Hepatitis B Vaccination of Hemodialysis Patients

Hepatitis B Vaccine

"Hepatitis B vaccination is recommended for all susceptible chronic hemodialysis patients. Vaccination is recommended for pre-end-stage renal disease patients before they become dialysis dependent and for peritoneal and home dialysis patients because they might require in-center hemodialysis.

“Patients with uremia who were vaccinated before they required dialysis have been shown to have higher seroconversion rates and antibody titers. The response may also be better in children.”

Dosage and Schedule

"For patients undergoing hemodialysis and for other immunosuppressed patients, higher vaccine doses or increased number of doses are required. A special formulation of one vaccine is now available for such persons (Recombivax HB, 40 μg/mL)".

“If an adult patient begins the vaccine series with a standard dose before beginning hemodialysis treatment, then moves to hemodialysis treatment before completing the series, complete the series using the higher dose recommended for hemodialysis patients. No specific recommendations have been made for higher doses for pediatric hemodialysis patients. If a lower than recommended vaccine dose is administered to either adults or children, the dose should be repeated.”

Immunogenicity and Duration of Immunity

"Although data concerning the response of pediatric hemodialysis patients to vaccination with standard pediatric doses are lacking, protective levels of antibody occur in 75% -97% of those who receive higher dosages (20-μg) on either the 3- or the 4-dose schedule."

"Limited data are available on the duration of immune memory after hepatitis B vaccination in . . . dialysis patients. No clinically important HBV infections have been documented among immunocompromised persons who maintain protective levels of anti-HBs. . . .However, among hemodialysis patients who respond to the vaccine, clinically significant HBV infection has been documented in persons who have not maintained anti-HBs concentrations of >10 mIU/mL."

Serologic Testing

Testing after vaccination is recommended for persons (including hemodialysis patients) whose subsequent clinical management depends on knowledge of their immune status. "Testing should be performed 1-2 months after administration of the last dose of the vaccine series by using a method that allows determination of a protective level of anti-HBs (>10 mIU/mL)."

"Persons found to have anti-HBs levels of <10 mIU/mL after the primary vaccine series should be revaccinated. Administration of three doses on an appropriate schedule . . ., followed by anti-HBs testing 1-2 months after the third dose, is usually more practical than serologic testing after one or more doses of vaccine."

"Persons who do not respond to revaccination should be tested for HBsAg. If the HBsAg test result is positive, the persons should receive appropriate management . . . and any household, sexual, or needle-sharing contacts should be identified and vaccinated. Persons who test negative for HBsAg should be considered susceptible to HBV infection and should be counseled about precautions to prevent HBV infection and the need to obtain HBIG postexposure prophylaxis for any known or likely parenteral exposure to HBsAg-positive blood."

Booster Doses

"For hemodialysis patients, the need for booster doses should be assessed by annual antibody to hepatitis B surface antigen (anti-HBs) testing. A booster dose should be administered when anti-HBs levels decline to <10 mIU/mL."

Reference

Guidelines for Vaccinating Kidney Dialysis Patients and Patients with Chronic Kidney Disease

summarized from
Recommendations of the Advisory Committee on Immunization Practices (ACIP)

Leptospirosis

Leptospirosis is a globally important zoonotic disease caused by spirochetes of the genus Leptospira. Leptospires are tightly and regularly coiled, with characteristic hooked ends (hence the species name interrogans), and are highly motile, spinning around their longitudinal axis and darting back and forth.

Cause/Mode of Transmission:

Human-to-human transmission does not occur. The most important sources of transmission to humans are rats, dogs, cattle, and pigs. Factors that facilitate human infection are those that bring susceptible persons into indirect contact with contaminated animal urine through surface waters, moist soil, or other wet environments or into direct contact with urine and other excreta (e.g., products of parturition, placenta) of infected animals. Leptospires infect humans through the mucosa (usually conjunctival and possibly oral or tonsillar) or through macerated, punctured, or abraded skin.

Signs/Symptoms:
Leptospirosis is classically described as biphasic. Acute fever in the initial leptospiremic phase lasts for 3–10 days, during which period the organism may be cultured from blood. In a later immune phase, fever is not responsive to antibiotic therapy but leptospires can be isolated from urine. Physical examination may include any of the following findings, none of which is pathognomonic for leptospirosis: conjunctival suffusion (dilated conjunctival blood vessels in the absence of discharge); pharyngeal erythema without exudate; muscle tenderness; rales on lung auscultation or dullness on chest percussion over areas of pleural hemorrhage; rash (which may be macular, maculopapular, erythematous, petechial, or ecchymotic); jaundice; meningismus; and hypo- or areflexia, particularly in the legs.

conjunctival suffusion

Weil's disease is characterized by variable combinations of jaundice, acute kidney injury, hypotension, and hemorrhage—mostcommonly involving the lungs but also potentially affecting the gastrointestinal tract, retroperitoneum, pericardium, and brain. Other syndromes include aseptic meningitis, uveitis, cholecystitis, acute abdomen, and pancreatitis (with hypo- or hyperglycemia).

Diagnostics:
The organisms cannot be seen by direct light microscopy. To visualize the spirochetes directly in culture or in clinical specimens, dark-field or phase-contrast microscopy must be used.

Treatment:
Mild leptospirosis often is not specifically identified and typically resolves without antibiotic treatment. Mild disease should be treated with oral antibiotics—in particular, doxycycline, especially where rickettsial infections (including scrub typhus) are coendemic. severe leptospirosis frequently requires empirical initiation of broad-spectrum parenteral therapy before the diagnosis can be confirmed.

Prevention

No vaccine is available for human leptospirosis. Preventive strategies, including prophylaxis with doxycycline, have been variably effective in different settings. General sanitation approaches (e.g., rodent control) and avoidance of swimming in potentially contaminated places (e.g., for recreational use) are recommended, but these measures are difficult to apply consistently.

Leptospirosis guidelines from PCP and PSMID

Resources:

Harrison's Principle of Internal Medicine 18th ed
Philippinr College of Physician