Questions Linger over Singapore’s Hepatitis C Outbreak

Public apologies from Singapore's ministers are a rarity from a government used to holding its citizens accountable for their behavior, especially at the polls. Yet, as Singapore's health minister apologized to affected patients and their families over a Hepatitis C outbreak in the nation's leading public hospital, questions lingered over the government's response.

On Dec. 8, the Health Minister Gan Kim Yong sought to put the questions to rest in a pess conference tied to the release of the results of a review chaired by a local expert in infectious diseases and epidemiology. The committee was convened by Gan in late September to investigate the outbreak in Singapore General Hospital. Some 25 people were affected by outbreak between April and September.

The findings

The committee concluded that a "combination of multiple overlapping factors was the most likely explanation" for the outbreak. Hepatitis C is a blood borne virus spread primarily through unsanitary injections, transfusions or blood products and inadequate sterilization of medical equipment.

The full report, nearly 80 pages long, ruled out drug diversion, foul play or contaminated medical products. A combination of lapses in the hospital's infection control practices, late recognition and subsequent responses mainly from the hospital led to the outbreak.

After screening for patients who were admitted to the two renal wards between January and September, the committee identified 25 cases affected by the cluster outbreak, with 20 of them kidney transplant patients. Eight deaths have occurred and Hepatitis C was "a likely contributory factor to the death of the seven cases." Hepatitis C "definitely" contributed to the deaths of five patients and "likely" contributed to the other two.

The report stated that kidney transplant patients with weak immune systems were highly susceptible and the introduction of the virus led to acute infections. The gaps in controls included multiple exposures to intravenous medications and laboratory tests exacerbated the spread. Intravenous procedures, environmental cleaning, prevention of environmental contamination and shifting to a new ward which the staff might not be familiar with also accentuated the transmission of the virus.

The committee also said multi-dose vials, which had been previously reported as a plausible key factor in causing the outbreak, could not be the sole factor in all cases although it might have played a role.

The apology

Public apologies from politicians might be deemed rare given the public image of the ruling party People's Action Party leaders that they are infallible. One local paper under the pro-establishment Singapore Press Holdings stable called the incident a "rare apology."

It isn’t without precedent, however. Prime Minister Lee Hsien Loong issued one to voters a few days before the general elections in 2011 that might be more familiar, but the current episode needs to be read in its own light. Gan has also issued apologies in two other instances.

The issues (I): the role of the public

While the report focused on the system of responses within the public health care setup regarding the incident, there is a nagging suspicion that the report and Gan's subsequent recommendations read like a self-contained internal act.

The report faulted the hospital's detection procedures for not recognizing the outbreak in a timely manner and pointed out the delays in the escalation of the issue to the ministry. However, it said that the ministry had "no one clear division" with "clear responsibility to deal with unusual HAIs (Health Associated Infections)" which hindered the ministry's ability to "respond in a timely way to the unexpected event."

The tone suggests the fault lies clearly below the ministry. At no point was there any mention in the report on public consultation or how the public should have been informed on similar issues.

The health minister also decided to set up a “taskforce” led by another minister to enhance the detection and response to infectious diseases outbreaks. In all, the responses by the ministry and Gan and the review committee's report read of one where the public health issue was meant to be assessed and dealt with internally -- one where the public had no role to play.

The issues (II): the review committee

The review committee was also separated into two tracks assessing different areas with different team members.

The first track investigated the "probable causes of the cluster" and the second investigated the responses within the "system" and the communications between the health ministry, SingHealth and the hospital.

The public health care system in Singapore under the health ministry is divided into two clusters, Singhealth and the National Healthcare Group under a cluster management system. Each cluster then further manages a group of hospitals and government-run polyclinics under its charge. The Singapore General Hospital falls under the purview of Singhealth.

While the first team investigating the probable causes involved international experts, all of the second team investigating the communications in the issue were local medical experts with some “resource” people appointed from other domains such as auditing.

This has raised concerns regarding whether the findings would be fully impartial, especially when almost all of the committee members investigating this track comprised medical experts working within the public healthcare system.

"I don't accept if people tell me that the local experts who come from within the same system as their counterparts who are being investigated will be fully impartial and objective in their assessment," said a local businessman who has been keeping track of the issue.

Yet given the complexity of medical investigations, as one source working within medical academia explained, it might be plausible to find local experts with more knowledge of the local healthcare system to come up with recommendations. Foreign experts without knowledge of the intricacies of the Singapore's healthcare system might recommend plans that are not useful.

The businessman, however, thinks otherwise. "The point of having an expert to investigate the levels of all communications is to have someone with access to all parties involved, including the health ministry. It's irrelevant to get an 'outsider' as the person might not fully understand the healthcare system as he or she would not know where to start off. However, this creates the situation whereby the local experts who are appointed have to have reputation of being fully independent and fully impartial, and given our local system where public institutions are closely aligned with our government I'm afraid it's almost impossible."

Familiar way forward?

Discussion on the issue on social media in Singapore has been far more muted compared to the first report on the outbreak in October 6. The report clarified that Gan only learned of the outbreak in mid-September, close to three months since the first major signs. This has not drawn the attention or invoked much public discussion online.

As with the two instances involving Gan's public apologies, a familiar script reads itself – the health ministry takes charge of implementing the necessary recommendations with the public is sidelined from the entire process, but confidence is restored in the healthcare system albeit temporarily. All looks set to be forgotten, perhaps until the next major issue.

YK Hu is a master’s degree journalism candidate in Hong Kong and an Asia Sentinel intern