VANCOMYCIN-RESISTANT ENTEROCOCCI (Outbreak)

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VANCOMYCIN-RESISTANT ENTEROCOCCI:

(Outbreak): 5.

Mdm Halimah Yacob asked the Minister for Health what is the cause of the outbreak of the vancomycin-resistant enterococci (VRE) at the Singapore General Hospital and what measures have been put in place to prevent a future occurrence of such an outbreak.

6.

Dr Amy Khor Lean Suan asked the Minister for Health (a) if he will provide an update of the vancomycin-resistant enterococci (VRE) outbreak at SGH; (b) what is the source or cause of this outbreak; (c) what are the risks of this outbreak spreading to other hospitals; and (d) what precautions have been or will be taken to reduce the risk of the development of VRE or other outbreaks within and across the different hospitals and possibly even the polyclinics.

7.

Dr Tan Sze Wee asked the Minister for Health whether he will consider gazetting vancomycin-resistant enterococci (VRE) as a disease under the First, Second and/or Sixth Schedule of the Infectious Diseases Act.

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The Minister for Health (Mr Khaw Boon Wan): Mr Speaker, Sir, with your permission, can I take Question Nos. 5 to 7 together?

Mr Speaker: Yes, you may.

Mr Khaw Boon Wan: Sir, several Members have asked about the VRE cases in the Singapore General Hospital. Let me assure Members that VRE is not like SARS.

All perfectly healthy people have billions of bacteria in their large intestines. Enterococci are examples of such bacteria. Normal healthy people also carry bacteria in their nose, mouth and skin. These usually harmless bacteria may occasionally cause infections like pneumonia (lung infection) or septicemia (infection in the blood). Such patients are then treated with antibiotics. Enterococci used to be always sensitive to the antibiotic, Vancomycin. But bacteria mutate and can develop resistance to a specific antibiotic. When bacteria become resistant to an antibiotic, a different antibiotic has to be used to treat infections caused by the bacteria.

The first antibiotic to be used in the world was penicillin. After many years of penicillin use, penicillin-resistant bacteria emerged. The same happened after years of use of Ampicillin and, more recently, Methicillin. Staphlycoccus aureaus - bacteria normally found on the skin which become resistant to methicillin is called MRSA. Not surprisingly, after many years of Vancomycin use, we now have enterococci bacteria that are resistant to Vancomycin - VRE.

VRE was first reported in England in 1986, nearly 20 years ago, and hospital-acquired outbreaks have subsequently been reported in USA and Europe. In Singapore, fortunately, VRE is still rare, with only a handful of cases reported in recent years.

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Very few patients actually fall sick because of VRE. Those who do tend to be patients with low immunity because of multiple medical problems such as renal failure, diabetes and cancer. In these patients the VRE may infect sites such as a wound or urinary tract. The enterococci infection is then treated with an antibiotic other than Vancomycin. Mdm Halimah and Dr Amy Khor asked for the source of the VRE cases in SGH. It is still being investigated. We may never know for sure. The bacteria could be bacteria that mutated locally or it could be bacteria brought into Singapore by healthy carriers who carried the bacteria in their large intestines.

The vast majority of patients with VRE are healthy carriers of the bacteria without any symptom. There are no effective treatments for healthy carriers since these bacteria are normal to the large intestines. Hospitals use many antibiotics within the hospital premises and the bacteria that survive and lurk in the hospital setting tend to be those that have antibiotic resistance. Outside of hospitals, the bacteria there tend to be the non-resistant type. So very often a VRE carrier in the hospital setting becomes VRE negative after being discharged. However, as this process may take some time, carriers can continue to shed VRE in their stools for many months. Hospitals have an interest to identify them early so that while in the hospital they can be isolated. This will reduce the risk of VRE spread.

In the current episode, VRE was first identified by SGH on 9th March 2005 in a 75-year-old patient with multiple medical conditions. Through screening his close contacts, SGH identified five other patients with VRE. At that point, SGH decided to screen all its inpatients with a view to identify the carriers so that they can be properly isolated. In parallel, SGH staff were reminded to step up good infection control practices such as

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mandatory hand washing in between patients and stricter compliance of the 2-visitor rule in the hospital.

