Singapore Healthcare System Delayed Reporting Virus Outbreak

For reasons that are unclear, Singapore’s leading public hospital – the one that Patriarch Lee Kuan Yew died in – delayed for months telling the public that an outbreak of hepatitis C had infected 23 kidney patients while receiving treatment, and that five had died.

The episode marks a blip in the history of the nation’s healthcare system, not helped by the delay in informing the public of the outbreak. The first press conference on the issue was on Oct 6 when the hospital said in a statement that 22 patients with renal diseases were hospitalized from mid-April April to June 2015 were diagnosed with hepatitis C virus infection and four of the 22 had died.

The announcement sent tremors through Singapore’s health care system, often described as the best in the region. The flagship of the system, Singapore General Hospital, is also the oldest and largest on the island. The country has long prided itself on having an efficient and quality health care system. The World Health Organization listed Singapore as sixth in the world in overall healthcare in 2000.

It is a major destination for health tourists, especially the wealthy from Indonesia and Malaysia who don’t trust their own health care systems.

For instance, Nina Gundowan (not her real name), an Indonesian who sometimes travels to Singapore for medical treatment said, “The hospital even filed a police report, compared to other countries, hospitals in other countries won’t even admit” to a lapse in care.

Last year, Bloomberg picked Singapore as the “most efficient healthcare system” in the world. It is also a notable medical tourism hub in the region, with the tourism board of Singapore billing the country as a “leading destination for advanced medical care” in Asia. Thus, publicity over a major outbreak of a communicable disease in the island republic’s most prominent public hospital was problematic to say the least.

The outbreak was first identified when abnormal clustering of seven cases in four weeks was discovered in the same period. The hepatitis C virus is largely transmitted by blood, acquired mainly through intravenous use, sharing of syringe needles or exchange of bodily fluids.

The four patients who died had other serious conditions, but the hospital was not able to rule out hepatitis C as a contributing factor for their deaths. The cause of one other death was pending review has since been concluded on Oct 19 that hepatitis C infection could have been a contributing factor, bringing the total number of deaths to five.

Following additional screening of patients who had been at the two renal wards during the period when the outbreak occurred, one of the 598 patients screened tested positive for the hepatitis C virus, bringing the total number to 23, with 66 results pending as of Oct 21.

Social media began raising questions over the delays in informing the public. The hospital first notified the health ministry of an “usually large cluster” of Hepatitis C patients in late August, more than two months after the 18th case was detected in June 26. The Health Minister Gan Kim Yong was first notified on Sept 18, according to the health ministry. The public was only informed almost five months after the first indication of the abnormal cluster.

The delay in notifying the public has also drawn the comments from members of opposition parties in Singapore. The Workers’ Party, Singapore’s main opposition party, called on the government to set up a committee of inquiry to investigate the delays from the hospital to the health ministry and from the ministry to the Health Minister. The Singapore Democratic Party, led by Chee Soon Juan, also called questioned whether there were any “political consideration” in the delay in informing the public, as the time lapse coincided with the Sept 11 general elections in Singapore.

The pro-establishment paper, The Straits Times, also chipped in with an opinion piece on Oct. 18 questioning whether the “flow of information from SGH through MOH to the political leadership” was “proper and if not, why not.” The op-ed article asked whether the members of the civil service involved in the incident faced “pressures, external or self-imposed” that delayed informing the political leadership during the period of elections in Singapore.

The article drew a sharp rebuke from the health ministry, with the press secretary labeling it as “irresponsible journalism” and “imputing improper motives” without evidence to the healthcare and public officers involved and the Straits Times subsequently apologized.

In addition to the delay in informing the public, the second issue was the use of multi-dose vials, cited by Singapore General as a key possible reason for the outbreak. The Public Health Service in Ontario states on its website that it discourages the use of multi-dose vials, warning that the increased risk of infection outweighs the cost savings compared to single-dose vials. Singapore General stopped the practice of multi-dose vials in the hospital on June 23 as a precautionary measure after the 15th case was detected, according to reports in local media.

A team comprised mainly of local medical professionals is still investigating the cause of the infections and two international experts from the US (who have since left the team) were subsequently invited to the board. A police report has also been filed by SGH to rule out possibility of foul play, according to a statement by the hospital on Oct 20.

Prime Minister Lee Hsien Loong also said on Oct 10 that that healthcare authorities need to be transparent and open to maintain the confidence of the public in the system.

Any dent in confidence in the healthcare system is likely to be from within the country rather than outside of it. Medical tourists who go to Singapore usually seek treatments at private hospitals rather than public ones like Singapore General as the fees at both private and public hospitals are similar for foreigners and the quality of care is perceived to be of higher quality at private hospitals.

Yet even as the prime minister maintains a need for transparency, the saga is reminiscent of the Little India riot in 2013 where authorities were slow to react in informing the public. Information first came from netizens who uploaded images on social media. The delay in the health ministry in informing the public is also in stark contrast to how the government reacted during the 2003 SARS crisis, the last major healthcare incident on the island.

Then the WHO praised the government for its risk communication and its proactive measures in combating the disease. The review committee on the hepatitis C outbreak is likely to take a few more months to publish their findings, and it would be interesting to see how the government reacts then.

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Y.K. Hu is a graduate student at the Hong Kong Journalism and Media Studies Center and an Asia Sentinel intern.