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  • The Screening, prevention & management of BBV In patients requiring RRT.

    Transplant, Urology & Nephrology Directorate Page 1 19/03/2014

    Transplant, Urology & Nephrology Directorate

    The Screening, prevention & management of BBV In patients requiring RRT

    Document Number:

    4

    Reason for Change

    Virology screening & prevention of BBV

    combined and updated, National

    Guideline change 2013.

    Original Date of Approval:

    14th

    Oct 2008

    Originally Approved By:

    Renal Committee

    Recent Date of Approval:

    Approved By: Renal Committee

    Date Effective From

    Superseded Documents

    3, 3C & 2D

    Review Date: March 2015

  • The Screening, prevention & management of BBV In patients requiring RRT.

    Transplant, Urology & Nephrology Directorate Page 2 19/03/2014

    CONTENTS

    Section 1

    1.0 Rationale

    1.1 Scope

    1.2 Principles

    Section 2

    2.0 Responsibilities of Medical and Nursing Personnel

    Section 3

    3.0 Haemodialysis

    3.1 BBVs screening and interpretation of results in HD units

    3.1.1 Hepatitis B

    Figure 1 Schedule for testing for HBV infection

    3.1.2 Hepatitis C

    Figure 2 Schedule for management HCV positive patient

    3.1.3 HIV

    3.2 Ordering virology screen prior to HD

    3.3 Virology results required before HD in open unit

    3.4 Emergency HD required

    3.4.1 Urgent results from NVRL

    3.5 Regular HD patients

    3.6 Management of Patients who have received HD in another unit

    3.6.1 Transfer from a unit within the Republic of Ireland.

    3.6.2 Transfer from a unit outside the Republic of Ireland 4.0 Home Therapies-CAPD/CCPD/Home Haemodialysis

    5.0 Therapeutic plasma exchange 6.0 CKD patients 7.0 Renal transplant patients Table 1 Routine Virology surveillance

    8.0 Patient Education & Consent

    9.0 Hepatitis B vaccination

    Table 2 Hepatitis B vaccination schedule

    Table 3 Action following Anti- HBs (titre) level post vaccine

  • The Screening, prevention & management of BBV In patients requiring RRT.

    Transplant, Urology & Nephrology Directorate Page 3 19/03/2014

    10.0 Infection control practices for the haemodialysis unit

    10.1 Environmental/ Design Considerations

    10.2 Standard precautions

    10.3 Documentation

    10.4 Management of BBV infected patients

    11.0 Distribution

    12.0 Filing

    13.0 Review

    14.0 Superseded / Obsolete Documents

    SECTION 4

    Development and Consultation Process

  • The Screening, prevention & management of BBV In patients requiring RRT.

    Transplant, Urology & Nephrology Directorate Page 4 19/03/2014

    SECTION 5

    Recommended Reading

    Appendices

    Appendix 1 Ordering of Hepatitis B & C, HIV and HCV PCR on computer

    Appendix 2 Renal Unit Virology Ordering and Testing out of office hours

    Appendix 3 Out of hours testing forms

    Appendix4 Correct use of transport container for all virology

    Appendix 5 NVRL out of hours Urgent dialysis record

    Appendix 6 Reserve label

    Appendix 7 Algorithm for Management of weak positive & positive HCV result

    Appendix 8 Algorithm for Management of weak positive & positive HBV result

    Appendix 9 Algorithm for Management of weak positive & positive HIV results

    Appendix 10 Algorithm for Management of a previously identified BBV positive result

    Appendix 11 Sample daily, weekly & monthly cleaning and disinfection schedule

    Appendix 12 Cleaning and disinfection following Hepatitis B HD treatment

    Appendix 13 Unscheduled Wall washing

    Appendix 14 Cleaning and disinfection after isolation HIV/ HCV treatment

    Appendix 15 Haemodialysis Infection risk questionnaire

    Appendix 16 Effectiveness of heating in dialysis machines

    Appendix 17 Geographical distribution of HBV/HC/HIV endemicity

  • The Screening, prevention & management of BBV In patients requiring RRT.

    Transplant, Urology & Nephrology Directorate Page 5 19/03/2014

    SECTION 1

    1.0 Rationale: End Stage Renal Failure requires various forms of Renal Replacement

    Therapies (RRT) which includes Haemodialysis (HD), Continuous Ambulatory Peritoneal

    Dialysis (CAPD) and Transplantation. Patients undergoing RRT are at a higher risk of acquiring

    Blood Borne Virus (BBV) infections due to factors like impaired cellular immunity, underlying

    diseases, blood transfusions, frequent hospitalisations and the procedure of haemodialysis

    itself which requires blood exposure through a vascular access for prolonged periods. This

    document aims to provide guidelines for nurses and medical staff on the screening,

    prevention and management of BBVs in patients requiring Renal Replacement Therapies.

