The Department of Health and the Renal Association have recommended that dialysis patients should be offered prophylaxis against hepatitis B by immunization.
Despite this guidance, surveys have shown that 95% of renal units in 1994 and 49% in 1995 were not routinely offering immunization to any patient groups with chronic renal failure.
The researchers determined whether provision of hepatitis B immunization had improved after publication of the 1996 Department of Health guidelines. They also identified barriers to implementation of existing guidelines.
The findings of the study were published in the latest issue of the British Medical Journal.
Postal questionnaires were sent to the clinical directors of all of the 87 main UK renal units and satellites.
The questionnaire covered hepatitis B immunization 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.
The response rate was 90%.
At least one incident of hepatitis B seroconversion in a dialysis patient was reported by 15% of the units.
It was found that 29% of the units did not immunize any patient groups.
|29% of renal units did not immunize any patients against hepatitis B.
|British Medical Journal|
A further 6 units offered immunization only to patients planning treatment in hepatitis B endemic areas outside the United Kingdom.
Completeness of hepatitis B immunization 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 immunization, 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.
Some 36 units (46%) followed the Renal Association's recommendations on hepatitis B immunization of patients with chronic renal failure; 42 did not. Fourteen units had developed their own policies.
The researchers found that one unit feared that staff might become less careful with universal precautions if all patients were immunized.
Other reasons for the guidelines not being followed included the units believing that the heavy workload produced little benefit, the barriers of costs and funding, and difficulty in tracking patients.
Dr Sunanda Ray, of the Communicable Disease Surveillance Centre, at the Birmingham Heartlands Hospital, said on behalf of the group, "Although the rate of hepatitis B immunization 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 immunization may be one solution, although this requires good collaboration between primary and specialist care.
"Strategies that may improve collaborative care are inclusion of immunization in service agreements, definition of responsibilities for initiation of immunization, follow up and evaluation of response, payment to general practitioners, and regular audit and shared feedback," it was added.
"The efficacy of the hepatitis B vaccine in end stage renal disease needs investigation to encourage its use in dialysis patients," it was concluded.