Transmission of hepatitis B virus in dialysis units: a systematic review of reports on outbreaks

Haemodialysis machine designation for patients with chronic Hepatitis B virus: A practice and attitudes survey of Australian renal healthcare workers

BACKGROUND

To reduce the risk of viral transmission, guidelines recommend the use of designated haemodialysis machines and patient isolation for patients with chronic hepatitis B virus (HBV). These practices are without a strong evidence base, and may no longer be necessary in the setting of heat disinfection programs and standard precautions.

METHODS

An online cross-sectional survey was developed for renal clinicians across Australia and New Zealand to explore infection prevention policy concerning patients with chronic HBV in haemodialysis units. We sought to determine whether psychosocial and cultural impacts might result from the mandatory use of machine designation and patient isolation practices, as perceived by multidisciplinary healthcare workers with experience working with this patient population.

RESULTS

Sixty-seven responses from 27 health districts across all states of Australia and one New Zealand district were received. Most respondents were from urban areas (65%), and were nurses (87%). 50% of health districts reported using designated machines, while 32% isolate patients. Lack of necessary resources limited the use of designated machines (57%), and patient isolation (78%). Respondents not routinely using these precautions were more likely to express concerns regarding patient psychosocial wellbeing and cultural appropriateness. Overall, 30% of respondents expressed concerns regarding the cultural appropriateness of these recommendations.

CONCLUSION

We demonstrate wide variation in haemodialysis infection prevention and control policy and practice with regards to managing patients with chronic HBV. While use of standard precautions and machine disinfection are consistently applied, resource availability and concerns for patient psychosocial wellbeing limit adherence to international guidelines.

Prevalence of Hepatitis B Virus, Hepatitis C Virus, and HIV Infections in Hemodialysis Patients at Kano Kidney Center

Background Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections are more prevalent in hemodialysis patients compared to the general population. The objective of this study was to evaluate the prevalence of HBV, HCV, and HIV infections in hemodialysis patients dialyzing regularly at Kano Kidney Center (KKC) in the Eastern Health Cluster of Saudi Arabia in 2022. Methods This retrospective study included all hemodialysis patients who were dialyzed regularly at KKC during 2022. Their electronic medical records were reviewed for the results of HBV, HCV, and HIV along with the patient's demographics, comorbid conditions, and dialysis history. The study was approved and monitored by the Institutional Review Board of Dammam Medical Complex. Results A total of 239 regular hemodialysis patients were included, consisting of 142 males and 97 females (59.41% and 40.59%, respectively), with a mean age of 52.71±15.83 years. Most of the patients were Saudis (156 patients, 65.27%) with the non-Saudi patients being composed mostly of Arabian patients. Nine patients (3.77%) tested positive for hepatitis B surface antigen (HBsAg), the serologic hallmark of HBV infection. Two patients (0.84%) had resolved HBV infections as evidenced by positive hepatitis B core antibody (anti-HBc) and hepatitis B surface antibody (anti-HBs). However, the majority (226 patients, 94.56%) were never tested for anti-HBc. Anti-HBs, which can imply long-term immunity against HBV from prior immunizations or infections, were positive in 165 patients (69.04%). A protective anti-HBs level of ≥ 10 IU/L was detected in 158 patients (66.11%) including 104 patients (43.51%) having ≥ 100 IU/L. Eighteen patients (7.53%) had reactive HCV antibodies. Four patients (1.67%) had chronic HCV infection as they had detectable HCV RNA. The remaining 14 patients (5.86%) cleared HCV either spontaneously (seven patients, 2.93%) or by medications (seven patients, 2.93%). HIV screening tests were negative in all 239 patients (100%). HBsAg-positive patients did not have any statistically significant differences from HBsAg-negative patients. On the other hand, the patients who were positive for HCV antibodies were older than the patients who were negative for HCV antibodies (60.66 vs 52.05 years on average, p-value <0.05). They also contained a statistically larger proportion of non-Saudi patients than the patients with no evidence of prior infections (61.11% vs 32.13%, p-value <0.05). Conclusions The study found that the prevalence of HBV and HCV infections among hemodialysis patients in KKC at 3.77% and 1.67%, respectively, is higher than that reported in the general population in Saudi Arabia, with non-Saudis having a higher prevalence rate of HCV infection than Saudis. However, the current prevalence rate is lower compared to the previous studies that were conducted in Saudi Arabia in the first decade of the 21st century, and there were no cases of HIV infections. Nevertheless, a significant proportion of patients had unprotective or negative anti-HBs antibody titers, indicating the need for strict vaccination protocols and monitoring of antibody titers to ensure optimal protection.

