Despite guidance from the Department of Health and the Renal Association that dialysis patients should be offered prophylaxis against hepatitis B by immunisation, surveys have shown that 95% of renal units in 1994 and 49% in 1995 were not routinely offering immunisation to any patient groups with chronic renal failure.1–4 We aimed to determine whether provision of hepatitis B immunisation had improved after publication of the 1996 Department of Health guidelines and to identify barriers to implementation of existing guidelines.1
Participants, methods, and results
We sent a postal questionnaire, piloted in five renal units, to the clinical directors of all 87 main UK renal units and satellites. The questionnaire (available on bmj.com) covered hepatitis B immunisation in patients with chronic renal failure, including those receiving renal replacement therapy; the number of cases of acute hepatitis B infection between 1997 and 1999; and reasons why patients might not be vaccinated.
Seventy eight (90%) units responded. Units in two teaching and four district general hospitals plus three satellites did not respond, despite reminders. Twelve units (15%) reported at least one incident of hepatitis B seroconversion in a dialysis patient. Twenty three units (29%) did not immunise any patient groups. A further six units offered immunisation only to patients planning treatment in hepatitis B endemic areas outside the United Kingdom.
Completeness of hepatitis B immunisation in dialysis patients was not known in 27 units (35%), less than 25% in 17 units (22%), 25-75% in 13 units (17%), and over 75% in 20 units (26%). Of the 55 units that provided immunisation, 70% gave the recommended higher dose of 40 μg whereas 30% gave the previously recommended dose of 20 μg. Most (72%) used the earlier schedule of doses at 0, 1, and 6 months instead of the recommended accelerated schedule of 0, 1, 2, and 12 months. The table lists the reasons why patients are not routinely immunised.
Thirty six units (46%) followed the Renal Association's recommendations on hepatitis B immunisation of patients with chronic renal failure; 42 did not. Fourteen units had developed their own policies. Eleven units (14%) mentioned alternative guidance on immunisation, including the Department of Health's “green book” on infectious diseases,1 the revised Rosenheim report (the draft Department of Health's policy in development),4 and the British National Formulary.
One unit feared that staff might become less careful with universal precautions if all patients were immunised. Two units thought that the heavy workload produced little benefit. One unit abandoned an immunisation programme it had started after a seroconversion incident in 1996, owing to logistical difficulties. Two units mentioned difficulties in tracking patients who had been referred to general practice; one unit reverted to immunisation through dialysis services rather than primary care after seroconversion of a patient who had been referred. Six units mentioned costs and funding as barriers. One unit thought our survey would encourage provision of funding.
Comment
Although the rate of hepatitis B immunisation of patients with chronic renal failure in the United Kingdom has improved in recent years, most renal units still fail to follow current guidance. Partial coverage is the norm, and outmoded regimens are still used. The shared care management of immunisation may be one solution, although this requires good collaboration between primary and specialist care. Strategies that may improve collaborative care are inclusion of immunisation in service agreements, definition of responsibilities for initiation of immunisation, follow up and evaluation of response, payment to general practitioners, and regular audit and shared feedback. The efficacy of the hepatitis B vaccine in end stage renal disease needs investigation to encourage its use in dialysis patients.
Supplementary Material
Table.
Reasons given by 78 renal units as to why dialysis patients are not routinely vaccinated for hepatitis B before starting dialysis and during dialysis. Values are numbers (percentages) of units
| Reason | Before dialysis | During dialysis |
|---|---|---|
| Logistics of administration and monitoring | 34 (44) | 35 (45) |
| Low perceived risk (outbreaks rare) | 26 (33) | 38 (49) |
| Awaiting revised guidelines from units committee | 24 (31) | 26 (33) |
| Effectiveness of universal precautions and screening of blood donors and patients | 23 (29) | 28 (36) |
| Poor efficacy of vaccine in patients receiving dialysis | 22 (28) | 35 (45) |
| Should be done in primary care | 21 (27) | 20 (26) |
| Not cost effective | 19 (24) | 22 (28) |
| Lack of awareness of higher dose (40 μg) vaccine | 14 (18) | 16 (21) |
Acknowledgments
We thank all UK renal units who completed the study questionnaire and the staff at the Communicable Disease Surveillance Centre, Birmingham Heartlands Hospital.
Footnotes
Funding: None.
Competing interests: None declared.
The questionnaire appears on bmj.com
References
- 1.Department of Health. Immunisation against infectious disease 1996. London: Stationery Office; 1996. [Google Scholar]
- 2.Royal College of Physicians; Renal Association. Treatment of adult patients with renal failure. Recommended standards and audit measures. London: RCP; 1997. pp. 64–74. [PMC free article] [PubMed] [Google Scholar]
- 3.Jibani MM, Heptonstall J, Walker AM, Bloodworth LO, Howard AJ. Hepatitis B immunization in UK renal units: failure to put policy into practice. Nephrol Dial Transplant. 1994;9:1765–1768. [PubMed] [Google Scholar]
- 4. Draft good practice guidelines for the prevention and control of blood borne virus infection in renal dialysis and renal transplantation units. London: Department of Health and Public Health Laboratory Service (in press).
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