead after 22 infected in SGH hepatitis C outbreak

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”.