Friday, 20 February 2009

Q & A: will travelling become more difficult for haemodialysis patients if hepatitis carriers increase?

Q: When patients dialyse at another unit it is general practice now to provide the temporary unit with blood results confirming that the patient is hepatitis free. It also seems some kidney units have a policy of isolating patients for 3 weeks on their return from dialysing in another unit in the UK to ensure cross infection does not occur. How big a problem is this and will travelling become more difficult for haemodialysis patients especially abroad, if the number of hepatitis carriers increase?"
Bindu Chauhan, Chair of Leicestershire KPA

A: Dear Bindu, safety and infection control are essential quality factors in kidney units. In the early years of dialysis, outbreaks of hepatitis B virus were a major risk. In Manchester and Edinburgh, the consultants I trained under were acutely aware of these problems, having seen patients and colleagues die after contracting hepatitis B on the dialysis unit. Hepatitis B can be highly infectious, even a small and invisible to the naked eye blood spray – that occurs every time a fistula is needled, or coming from the machine – can infect members of staff or a patient if they are too close. The frequency of hepatitis has markedly improved over the past 20 years as a result of general, universal precautions, machine design, hepatitis immunisation, blood transfusion screening and isolation. The last UK survey showed a hepatitis B virus carriage rate of 0.5% and a hepatitis C virus infection rate of 2%. So the risks of hepatitis and other blood-borne viruses remain real and have been contained rather than eliminated.

Over the last decade the major infection problem in kidney units has been bacterial rather than viral infections. Bacterial infections are spread in different ways and you are probably aware that dialysing through a neckline rather than a graft or fistula is the main risk factor. That is why we placed such emphasis on improved vascular access and setting the target that every patient should have a fistula created 6 months before starting dialysis in the Renal NSF. Of course a small proportion of people can’t have fistulas made for technical reasons. So, like viral precautions, precautions against MRSA need to be strictly enforced. Such an approach has seen more than 50% fall in the incidence of MRSA bacteraemia in England.

The best ways to reduce the hepatitis B risk is to vaccinate against the disease. But people with advanced kidney disease and those on dialysis often don’t sero-convert - by that I mean the vaccine doesn’t, work. It is therefore important that hepatitis B vaccine is given early, long before dialysis is needed, so that it works and provides the same protection for people when they need dialysis as it does for people without kidney disease.

Every patient with chronic kidney disease who might eventually dialyse should receive hepatitis B immunisation.

The constraints on dialysis away from base units imposed on kidney patients within the UK is a continuing challenge. I have therefore asked Bob Dunn (NKF National Patient Advocacy Officer) along with a working group, to collect the evidence and make recommendations for improvement on this issue. I have worked with Bob form the start of the NSF and he has taught me as much as any of the consultants who trained me and they were the best in the world. Bob of course had taught me different things – so I was thrilled when I read of his MBE award to services to healthcare in the New Year’s Honours List. I look forward to the Dialysis Away from Home Base Unit report and expect real improvement from the recommendations. People on dialysis should be encouraged and supported to have holidays. There are many reasons to travel around the country – for family events, work, sport – so why should people on dialysis be further restricted?

Quality is the organising principle of the NHS - you can’t have quality without safety, so infection control procedures and vigilance must be the watchwords on kidney units. Units know the viral status – infected, carrier or clear from viral infection – of every patient they provide dialysis for, even if it’s only one session. This approach and our zero-tolerance approach to MRSA, has made UK kidney units amongst the safest in the world. So quarantine or isolation on return from dialysis in other UK units is not normally needed. Several countries have similar high standards of care and use the same universal precautions we have developed. In some other countries, however, the safety record is much worse and in some the risks of contracting hepatitis are, frankly, high if you have not been successfully vaccinated. You should discuss this with your dialysis team and the NKF when considering travel. On return from abroad therefore, a period of quarantine of up to 6 months is often needed if you have received dialysis in a country without the same high standards of infection control as the UK.

published in "Kidney Life" magazine Spring 2009