1. BBV in Wales Renal Units: a focus on prevention of Hepatitis B infection in dialysis unit M Kumwenda on behalf of the Welsh Audit Group Cardiff 11.09.15

2. BBV audit : closing the loop in the north and extending south

3. Scale of the problem Worldwide – blood contamination: sexual intercourse, transfusion, surgery and needle- sharing 2 billion people infected with HBV (1/3 people) 780000 deaths per year 1/350 people have chronic hepatitis in UK

4. Universal precautions 1972 UK HBV infection outbreak Wear gloves, a gown, and/or face protection when you think you may come into contact with blood or other potentially infectious materials Change gloves during patient care if the hands will move from a contaminated body-site to a clean body-site Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) Do not wear the same pair of gloves for the care of more than one patient

6. Incidence of hepatitis B in Europe

8. Incidence of HBV in Wales

9. Near miss incidents

12. Vaccination with Hepatitis B is safe Response rate is 40-95%

13. Please who are at risk of Hepatitis B infection are offered testing and vaccination People who frequently require blood or blood products, dialysis patients, recipients of solid organ transplantations; People interned in prisons; Persons who inject drugs; Household and sexual contacts of people with chronic HBV infection; People with multiple sexual partners; Health-care workers and others who may be exposed to blood and blood products through their work; and Travellers who have not completed their hepatitis B vaccination series, who should be offered the vaccine before leaving for endemic areas.

14. Renal Association audit standards 2009 Screening at least 3 monthly Number of patients e GFR < 10ml/min on vaccination programme Proportion of prevalent and incident patients with HBs > 10mIU/ml Segregation of infected patients

15. Objectives of the audit?

16. Determine compliance of Welsh renal units All patients with e GFR <15ml/min should be screened for BBV All patients with e GFR <15mil/min should be vaccinated against HBV Infected patients with HBV should be segregated Patients who dialyse outside the UK should be segregated on return until they have –ve monthly tests for 3 months Non immune nurse should avoid needling infected patients with HBV if possible A dedicated co-ordinator must be identified to run a vaccination programme

17. Prevalence of BBV: Number of patients with BBV per centre HBVHCVHIV YG1(CKD5)01(HHD) Wrexham000 YGC1(CKD5)00 Morriston011 With000 Car000

18. Type of vaccine in use Engerix BHBVaxPro YGNoYes WrexhamYesNo YGCYesNo MorristonNoYes With?? CarYesNo

19. Proportion of patients vaccinated (%) HDPDCKD5Comments YG80 (76)15 (100)29 (72)HD 88% 2014 Wrexham111 (94)20 (67)62(48)HD 83% 2014 YGC71 (85)12 (71)21(43)HD 94% 2014 Morriston228 (72)56 (89)266 (?)GP vaccination programme With50 (74)00All patients in the a vaccination programme Car62 (100)00HD 87% 2014

21. Vaccination response rate (%): Proportion of patients achieving antibody >10u/l HDPDCKD5Comments YG67 76 Better response in CKD5 Wrexham557595 Better response in CKD5 YGC516743 Morriston27?? With Car47??

22. Vaccination co-ordinator YGNo WrexhamNo Welsh poolYes YGCYes MorristonYes WithNo CarYes

23. Frequency of testing HospitalHDPDCKD5Comments YG3/3/123/3/012/12/12 YGC3/6/1212/12/12Repeated near to dialysis Wrexham3/3/123/6/12NoneDone near to dialysis Morriston1/3/6None Done near to dialysis With1/0/0None Done near dialysis Car1/1/1None Done near dialysis

24. Unit policies HospitalYGYGCWrexMorrisCarWit h Non immune nurses needling No YesNo Vaccinate SpousesYes(HHD)No Infected holiday patientsNo YesNo Yes On return segregationYes No No segregation if UK holiday all Euro/Can/US – Car Euro -With

25. Determine compliance of Welsh renal units All patients with e GFR <15ml/min should be screened for BBV All patients with e GFR <15mil/min should be vaccinated against HBV Infected patients with HBV should be segregated Patients who dialyse outside the UK should be segregated on return until they have –ve monthly tests for 3 months Non immune nurse should avoid needling infected patients with HBV if possible A dedicated co-ordinator must be identified to run a vaccination programme

26. Conclusion BBV in patients with e GFR <15ml/min is very low in Welsh units 100% of units have a vaccination programme Seroconversion rates of patients who completed vaccination against HBV varied between 40 and 95% Segregation facilities were available in all units HBV vaccination coordinators needed

27. Discussion SMART PROJECT? Indications - CKD 5:for RRT - patients on dialysis - renal transplants Screening Vaccination and response Annual audit

28. Discussion Data collection – Kim Vital data Frequency of screening Non-immune staff band needling Boost only when risk of exposure Coordinator