Ministry of Health Convenes Independent Review Committee on Hepatitis C Cluster in Singapore General Hospital
6 October 2015
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The Ministry of Health (MOH) has been informed of a cluster of 22 cases of acute Hepatitis C Virus (HCV) amongst patients with kidney disease who had been admitted to Ward 64A or Ward 67 at the Singapore General Hospital (SGH) during the period from April to June 2015. The initial identification of an unusual increase in the number of HCV infections (from 2 to 4 per year on average in SGH’s prevalent pool of renal transplant patients in previous years to 5 within the space of a few weeks) was made by SGH in early June. SGH began its internal investigations in June, and took precautionary measures. SGH made an initial presentation to MOH in late August 2015 and informed MOH of the unusually large cluster of Hepatitis C patients who had been admitted to Ward 64A or Ward 67 during a period from April to June 2015. They submitted their final report to MOH late last month.
2. MOH has convened an independent Review Committee to provide an objective and critical review of SGH’s investigation and findings, to provide added assurance and to glean learning points for the wider healthcare system. In particular, the Review Committee has been tasked to ascertain if all possible measures had been taken to identify the possible points of infection control breach, and remedy any weak point in the overall workflow with regard to infection control.
3. Minister for Health Mr Gan Kim Yong said, “I am gravely concerned and disappointed with the occurrence of the cluster of Hepatitis C cases in SGH. My thoughts are with the affected patients and families.
4. “MOH takes this incident very seriously. SGH has conducted its own internal investigation to review and determine the possible sources of infection. They have taken some immediate precautionary measures to improve internal work processes while investigations were ongoing.
5. “I have decided to appoint an independent Review Committee to provide added assurance that there is an objective and critical review of the internal findings by SGH. MOH will share the findings of the Review Committee with the public. Useful learning points will also be shared with the wider healthcare system, in the spirit of learning and continuous improvement. SGH has assured me that it is committed to the care of its patients and will provide its full support and appropriate care to the affected patients. It will also extend its full cooperation to the independent review.”
6. The composition of the Review Committee appointed by MOH and its Terms of Reference can be found in Annex A.
7. The Review Committee will complete its work in about two months’ time.
MINISTRY OF HEALTH
6 OCTOBER 2015
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Annex A
INDEPENDENT REVIEW COMMITTEE APPOINTED BY MOH
Members and Terms of Reference
Table caption
Member | Designation |
---|---|
Prof Leo Yee Sin (Chairman) | Director (Institute of Infectious Diseases & Epidemiology) / Clinical Director (Communicable Disease Centre), Tan Tock Seng Hospital |
Prof Lim Seng Gee | Senior Consultant (Division of Gastroenterology & Hepatology, Department of Medicine), National University Hospital |
A/Prof Helen Oh | Head (Infectious Diseases), Changi General Hospital |
Dr Titus Lau | Senior Consultant (Division of Nephrology), National University Hospital |
Ms Paulin Koh | Chief Nurse, Changi General Hospital |
A/Prof Quek Swee Chye | Deputy Chairman of Medical Board, National University Hospital |
Dr Jeffery Cutter | Director (Communicable Disease Division), MOH |
The Terms of Reference of the Committee are as follows:
a) To provide an independent, objective and critical review of SGH’s report, and seek to ascertain if all possible measures had been taken to:
i. Identify the possible points of infection control breach;
ii. Remedy any weak points in the overall workflow particularly with regard to infection control;
b) To reasonably investigate any activity within its terms of reference, which will include but is not limited to the following:
i. Review the work and findings of the two Committees convened by SGH to investigate this Cluster (i.e. the Medical Review Committee and Quality Assurance Review Committee)
ii. Interview any staff member to clarify issues; and
iii. Perform site inspections at SGH.