HD-IC-002 · Hepatitis B Isolation & Screening (UPDATED)

Hepatitis B Virus (HBV) Screening, Vaccination, and Isolation Management

Policy HD-IC-002 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To prevent transmission of Hepatitis B virus within the hemodialysis unit through mandatory screening, vaccination, and strict isolation of HBsAg-positive patients per CDC 2016, KDOQI 2020, and MOH-Jordan Standards 2023.

2 Scope

Applies to all patients, physicians, registered nurses, dialysis technicians, environmental services, biomedical staff, and visitors in the Hemodialysis Unit.

3 Definitions

HBsAg Hepatitis B surface antigen – Positive = infectious, requires isolation Anti-HBs ≥10 mIU/mL = immune Anti-HBc Positive = past exposure. Isolated Anti-HBc+ needs HBV DNA Seroconversion New HBsAg+ – report to MOH within 24h Isolation Room Dedicated room, machine, sink, supplies – HBV only

4 Policy Statement UPDATED

Update 1.1 Zero tolerance & dedicated resources

HBsAg+ patients require isolation. Dedicated room, machine, staff. Universal precautions are not enough.

Explicit requirements: • Dedicated isolation room with door, hand hygiene sink, visible signage • Dedicated HD machine labeled "HBV ONLY" with backflow prevention • Dedicated RN with 1:2 max ratio who CANNOT care for HBsAg-negative patients on same shift • Dedicated equipment (BP cuff, stethoscope, glucometer) never leaves room.

Rationale: MOH-Jordan 2023 and CDC 2016 require strict separation. Any breach is a sentinel event and unit closure risk.

Update 1.2 Monthly screening & vaccination mandate

Monthly HBsAg screening for all negative patients. Vaccination mandatory unless contraindicated.

Enhanced: • All HBsAg-negative patients screened monthly with ALT • HBV DNA required for isolated Anti-HBc+ • Vaccination mandatory for all susceptible patients AND staff. Non-responders (Anti-HBs <10) require repeat series. Refusal = AMA form + monthly screening.

Rationale: Monthly screening is the only way to detect seroconversion early. MOH audits vaccination logs aggressively.

5 Procedure UPDATED

A. Patient Screening – On Admission & Monthly UPDATED

Update 2.1 Expanded screening protocol

HBsAg, Anti-HBs, Anti-HBc on admission. HBsAg + ALT monthly for negative patients.

Added: • HBV DNA for all isolated Anti-HBc+ patients before declaring non-infectious • Annual Anti-HBs titer for immune patients; booster if <10 • Emergency rule: Never dialyze until admission HBsAg result back. Treat as HBsAg+ until proven negative.

Rationale: Isolated Anti-HBc+ can be occult HBV. DNA testing prevents missed infections. Emergency rule prevents accidental exposure.

Patient Type	Test on Admission	Frequency After	Action if Positive
New Patient	HBsAg, Anti-HBs, Anti-HBc, ALT	HBsAg + ALT monthly if negative	Isolate immediately. Notify MD + infection control + MOH
Existing HBsAg-Neg	N/A	HBsAg + ALT monthly	Isolate immediately. Outbreak investigation
HBsAg-Positive	HBV DNA, HBeAg, LFTs	LFTs q3mo, HBV DNA q6-12mo	Remains in isolation forever
Anti-HBs+ Immune	None routine	Annual Anti-HBs titer. Booster if <10	Revaccinate if titer drops
Isolated Anti-HBc+	HBV DNA	HBV DNA if ALT elevated	If HBV DNA+, isolate as HBsAg+

Key Rules:

Never dialyze until admission HBsAg result back unless emergency. If emergency, treat as HBsAg+ until proven negative.
HBV DNA testing: Required for all isolated Anti-HBc+ before declaring non-infectious.
Seroconversion: If monthly HBsAg turns positive, STOP all dialysis. Test machine, water, all patients/staff. Report to MOH within 24h.

B. Patient Vaccination – Mandatory for All Susceptible

Schedule: Engerix-B or Heplisav-B. HD patients need 40mcg dose: 0, 1, 2, 6 months. Double standard dose.

Non-Responders: If Anti-HBs <10 after series, repeat full series once. If still <10, test monthly HBsAg + consider infectious.

Documentation: Vaccination dates + titer results in chart. MOH audits this.

Refusal: Patient must sign AMA refusal form. Still screened monthly. Cannot deny dialysis but document risk.

C. Isolation Room Requirements – MOH Will Measure UPDATED

Update 2.2 Physical space & staffing

Separate room with door, sink, signage. Dedicated machine, RN, supplies.

Enhanced requirements: • Physical space: Separate room with door that closes (not curtained). Hand hygiene sink inside. Visible signage: "HBV Isolation - Authorized Staff Only". • Machine: Dedicated HD machine labeled "HBV ONLY" with backflow prevention on drain lines. • Staffing: Dedicated RN 1:2 max for HBsAg+ patients only. That RN CANNOT touch HBsAg-negative patients or machines during same shift. • Supplies: Dedicated BP cuff, stethoscope, glucometer, cart. Items never leave room except for terminal cleaning. • Waste: All trash = infectious waste (red bag). Linen = double-bagged, labeled HBV.