Healthcare-associated hepatitis B and C transmission to patients in the EU/EEA and UK: a systematic review of reported outbreaks between 2006 and 2021

Healthcare-associated transmission was the second most common hepatitis B (HBV) and hepatitis C (HCV) transmission route according to 2006-2012 European surveillance data, but data quality and completeness issues hinder comprehensive characterisation of this important issue. We carried out a systematic review of published literature on healthcare-associated transmission of HBV or HCV in European Union (EU) and European Economic Area (EEA) countries and the United Kingdom to complement surveillance data and identify higher-risk settings. We searched the PubMed and Embase databases and grey literature over the period January 2006 to September 2021, for publications reporting transmission events after 2000 in the EU/EEA and UK related to a healthcare setting or procedure. We collected data on the country, number of patients, setting type and route of transmission. In 65 publications from 16 countries, 43 HBV and 48 HCV events were identified resulting in 442 newly infected patients. Most events were reported from Italy (7 HBV and 12 HCV), Germany (8 HBV and 5 HCV) and the United Kingdom (8 HBV and 5 HCV). The number of patients infected from a single source within an event ranged from 1 to 53. Five large outbreaks of over 20 cases were identified, including two in Poland and one each in Belgium, Hungary and Slovakia. The majority of transmission events occurred through blood transfusions or in dialysis units. However, there were a number of outbreaks in seemingly low risk settings such as CT/MRI scanning units. A failure to adequately follow infection prevention control (IPC) precautions was reported in 30% of included studies. Healthcare-associated transmission of hepatitis B and C continues to occur in a range of community and hospital settings across EU/EEA countries and often results in large outbreaks, although the true extent of the situation cannot be fully determined due to under-reporting. Strict IPC precautions should be implemented across all healthcare settings and regularly audited, and surveillance systems strengthened and standardised to allow for comprehensive and consistent reporting of nosocomial transmission of hepatitis across the EU.

Hepatitis B virus vaccine and chronic kidney disease. The advances

BACKGROUND

Hepatitis B is an important agent of liver disease in patients with chronic kidney disease and chronic HBV infection promotes the development of CKD in the adult general population. Patients with CKD have a suboptimal response to various vaccines, and it remains unclear how we boost the immune response of CKD patients to HB vaccine.

STUDY AIMS AND DESIGN

We performed a narrative review to assess the mechanisms of lower immunogenicity of HBV vaccine in CKD population; multiple approaches to improve the response rate of CKD patients to HBV vaccine have been reported. This is a very important topic for nephrologists who often serve as primary case providers for patients with CKD.

RESULTS

The recommended vaccine schedule for CKD patients including those on maintenance dialysis is based on recombinant vaccine, four doses (month 0,1,2, and 6; 40mcg each) by intramuscular route (deltoid muscle). According to RCTs or observational studies, some recombinant vaccines with adjuvants (i.e., HBV-AS02 and HBV-AS04) look promising. HBV-AS04 showed to give better seroprotection rates and durable immune response over extended follow-ups compared with licensed HBV vaccine in CKD patients. The seroprotection rate was 95% (97/102) and 82% (202/248) in pre-dialysis and dialysis patients, respectively, one month after completing vaccine schedule with HBV-AS04. HBV-AS02 was superior to licensed vaccine in terms of seroprotection rate, 76.9% vs. 37.6%.