    1.1 Scope: This guideline is in line with the guidelines published by the Department of

    Health and Children (DoHC) on Blood-Borne Viruses in Haemodialysis, CAPD and Renal

    Transplantation 2013.

    This guideline applies to all medical and nursing staff working in the Transplant, Urology &

    Nephrology Directorate.

    1.2 Principles: The Renal Unit strives to minimise the risk of transmission of blood borne

    viruses within all the patients undergoing Renal Replacement Therapies by the

    implementation of evidence based practice, standard and transmission based precautions.

    SECTION 2

    2.0 Responsibilities of Medical and Nursing Personnel:

    1 Nursing staff must be aware that frequency of re-screening depends on the patients respective treatment modality and previous screening results (See Table

    1).

    2 Nursing or medical staff must ensure patients are informed prior to all screening. 3 Medical staff should order virology screening prior to commencement of HD and

    review results.

    4 Nursing staff must review virology screening results prior to commencement of each HD.

    5 Nursing staff must manage HD machines as per the guidelines for the screening, prevention & management of BBV in patients requiring RRT.

    6 Formal informed consent will be taken for routine virology screening in conjunction with consent for haemodialysis/CCPD/CAPD treatment.

    7 Patients refusing consent for virology screening must be treated as positive for a BBV with isolation of machine and patient. Machine number used for these

    patients must be registered onto Clinical Vision.

  • The Screening, prevention & management of BBV In patients requiring RRT.

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    SECTION 3

    3.0 Haemodialysis

    Transmission of BBVs in HD units

    BBV infections are much more common in the haemodialysis population than the general

    population. Most reported Hepatitis B Virus (HBV) outbreaks among haemodialysis patients

    have occurred because of significant breeches in infection control practices and failure to

    vaccinate against hepatitis B. Prevalence of HBV in HD units has decreased dramatically due

    to increased adherence to infection control practices and availability of HBV vaccination. In

    contrast Hepatitis C Virus (HCV) infection is still highly prevalent in HD units. Two major

    factors associated with the higher prevalence of HCV are the number of blood transfusions

    received and the length of time on HD. With regards to transmission of Human Immuno

    Deficiency Virus (HIV), most studies fail to show transmission of the virus in HD units.

    Prevention of Transmission

    In order to prevent transmission of BBVs among patients undergoing RRT, rigorous

    adherence to the proposals in this guideline is imperative. Regular screening of all patients

    undergoing RRT must be performed and these patients must be considered potentially

    infected until fully tested. Prior to commencing HD all patients should be screened for

    evidence of HBV, HCV and HIV.

    3.1 BBVs Screening and interpretation of results in HD units

    3.1.1 Hepatitis B

    Pre-HD

    Pre-HD testing for HBV should include hepatitis B surface antigen (HBsAg), hepatitis B core

    antibody (anti-HBc), and hepatitis B surface antibody (anti-HBs) (Also refer to Figure 1 &

    Table 1).

    Regular testing while on HD

    Weak positive HBsAg can occur immediately after HBV vaccination. Therefore HD patients

    should not be screened for HBsAg for at least 10 days after HBV vaccination.

    1. HBV susceptible patients (i.e. unvaccinated or non-responders to vaccine) should have HBsAg tested monthly (Refer to Table 1)

    2. Patients who have shown an initial good response to vaccination (anti-HBs 100 mIU/ml) should be tested for anti-HBs annually and for HBsAg three monthly.

    3. Patients who have shown an initial low level response to vaccination (anti-HBs 10-99 mIU/ml) should be tested for anti-HBs annually and for HBsAg three monthly (See

  • The Screening, prevention & management of BBV In patients requiring RRT.

    Transplant, Urology & Nephrology Directorate Page 7 19/03/2014

    paragraph 9.0 for further information on HBV vaccination and table 2 & 3 ).

    4. Patients who are anti-HBc positive and HBsAg negative should have monthly HBsAg testing.

    5. Anti HBcAb positive patients who are immunosuppressed* or likely to become immunosuppressed:

    Test HBsAg weekly during period of immunosuppression, and for two mont