Mass screening of all the inpatients in SGH has so far identified 93 patients with VRE. Of these, only three were found to be infected, with clinical symptoms. They were patients with multiple chronic medical conditions.

To minimise the spread of VRE to other hospitals, we have also reminded them to step up infection control procedures. At the same time, SGH shares with the other hospitals the list of their recently discharged patients so that they can be isolated and screened for VRE if they are admitted there.

So far, one such patient has been admitted to NUH. NUH has since identified another case of VRE in a foreign patient, but this patient was not related to the SGH cases.

Mdm Halimah and Dr Amy Khor asked what precautions have been or will be taken to reduce the risk of future occurrences of VRE cases in hospitals. This is best done through a combination of measures. First, there must be a rational usage of Vancomycin. Second, there must be good surveillance for hospital-acquired infections. Third, there must be strict adherence to sound infection control principles such as prompt isolation of patients with infectious diseases, barrier nursing and hand washing.

These are good hospital practices which all hospitals should adopt. Like penicillin resistant bacteria and MRSA, VRE may eventually become part of our bacterial landscape. If this happens, infections now treated with Vancomycin will have to be treated by other antibiotics. The greatest danger is bacteria that becomes resistant to multiple antibiotics. To minimise this risk,

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antibiotics must not be used indiscriminately. Doctors should use antibiotics only when indicated and patients should complete their course of antibiotics when it is prescribed to them.

Dr Tan asked whether VRE should be gazetted under the Infectious Diseases Act. We see no need as VRE is not a community-based infectious disease like tuberculosis or SARS. However, it poses a risk to immune-compromised patients in hospitals. We have therefore included VRE as a target in their infection control programmes.

Mdm Halimah Yacob (Jurong): Sir, the Minister did mention that VRE may become part of our eco-system. My question is whether there is a danger of VRE becoming entrenched in our hospitals, like the situation we see in some US hospitals and therefore becoming quite a menace.

My second question is: is there a need for us to educate the doctors and the public on the use of antibiotics because that apparently seems to be the cause and the bacteria become more and more resistant to the use of antibiotics?

Mr Khaw Boon Wan: Sir, the answer to both queries is yes. In the US, UK and parts of Europe, VRE is now entrenched and the US' experience has been going on for about 20 years. We have been fairly lucky but I doubt that it has a lot to do with luck. It has to do with the practices. And careful usage of antibiotics and making sure that they are not used indiscriminately is one of the key measures besides the usual infection control procedures. We had SARS and that was a period when we reminded everybody about the importance of infection control.

Now, we have the bird flu and VRE and potentially it could be a major risk for

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us. I think it will be extremely difficult to eradicate VRE to make sure that it is not part and parcel of our eco-system because we are such an open economy. Just like the NUH case that I mentioned in my reply, it was a foreigner who came in for treatment. We look around the region and we know that antibiotic usage is almost rampant and that is a major risk.

Dr Amy Khor Lean Suan: Sir, I would like to ask the Minister that if large hospitals like SGH are more susceptible to the spread of infectious diseases, not necessarily just the VRE, because of the volume of traffic, the number of patients and the sheer size of the hospital, are there any additional precautions that are necessary in addition to what has been listed.

Mr Khaw Boon Wan: Sir, this is one hypothesis. It is not just the size of the hospital but it is also the range of specialties although the two tend to be linked. When you have a large hospital you will also have multiple disciplines, especially tertiary disciplines, with greater mixing of patients. One observation that some doctors made during the SARS period was why is it that SARS became such a problem in those major centres with modern hospitals whereas in the third world, in the villages, somehow it was not a problem. One hypothesis was that it was because of concentrating the multi-specialty patients together. Because of specialisation, the same patient is being handled by different departments and the patient has to go through several departments instead of just going to one place. Therefore, if there is a carrier of the bacteria, you expose the various patients in different parts of the hospital. I think it is a fairly reasonable hypothesis.

Like all things, such as casinos, you open the window and all sorts of things will fly in. So we have to decide whether or not we want to shut the window and if we do so, of course, we will be secluded.

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But how do we stay secluded in a modern world?

