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Policies,Clinical,UWHC Clinical,Department Specific,Hemodialysis

Hepatitis B and C Screening and transmission prevention in Hemodialysis (5.0)

Hepatitis B and C Screening and transmission prevention in Hemodialysis (5.0) - Policies, Clinical, UWHC Clinical, Department Specific, Hemodialysis

5.0

University of Wisconsin Hospital and Clinics
Inpatient Hemodialysis
Department 55400
TITLE: Hepatitis B and C Screening and
transmission prevention in Hemodialysis.
POLICY #: 5.0
REVISED: October 2016
Page 1 of 6
Nurse Manager: Joan Watson, MS, RN
Director: Ann Malec, DNP, RN, NEA-BC
Medical Director: Alex Yevzlin, MD
Infection Control: Marc Oliver Wright, ICP
I. PURPOSE
To define the serological lab testing performed and/or reviewed on University of Wisconsin
Hospital and Clinics (UWHC), American Family Children’s Hospital (AFCH) and Veterans
Hospital (VHA) patients receiving Hemodialysis and/or Continuous Renal Replacement Therapy
(CRRT) services, provide guidance with interpretation of results and to describe precautions
taken to prevent the transmission of Hepatitis B (HBV) and Hepatitis C (HCV) Viral infections.
II. POLICY
A. The following Hepatitis B serology test results are necessary to determine HBV
infectious disease status, Hepatitis B surface antigen (Hep B sur AG), Hepatitis B surface
antibody (Hep B sur AB) and Hepatitis B core antibody (Hep B core AB). If the Hep B
core AB is positive but the Hep B sur AB is negative additional Hepatitis B core IgM
antibody (Hep B cor AB, IgM) used to determine acute or chronic HBV infection.
Interpretation of Hepatitis B Serology Test
Health Link Test Name Other common Names Results Interpretation
Hep B sur AG
Hep B sur AB, total
Hep B core AB
HbsAg
Hbs Ab, Anti-HBs
Hbc Ab, Anti-HBc
Non-reactive
<8 is Negative
Non-reactive
Susceptible
Hep B sur AG
Hep B sur AB, total
Hep B core AB
HbsAg
Hbs Ab, Anti-HBs
Hbc Ab, Anti-HBc
Non-reactive
High #
Reactive
Immune due to
natural infection
Hep B sur AG **
Hep B sur AB, total
Hep B core AB
HbsAg
Hbs Ab, Anti-HBs
Hbc Ab, Anti-HBc
Non-reactive
High #
Non-reactive
Immune due to
hepatitis B
vaccination
Hep B sur AG
Hep B sur AB, total
Hep B core AB
HbsAg
Hbs Ab, Anti-HBs
Hbc Ab, Anti-HBc
Reactive**
<8 is Negative
Non-reactive
Early incubation/
Vaccination false
positive**
Hep B sur AG
Hep B core AB
Hep B core AB, IgM
Hep B sur AB, total
HbsAg
Hbc Ab, Anti-HBc
IgM anti-HBc
Hbs Ab, Anti-HBs
Reactive
Reactive
High #
Low #
Acutely infected
(see precautions)
Hep B sur AG
Hep B core AB
Hep B core AB ,IgM
Hep B sur AB, total
HbsAg
Hbc Ab, Anti-HBc
IgM anti-HBc
Hbs Ab, Anti-HBs
Reactive
Reactive
Low #
Low #
Chronically infected
(see precautions)
Hep B sur AG
Hep B core AB
Hep B sur AB, total
HbsAg
Hbc Ab, , Anti-HBc
Hbs Ab, Anti-HBs
Nonreactive
Reactive
<8, Negative
Four interpretations
possible (consult
Infectious disease)
**Transient HBs-AB positivity lasting < 18 days is seen in some patients during vaccination.