CONCLUSIONS

We suggest adjuvanted recombinant (HBV-AS04) vaccine (0,1,2 and 3 months; 20 mcg each dose) and post vaccination testing of anti-HBs antibody after vaccination. Booster doses to patients whose anti-HBs titers fall below the seroprotection level (<10IU/mL) during the follow-up are appropriate. The patho-physiologic mechanisms responsible for the poor immunogenicity of HBV vaccine in CKD patients are under active investigation.

Hepatitis B related dilemmas in the renal unit

Testing for hepatitis B in dialysis patients is routine, but newer and more sensitive detection methods mean that there is sometimes confusion around viral loads and occult infection. There are frequently difficult choices surrounding isolation and treatment. Here we describe the use of HBV serology and DNA testing in decisions around patients with end-stage renal disease. We also suggest isolation decisions based on our current understanding of the virus and its infectivity.

Effect of isolation practice on the transmission of middle east respiratory syndrome coronavirus among hemodialysis patients: A 2-year prospective cohort study

Hemodialysis (HD) patients had a high rate of infection transmission and mortality during the middle east respiratory syndrome coronavirus (MERS-CoV) outbreak in Saudi Arabia. A standardized guideline on isolation technique for exposed HD patients is not available. Thus, this study aimed to evaluate the effect of different isolation strategies on the prevention of secondary viral transmission and clinical outcomes among exposed HD patients.During the 2015 MERS-CoV outbreak in Korea, 116 patients in 3 HD units were incidentally exposed to individuals with confirmed MERS-CoV infection and underwent different types of isolation, which were as follows: single-room isolation (n = 54, 47%), cohort isolation (n = 46, 40%), and self-imposed quarantine (n = 16, 13%). The primary outcome was rate of secondary viral transmission. The secondary outcome measures were changes in clinical and biochemical markers during the isolation period, difference in clinical and biochemical markers according to the types of isolation practice, and effect of isolation practice on patient survival.During a mean isolation period of 15 days, no further cases of secondary transmission were detected among HD patients. Plasma hemoglobin, serum calcium, and serum albumin levels and single-pool Kt/V decreased during the isolation period but normalized thereafter. Patients who were subjected to self-imposed quarantine had higher systolic and diastolic blood pressure, lower total cholesterol level, and lower Kt/V than those who underwent single-room or cohort isolation. During the 24-month follow-up period, 12 patients died. However, none of the deaths occurred during the isolation period, and no differences were observed in patient survival rate according to different isolation strategies.Although 116 participants in 3 HD units were incidentally exposed to MERS-CoV during the 2015 outbreak in Korea, strict patient surveillance and proper isolation practice prevented secondary transmission of the virus. Thus, a renal disaster protocol, which includes proper contact surveillance and isolation practice, must be established in the future to accommodate the needs of HD patients during disasters or outbreaks.

Clinical practice guideline management of blood borne viruses within the haemodialysis unit

Some people who are receiving dialysis treatment have virus infection such as hepatitis B, hepatitis C and/or HIV that is present in their blood. These infections can be transmitted to other patients if blood is contaminated by the blood of another with a viral infection. Haemodialysis is performed by passing blood from a patient through a dialysis machine, and multiple patients receive dialysis within a dialysis unit. Therefore, there is a risk that these viruses may be transmitted around the dialysis session. This documents sets out recommendations for minimising this risk.There are sections describing how machines and equipment should be cleaned between patients. There are also recommendations for dialysing patients with hepatitis B away from patients who do not have hepatitis B. Patients should be immunised against hepatitis B, ideally before starting dialysis if this is possible. There are guidelines on how and when to do this, for checking whether immunisation is effective, and for administering booster doses of vaccine. Finally there is a section on the measures that should be taken if a patient receiving dialysis is identified as having a new infection of hepatitis B, hepatitis C or HIV.

