After a period of 6-7 years of “rational MRSA control’ targeted towards MRSA containment rather than eradication, many Singaporean public sector hospitals stepped up efforts to reduce their MRSA burden again. While it was clear that the infection control staff from different hospitals were communicating with each other, there was no overall or coordinated strategy among them. Why were such efforts started again at this time (2006-2007)? I don’t have the answer, but the following chart from a previous post – now annotated – shows an intriguing association. Each of the two MRSA “campaigns” appeared to have started after reports of MRSA in local hospitals have appeared in the local news.

MRSA in the local news.

Whatever the case may be, the infection control staff in local hospitals – many of whom had firsthand experience with the earlier campaign in 1994-1995 – took care to avoid the same mistakes.

There was tremendous renewed focus on hand hygiene. Tan Tock Seng Hospital’s (TTSH’s) hand hygiene drive culminated in a 3-month long public campaign and a lucky draw with the chance to win a Subaru car (27th April to 3rd July 2009).

TTSH CSI campaign with lucky draw.
Image cropped from: http://www.motorimage.net/enewsletter/200905_Vol-35/

National University Hospital (NUH) has also consistently held annual hand hygiene campaigns, and the frontline healthcare staff from that hospital have to pass a hand hygiene test in order to be eligible for certain hospital benefits (including reimbursement of Medical Protection Society subscription fees for doctors).

NUH Hand Hygiene posters in 2010 (13m tall) and 2014 (21m long).
Images obtained from: http://www.nuh.com.sg/

The Singapore General Hospital (SGH) was also not far behind with regards to hand hygiene campaigns.

Huge hand hygiene poster on the wall of SGH in 2009.
Image from: http://www.sgh.com.sg/about-us/newsroom/News-Articles-Reports/2009/Pages/sgh-steps-clean-hands-campaign-straits-times-thu-pg-b6.aspx

Medical students at the oldest medical school in Singapore were also taught hand hygiene and how to audit hand hygiene compliance, and it was a considerable achievement when compliance to hand hygiene was formally incorporated – not without considerable opposition from many professors – into the marking scheme of the final medical school short case exams (Medicine). This work is published as a letter in the journal Medical Teacher, but is behind a pay wall.

Besides hand hygiene, hospitals also took the effort to uncover the huge reservoir (patients with clinical MRSA infections represent only the tip of the “MRSA iceberg” – the majority of patients with MRSA do not manifest any sign of infection) of asymptomatic MRSA carriers among the patients. This was a staged process taking several years, as laboratory facilities had to be ramped up in order to deal with the increased workload, and ward staff had to be trained to collect such samples. TTSH has again gone the furthest in this regard, screening patients at the Emergency Department directly since 2012. Better bed management implementation allowed more MRSA-positive patients to be either isolated or cohorted together, although this has been difficult in recent years because of the congestion in all local hospitals.

The result of this second “campaign”, unlike the first, was a dramatic fall in MRSA rates at the three major hospitals mentioned above. Part of the fall in MRSA rates since 2008 and up to 2010 in two of the three hospitals was captured as part of an unofficial “national surveillance” and published (also behind a pay wall – but I can provide a graphic of the figure used in the journal below).

MRSA in Singapore hospitals. 2010. NARSS.

NUH’s experience in bringing down its MRSA rates have also been published in the Journal of Hospital Infection (unfortunately, another paywall!).

With such successes, will we in the Singapore hospitals be able to eradicate MRSA (or at least markedly reduce to less than 10%) much like the Scandinavian and Western Australian hospitals? That is a final reflection for another time…