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B. Hepatitis C antibody (HCV) test is used to screen for infection. It detects the presence of
antibodies to the virus, indicating exposure to HCV. This test cannot distinguish between
active or previous HCV infection and it is believed that patients with previous HCV
infection are still capable of transmitting the disease regardless of treatment for HCV. No
further lab testing is required to determine HCV infection disease status.
C. Prior to initiating hemodialysis or CRRT determine HBV and HCV infectious disease
status.
1. If serological testing results are not readily available draw the following
serological tests and enter the order in the electronic medical record per
policy: Hep B sur AG, Hep B sur AB and Hep B core AB and Hepatitis C AB
2. Chronic End Stage Renal Disease (ESRD) patient populations:
Obtain a written copy of serological testing results from the referring ESRD
facility prior to or immediately after the first hemodialysis treatment. For more
detailed information on routine HBV and HCV testing of ESRD patients see
Recommended Infection Control Practices for Hemodialysis Units at a Glance
3. If the lab test results provided are older than established parameters below, draw
the necessary serological tests to determine Hepatitis B and C status.
a. If the patient is documented Hep B sur AB positive, a Hep B sur AG is not
required however the Hep B sur AB test result provided must be within the
past 12 months.
b. If the patient is documented Hep B sur AG negative and has received one
or more of the Hepatitis B vaccination series the patient should not be
tested for Hepatitis until 8 weeks (56 days) after completion of the series.
At that point draw a Hep B sur AB to test for seroconversion to Hep B sur
AB positive.
c. If the patient is documented Hep B sur AG negative and has not received
the vaccination and/or did not convert after vaccination draw a Hep B sur
AG every 30 days.
d. If the patient is documented Hep C AB negative, test results provided must
be within 30 days. If the patient is Hep C AB positive no further testing is
required.
D. All patients will be treated following Standard Precautions.
E. Patients with known HCV infection or unknown HBV/HCV infection status will be
treated following Section IV. Procedures, 3. Infection Control Precautions.
F. Patient determined to be Hep B sur AG positive (acute or chronic) will be treated
following Section IV. Procedures, 4. Infection Control Precautions for patients with
known HBV infection.
III. GENERAL INFORMATION
A. The presence of a confirmed Hep B sur AG positive result in serum indicates active HBV
infection. All Hep B sur AG positive persons should be considered infectious.
1. In newly infected persons, Hep B sur AG is the only serologic marker detected during
first 3--5 weeks after infection. The average time from exposure to detection of Hep B
sur AG is 30 days (range: 6--60 days).

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2. Hep B core AB appears at the onset of symptoms or liver-test abnormalities in
acute HBV infection and persists for life. Acute or recently acquired infection can
be distinguished by the presence of the immunoglobulin M (IgM) class of Hep B
core AB, which is detected at the onset of acute hepatitis B and persists for up to 6
months if the disease resolves.
B. In persons who recover from HBV infection, Hep B sur AG is eliminated from the blood,
and Hep B sur AB develops, typically within 3-4 months. CDC recommends re-testing
newly diagnosed HBV infection in six months for the presence of Hep B sur AB typically
indicating immunity from HBV infection.
1. Persons who recover from natural infection typically will be positive for both Hep
B sur AB and Hep B core AB, whereas persons who respond to hepatitis B
vaccine have only Hep B sur AB
C. Hepatitis B Surface Antigen (Hep B sur AG): A serologic marker on the surface of HBV.
It can be detected in high levels in serum during acute or chronic hepatitis. The presence
of Hep B sur AG indicates that the person is infectious. The body normally produces
antibodies to Hep B sur AG as part of the normal immune response to infection.
D. In persons who become chronically infected, Hep B sur AG and Hep B core AB persist,
typically for life. Hep B sur AG will become undetectable in approximately 0.5%-2% of
persons with chronic infection yearly; Hep B sur AB will occur in the majority of these
persons.
E. Hepatitis B Surface Antibody (Hep B sur AB): The presence of Hep B sur AB is
generally interpreted as indicating recovery and immunity from HBV infection.
Hep B sur AB also develops in a person who has been successfully vaccinated against
hepatitis B.
F. Hepatitis B Core Antibody (Hep B core AB): Appears at the onset of symptoms in acute
hepatitis B and persists for life. The presence of Hep B core AB indicates previous or
ongoing infection with hepatitis B virus (HBV) in an undefined time frame.
G. Hepatitis B Core Antibody, IgM (Hep B core AB, IgM) antibody appears during acute or
recent HBV infection and is present for about 6 months.
IV. PROCEDURES
1. Standard Precautions are used on all patients and include use of gloves, gown, mask,
goggles or face shield whenever needed to prevent contact of the health-care worker with
blood, secretions, excretions, or contaminated items.
2. The nurse clinician assigned to perform the first inpatient dialysis for the current hospital
stay is responsible for the reviewing the patient’s medical record to ascertain the patient’s
HBV status. The HBV status will be recorded on the Inpatient Hemodialysis Kardex,
note any serology lab test drawn and communicate the status to the charge nurse to be
documented on the daily assignment sheet.
3. Infection Control Precautions for patients with known HCV infection or unknown
HBV or HCV status.
a. The dialysis machine and all other equipment used are to be wiped clean with
EPA registered hospital grade cleaner/disinfectant and the internal fluid pathways
will be chemically disinfected (bleached) after each treatment.