High rate of occult hepatitis B virus infection in hemodialysis units of KwaZulu-Natal, South Africa

Occult hepatitis B virus (HBV) infection (OBI) is defined as the presence of HBV DNA in the liver with or without detectable HBV DNA in the serum of individuals testing HBV surface antigen (HBsAg) negative using currently available assays. The prevalence of OBI among patients receiving hemodialysis (HD) treatment remains poorly characterized in South Africa despite the high prevalence of HBV. We sought to determine the prevalence of OBI in HD units in tertiary hospitals of KwaZulu-Natal and to characterize the HBV S gene mutations potentially responsible for OBI. A cross-sectional descriptive study of residual diagnostic plasma samples from 85 HBsAg-negative patients receiving HD treatment was included. The PreS/S gene was amplified with a nested HBV polymerase chain reaction for downstream next-generation sequencing, to determine the viral genotype and identify S gene mutations associated with OBI. Nine of the 85 samples had OBI, based on detectable HBV DNA. The point prevalence of OBI was 10.6% (95% control interval: 5.5%-19.1%). Phylogenetic analysis of the samples with OBI showed that all belonged to genotype A. Three (~33%) samples had mutations in the major hydrophilic region (MHR) within the S gene, three (~33%) had mutations within the S gene but outside the MHR, whilst the remaining three had no mutations observed. The prevalence of OBI in HBsAg-negative patients undergoing HD was 10.6%, suggesting that OBI is a clinically significant problem in patients with HD in this region. The screening methods for HBV infection need to be revised to include nucleic acid testing.

Low prevalence of occult hepatitis B virus infection in chronic haemodialysis and kidney transplant patients

BACKGROUND

Occult hepatitis B virus infection (OBI) is defined as the presence of hepatitis B virus (HBV) DNA in serum and/or liver in HBsAg-negative patients. We investigated the prevalence of OBI in large chronic haemodialysis (CHD) and kidney transplant recipients (KTxR) cohorts, including determination of HBV DNA in peripheral blood mononuclear cells (PBMCs).

METHODS

HBV DNA was determined in both serum and PBMCs in 417 CHD patients, 417 KTxR, 20 HBsAg-positive non-CHD non-KTx patients (positive controls) and 40 HBsAg-negative healthy subjects (negative controls).

RESULTS

Chronic haemodialysis group: two of 376 patients were HBsAg-positive. The 374 HBsAg-negative patients tested negative for HBV DNA in both serum and PBMCs. KTxR group: 14 of 417 patients were HBsAg-positive. One of 403 HBsAg-negative patients tested positive for HBV DNA in serum but not in PBMCs. Positive controls: six of 20 patients were under antiviral therapy and had negative HBV DNA in both serum and PBMCs. In 11 of 14 remaining patients, HBV DNA was detected in serum and in both serum and PBMCs in 3 patients. Negative controls: All 34 patients were anti-HBc-negative and HBV DNA-negative in both serum and PBMCs. In the long term, the only case of anti-HBc-negative OBI lost anti-HBs 5 years after inclusion in the study and showed HBV reactivation with HBsAg re-seroconversion.

CONCLUSIONS

We found nil prevalence of OBI in CHD patients and a very low prevalence (<1%) in KTxR suggesting that routine screening for HBV DNA is not required in CHD population in our region. However, in KTxR, pretransplant screening with HBV DNA should be considered. Testing for HBV DNA in PBMCs does not seem to be of additional value.

Decline in hepatitis B and C prevalence among hemodialysis patients in Tocantins, Northern Brazil

Infection control measures have been responsible for a decline in the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in hemodialysis patients. In Brazil, these measures have been in place since 1996. The aim of this study was to evaluate the current HBV and HCV epidemiology among hemodialysis patients in the State of Tocantins comparing them with those found 14 years ago. There was a significant decline in hepatitis B surface antigen (HBsAg) and anti-HCV prevalence from 4% and 13% in 2001 to 0.8% and 2.8% in 2014-2015, respectively (p < 0.05). Variables related to hemodialysis environment such as working shift and length of time on hemodialysis treatment were no longer associated to HCV and HBV exposure in 2014-2015. A high prevalence of self-reported hepatitis B vaccination was observed in both periods, but only 30% of the individuals showed serological profile of effective previous immunization, suggesting a low compliance with surveillance of hepatitis B immunization in hemodialysis centers. The significant decline in viral hepatitis B and C prevalence in hemodialysis patients in Tocantins underscores the importance of infection control measures, but the low frequency of protective serological profile after immunization against hepatitis B points to the need for greater vigilance of the patients’ vaccination.

