1. BARBARA DOMMERT-BRECKLER RN BSN QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK Hepatitis B: Anti-bodies, Antigens and Immunity 7/9/2016

2. Objectives Participants will be able to: List required testing for Hepatitis B Know the antibody level that indicates immunity Know vaccination requirements List one method to prevent transmission 2

3. The New Executive Director Please take a minute to meet Stephanie. Make sure you get a card.

4. Hepatitis B Incidence It is estimated that approximately 350 million people are chronic hepatitis B carriers worldwide. After the initial infection, 60% of hemodialysis patients become chronic carriers vs. 5% of the general population. 30% of carriers develop confirmed chronic hepatitis Carriers have an increased risk after transplant. T Eleftheriadis, et al. Infections in hemodialysis: a concise review. Hippokratia. 2011 Apr-Jun 152: 120-126

5. Hepatitis B Transmission HBV is relatively stable in the environment and remains viable for at least 7 days on environmental surfaces at room temperature. Percutaneous or Permucosal Detected on : clamps scissors dialysis machine doorknobs

6. Hepatitis B Test Hepatitis B surface antigen HBsAg A protein on the surface of the hepatitis B virus: it can be detected in high levels in serum during acute or chronic hepatitis B infection.

7. Hepatitis B Test Hepatitis B surface antibody anti-HBs The presence of anti-HBs is generally interpreted as indicating recovery and immunity from hepatitis B infection. Also positive after successful vaccination.

8. Hepatitis B Test Total hepatitis B core antibody anti-HBc Appears at the onset of symptoms in acute hepatitis B and persists for life. The presence of anti-HBc indicates previous or on-going infection.

9. Hepatitis B Test IgM antibody to hepatitis B core antigen IgM anti-HBc Positive result indicates recent infection with hepatitis B virus (<6 months). Its presence indicates acute infection.

10. You have been exposed

11. Susceptible HBsAgNegative anti-HBcNegative anti-HBsNegative Anti-HBs titer <10 mIU/mL

12. Immune Due to Natural Infection HBsAgNegative anti-HBcPositive anti-HBsPositive

13. Immune Due to hepatitis B vaccination HBsAgNegative anti-HBcNegative anti-HBsPositive

14. Acutely infected HBsAgPositive anti-HBcPositive IgM anti-HBcPositive anti-HBsNegative

15. Chronically infected HBsAgPositive anti-HBcPositive IgM anti-HBcNegative anti-HBsNegative

16. Interpretation Unclear HBsAgNegative anti-HBcPositive anti-HBsNegative Four Possibilities: Resolved Infection (most common) False Positive anti-HBc (susceptible) Low Level chronic infection Resolving acute infection

17. CMS Expect Testing Patient Status On Admission MonthlyAnnual AllHBsAg Anti-HBc Anti-HBs HBV Susceptible HBsAg Anti-HBs positive (>10mIU/m L), anti-HBc negative Anti-HBs Anti-HBs and anti- HBc positive None

18. Infection Prevention: Vaccination 18 Vaccination is recommended for pre-end stage renal disease prior to dialysis dependency. These patients have been shown to have higher seroconversion rates and antibody titers. Adapted from CDC. Recommendations for Preventing Transmission of Infections....Patients. 2001;50

19. Infection Prevention: Vaccination 19 Adapted from CDC. Recommendations for Preventing Transmission of Infections....Patients. 2001;50 >20 years of age: Dialysis-dependent Recombivax HB 40 mcg3 Doses: 0, 1 and 6 months Enerix B 40 mcg4 Doses: 0, 1, 2, and 6 months No specific recommendation have been made for pediatric patients.

20. Infection Prevention: Vaccination 20 Booster Doses: A booster dose should be administered when anti-HBs levels decline to <10 mIU/mL. Adapted from CDC. Recommendations for Preventing Transmission of Infections....Patients. 2001;50

21. Infection Prevention: Vaccination 21 Only 50-70% of hemodialysis patients seroconvert following vaccination. Possible reasons: Anemia and ESAs Smoking Obesity Age Poor immune response Diabetes or other comorbidities Adapted from CDC. Recommendations for Preventing Transmission of Infections....Patients. 2001;50

22. Infection Prevention: Isolation Isolating HBs-Ag Positive Patients and their equipment from HBV-susceptible patients resulted in a 70-80% reduction in incidence of HBV infection. Appropriate placement of patient around the isolation room and staff only treating patients with immunity is important. Are you protecting your facility?

23. Infection Prevention: Dialysis Environment

24. Widespread Luminescence Contamination Identified Bergervoet P. J Hosp Infect 2008; 68:323-333

25. Infection Prevention: Dialysis Environment Other Areas of Luminescence Hemodialysis machine & syringe pump: areas most frequently touched by fingertips were most contaminated Lid of laundry container: places touched with hands Telephone and computer keyboard: keys were contaminated CDC recently replicated this experiment during an investigation & found nonvisible evidence of blood on several surfaces in the center.

26. Infection Prevention: Dialysis Environment Common Themes in CDC Outbreak Investigations Patient overlaps in space and time (i.e., transmission from): – One patient to the next at same station – One patient to another at adjacent stations Breaches in medication preparation and administration practices – Preparing medications in potentially contaminated area – Mobile medication carts – Not wiping injection ports prior to accessing Breaches in environmental cleaning and disinfection practices – Surfaces wiped down with patient still at station – Rushed turnover processes Information from Dr. Priti Patel, CDC

27. Infection Prevention: Dialysis Environment Common Themes in CDC Outbreak Investigations No physical barrier between stations Frequent blood contamination of surfaces Staff feel pressured to turnover stations quickly Multi-tasking – Easy to miss surfaces, even entire stations – Recontamination of cleaned surfaces Shared computer charting stations within treatment station Difficult to clean high touch surfaces, e.g. keyboards Information from Dr. Priti Patel, CDC

28. Infection Prevention: Dialysis Environment Common Themes in CDC Outbreak Investigations http://www.cdc.gov/dialysis/PDFs/collaborative/Env_checklist-508.pdf

29. Questions? 29 Barbara Breckler bbreckler@nw16.esrd.net 206.923.0714

30. Northwest Renal Network Network Mission The mission of Northwest Renal Network is to promote optimal dialysis and transplant care for kidney patients in Alaska, Idaho, Montana, Oregon and Washington.