Page 4 of 6
4. Infection Control Precautions for patients with known HBV infection
a. A dialysis machine will be designated for use by this patient and/or other HBV
patients and will be sequestered for the duration of the inpatient stay.
b. Disposable supplies are for single use only, when caring for Hepatitis B antigen
(HbsAg) positive patients, the nurse server will be placed outside the room.
c. Any supplies that need to be readily available at the bedside will be placed in a
separate container, labeled with the patient’s name and will be stored with the
designated machine.
d. The dialysis machine and all other equipment are to be wiped clean with EPA
registered hospital grade cleaner/disinfectant and will be chemically disinfected
(bleached) after each treatment.
e. Upon patient discharge the machine will receive a detailed surface cleaning. Refer
to HD Policy 2.6: Routine Cleaning, Disinfect, and Maintenance of the
Hemodialysis Machine: Appendix B. Dialysis Machine Surface Detailing
Checklist.
f. The machines internal pathways will be chemically disinfected with bleach prior
to returning to general use and if applicable any internal transducer protector
changed.
g. Staff should not care for HBsAg+ (Hepatitis B antigen positive) and HBs
antibody negative (susceptible) patients on the same shift or at the same time
h. Staff may care for both HbsAg+ (Hepatitis B antigen positive) and HBs Antibody
positive (immune) patients at the same time.
i. Staff with positive hepatitis antibodies (HBs antibody positive) should be
assigned to care for patients who are HBsAg+ whenever possible. However, HBs
antibody negative staff may care for HBsAg+ patients if necessary.
V. DOCUMENTATION
A. Documentation of the most recent Hepatitis B Lab screening results and interpretation
should be entered into the Hemodialysis Kardex.
B. If the interpretation of the patient’s status is based upon Lab results and immunization
information obtained from another facility faxed copies of results should be scanned into
Health Link as Dialysis related Lab results.
VI. RESOURCES
A. Centers for Disease Control: Recommendations for Preventing Transmission of
Infections Among Chronic Hemodialysis Patients
B. Recommended Infection Control Practices for Hemodialysis Units at a Glance
C. ESRD Surveyor Training Interpretive Guidance
D. Appendix A: Schedule for Routine Testing of Hepatitis B and C
E. Appendix B. Dialysis Machine Surface Detailing Checklist.
REVIEWED: 12/1/2016
Jmw08/10/13

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Appendix A:














Page 6 of 6

Appendix B. Dialysis Machine Surface Detailing Checklist

 Remove all jugs i.e., dialysate, bicarb, bleach or citric acid.
 Gambro Machine: remove front and back platforms.
 Use spray vinegar to loosen any mineral deposits or debris. Use Mister Clean Eraser ™ to
remove any stains.
 Use mechanical scrubbing motions to clean all surfaces top to bottom with EPA
registered hospital grade cleaner/disinfectant.
 Scrub any hanging instructions or trouble shooting cards, blue clamps, blood pressure
cuff and hoses.
 Scrub all dialysate, drain and water connection hoses and electrical cords.
 Clean hand crank on back of the machine.
 Remove Dialyzer (Hansen) connectors from the machine and place them in a container of
vinegar to remove acid crystals and/or bicarb residue.
 Remove all dialysate and cleaning solution connectors both front and back and place in
vinegar to remove acid crystals and/or cleaning solution residue. Replace “o” rings on
any loose connectors.
 Open bicart™/bi-bag™ and WHO doors. Use spray vinegar clean and remove any
mineral deposits or residue from connector ports.
 Gambro: Clean the underside of the machine, especially the front panel where the
platform connects. Clean platforms with bleach to remove any stains and reattach. Wipe
the outside of any cleaning solution jugs. Check the fill volume, expiration date and re-
fill/replace disinfectant containers as needed. Place on the appropriate platform and
connect as appropriate.
 Open blood pump door and use vinegar to scrub the occlusive roller clamp assembly.
 Apply grease top the “o” ring on the blood pump. Please avoid the metal area of the
pump assembly.
 On the back of the machine place a sticker with the date and initials.
 Document detail cleaning and any maintenance performed on in the machine log book.