Significant proportion of acute hepatitis B in Poland in 2010-2014 attributed to hospital transmission: combining surveillance and public registries data

BACKGROUND

Efficient control of acute hepatitis B requires identification of current transmission routes. Countries in Central-Eastern Europe including Poland attribute an important fraction of cases to nosocomial transmission, as opposed to Western European countries. However, due to possible multiple exposures during the incubation time such assignment may be debatable. This study aimed at assessing of most affected groups and current transmission pattern of acute hepatitis B.

METHODS

We investigated exposures reported by acute hepatitis B cases notified to routine surveillance system in Poland in 2010-2014 in comparison to data on hospitalization rates in general population.

RESULTS

Hospitalization during incubation time significantly increased the risk of HBV infection (RR 3.13, 95%CI 2.58-3.80). Overall hospitalization population attributable risk (PAR%) was 25.7% (95% CI 20.3%-31.1%) as compared to 35% of acute cases assigned to hospital transmission in surveillance database. PAR% increased from 9.5% (1.12%-17.8%) in the age group 25-34 to 41.1% (28.2% - 53.9%) among those 65 +. In addition, cases < 40 more frequently than the older ones reported history of injecting drugs and risky sexual contacts (25% vs 5%). 27% of men < 40 did not report any exposure at all, drawing attention to possible underreporting of risk behaviors.

CONCLUSIONS

The distribution of probable transmission routes differed by age and gender. Further improvement of HBV control requires better coverage of vaccination in risk groups but also strengthening the blood-borne infections control in hospitals.

Dangerous practices in a hemodialysis unit in Vietnam identify from mixed methods

BACKGROUND

Non-compliance with infection control practices poses a serious risk to patients receiving chronic hemodialysis. We aimed to identify the type and frequency of non-compliance with infection control practices in a hemodialysis unit in Vietnam where a large outbreak of hepatitis C infection had occurred.

METHODS

Mixed methods approach included observations and discussions of non-compliance with all 12 nurses at the Hemodialysis Unit, District-6 Hospital in Ho Chi Minh City. Observations of nursing care activities were made between September 2013 and January 2014. Compliance with hand hygiene and glove use during nursing care activities were classified according to the potential for a serious risk of transmission of infection and reported as percentages. Each nurse was expected to provide 11 nursing care activities to three patients assigned per hemodialysis sessions. Activities were to be given on an individual patient-centered care basis, that is, one patient was to receive all 11 activities by their assigned nurse. On completion of the observations all nurses were enrolled in a focus group where observed non-compliance was discussed and transcripts were examined for themes.

RESULTS

Hand hygiene compliance rate was low (27%, 95%CI 25%-28%, 1633/6140) regardless of classification of seriousness of risk from this breach. Although glove use (76%, 95%CI 74-78%, 1211/1586) and other personal protective equipment use (81%, 95%CI 78%-83%, 773/959) were high gloves were observed to be reused with multiple patients during a single nursing care activity provided to consecutive patients. Nurses explained the breakdown of providing nursing care activities on an individual patient-centered basis was a response to limited supply of gloves and hand hygiene facilities and was exacerbated by nursing being co-opted by overly demanding patients to provide services without delay.

CONCLUSIONS

The adaption by the nurses to provide 11 single care activities to multiple consecutive patients in the absence of changing gloves and low hand hygiene compliance was potentially the central risk factor that facilitated the hepatitis C outbreak. Patient-centered care needs to be enforced to minimize multiple nurse-patient contacts that are associated with non-compliance classified as serious risk of infection transmission. Nurse empowerment to resist unreasonable patient demands may also be pivotal to assisting their compliance with hand hygiene and single patient-centered care. An audit program to measure infection control resources and practices may facilitate enforcement of the guidelines.