Dr Tan Sze Wee (Nominated Member): Sir, the Minister has suggested that there are probably no grounds to consider VRE being gazetted as a disease under the Infectious Diseases Act. But I would like to clarify that it was reported in the papers that SGH had given the names of the patients tested positive for VRE to all hospitals. I agree that there are many good reasons for SGH to do so. However, I would like to know if consent from these patients has been expressly sought. If not, the privacy and confidentiality rights of these patients perhaps could have inadvertently been violated in the process. This is because VRE at present is not a disease on any Schedule of the Infectious Diseases Act and SGH may not be empowered ---

Mr Speaker: Dr Tan, no speeches. Please ask your question.

Dr Tan Sze Wee: I would like to ask, on the grounds of privacy and confidentiality, perhaps the Minister may want to consider gazetting VRE as one of the diseases under the Infectious Diseases Act.

Mr Khaw Boon Wan: I honestly do not see a compelling need to do so because VRE is not like VD or HIV where there is a stigma associated with it. It is one of those "bad luck" illness, if you get it.

Even with HIV, confidentiality is always preserved by hospital workers, in the sense that when we take a particular decision - in this case, circulate the list - it was purely on a need-to-know basis because, what is the alternative? The alternative is not to inform. Then we are exposing the patients, say, in the private hospitals to a potential spread. So, on this score, our conscience is quite clear, ie, there is nothing wrong in sharing the list for the greater good of society.

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Dr Lily Neo (Jalan Besar): May I ask the Minister whether there will be more liberal use of Vancomycin in SGH compared to other hospitals that caused the VRE outbreak in SGH? Has there been a review done on the prescription habits of doctors in SGH, especially on the prophylactic use of strong antibiotics? Should there be better guidelines on such prescription to prevent future recurrences?

Mr Khaw Boon Wan: Mr Speaker, Sir, I am not personally aware whether such studies were done. There may be. I would have to check. But it is traditionally very difficult to compare practices between two hospitals, unless they have identical patient profiles. SGH, being our major tertiary institution with multiple specialties, their patients' needs for vancomycin may be higher than the others, everything being equal. But what I can say safely is that we in Singapore, compared to many developed countries in terms of usage of antibiotics, are a lot more careful. And, as I said just now, it is not a result of good luck or whatever. Pricing has to do with it too. Vancomycin, for example, is a non-standard drug and, in countries where they subsidise until everything is free, the tendency to over-prescribe may be greater.

Dr Lily Neo: May I ask the Minister whether in view of the fact that VRE infection is a hospital-acquired disease, affected patients will be given free follow-up treatment and are hospitals covered under insurance for such eventualities? May I also ask the Minister whether he really looks for the causative agent or the factor that caused the VRE outbreak so that other hospitals can learn from the mistake?

Mr Khaw Boon Wan: I think the reply to the second question is, yes, we are checking what actually caused this

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cluster. As I said, although VRE is rare in Singapore, it does not mean we have none. All these years, looking at some of the data, each hospital may report one or two cases. It is a handful of cases. The trouble is, this phenomenon has been around for 20 years now and we are so well connected to the rest of the world, one, two or even a handful of cases a year should be considered as a fairly good outcome.

As to her first question, hospital-acquired infections are now very much acknowledged as one of the complications of being hospitalised in a hospital, not just here but worldwide. Therefore, the practice worldwide, in fact, is not for hospitals to take responsibility for picking up the bills, for the simple reason that the cause of infection is very hard to establish. Is it the fault of the doctor, nurse or the patients themselves? So, instead, the global hospital practice is to look at what is the infection rate. Even in the best-run hospitals, it cannot be zero. It is almost impossible. Instead, what we do is that we benchmark ourselves against others to compare with our incidence rate. I look at those rates occasionally and, by and large, Singapore's situation is not bad. But I wanted to take the next step, which I think I have expressed before. I will be starting to publish some of our infection rates post-surgery, and we go by types of major surgeries, eg, hip replacement, what is the infection rate in Singapore among the various hospitals, and then we can benchmark against the other hospitals. And if we find that a particular hospital has an excessively high infection rate, then, as regulator, I think I would need to step in to perhaps, in extremis , even suspend the operation of that department until they clean up the operation.