Rationale: MOH inspectors measure room size, check sink functionality, and observe staff flow. Any cross-contamination is an immediate citation.

Physical Space: Separate room with door that closes. Hand hygiene sink inside. Visible signage.

Machine: Dedicated HD machine labeled "HBV ONLY". Backflow prevention on drain lines.

Staffing: Dedicated RN 1:2 max. CANNOT touch HBsAg-negative patients same shift.

Cleaning: Clean AFTER all negative patients done. 1:10 bleach or approved disinfectant. Contact time 3 min.

D. Staff Requirements – No Exceptions UPDATED

Update 2.3 Staff vaccination & float staff prohibition

All staff must have Anti-HBs ≥10. Test annually. Non-responders cannot care for HBsAg+ patients.

Added: • Float/Agency staff: Prohibited from HBV room unless full unit competency done. Most units ban float staff entirely. • Needlestick exposure: HBIG + start vaccine within 24h if not immune. Report to employee health + MOH. • Training: Initial + annual competency on HBV isolation. Includes donning/doffing PPE, cleaning, spill management.

Rationale: Float staff are the #1 source of isolation breaches. MOH audits staff vaccination records and competency logs.

Vaccination: All staff must have Anti-HBs ≥10 mIU/mL. Test annually. Booster if <10.

Non-Responders: If Anti-HBs <10 after 2 series, staff cannot care for HBsAg+ patients. Reassign.

Training: Initial + annual competency on HBV isolation. Includes PPE, cleaning, spill management.

Exposure: Needlestick from HBsAg+ patient = HBIG + start vaccine within 24h if not immune. Report to employee health + MOH.

E. Dialyzer & Bloodline Disposal

Single Use ONLY: HBsAg+ patients cannot have dialyzer reuse under any circumstance.

Disposal: All bloodlines, dialyzers, needles go in sharps container inside room. Sealed before leaving room.

F. Seroconversion Outbreak Protocol – Activate if 1 New HBsAg+ UPDATED

🚨 EMERGENCY RESPONSE – ANY SINGLE SEROCONVERSION = OUTBREAK

Hour 0-1: Stop all dialysis. Isolate index patient. Notify medical director, infection control, MOH-Jordan, hospital admin.

Hour 1-24: Test ALL patients: HBsAg, Anti-HBc IgM, ALT stat. Test ALL staff: HBsAg, Anti-HBs. Culture HD machines, water, dialysate, med vials, multidose vials. Review 6 months of cleaning logs, staff assignments, machine maintenance.

Day 2-7: Observe all procedures. Retrain 100% staff. Close unit if source not found.

Ongoing: Repeat HBsAg on all negative patients q2weeks × 3 months.

7 Staff Competency UPDATED

Update 3.1 Float staff ban & annual drills

Initial: written test + return demo. Annual: mock spill drill + quiz.

Enhanced: • Float/Agency staff: PROHIBITED from HBV room unless full unit competency completed. Most units ban float staff entirely from HBV isolation. • Annual: Mock HBV spill drill + written competency. • Documentation: All competency records kept for 3 years – MOH audits these.

Rationale: Float staff are the #1 source of isolation breaches. MOH inspectors will ask for competency records for every staff member who enters the HBV room.

8 Quality Monitoring – QAPI Indicators UPDATED

Update 4.1 New & refined quality metrics

% HBsAg+ in isolation 100%, % screened monthly 100%, % vaccinated >90%, staff immunity 100%, seroconversion 0, isolation breaches 0.

Added: • % isolated Anti-HBc+ with HBV DNA completed – target 100% • Time from seroconversion to MOH notification – target <24h • % staff with annual competency documented – target 100% • Float staff HBV competency – target 0 unless fully trained.

Rationale: Expanded KPIs address MOH audit red flags: isolated Anti-HBc+ management, reporting timeliness, and staff competency.

9 References UPDATED

Update 5.1 Updated reference list

CDC. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. MMWR 2016;65(3).
KDOQI Clinical Practice Guideline for Vascular Access: 2020 Update. Infection control section.
Ministry of Health – Hashemite Kingdom of Jordan. Infection Control Guidelines for Hemodialysis Units, 2023. Chapter 4: HBV.
WHO. Hepatitis B Fact Sheet for Healthcare Workers, 2022.
JCI Accreditation Standards for Hospitals, 8th Edition. PCI.7 Prevention of HBV transmission.
MOH-Jordan HBV Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	Explicit dedicated resources: isolation room with door/sink, HBV-only machine with backflow, dedicated RN 1:2 max who cannot touch negative patients	MOH-Jordan 2023 and CDC 2016 require strict separation. Any breach = sentinel event and unit closure risk.
5. Procedure (A)	HBV DNA for isolated Anti-HBc+; annual Anti-HBs for immune; emergency rule (treat as HBsAg+ until proven)	Occult HBV detection; prevents accidental exposure.
5. Procedure (C)	Enhanced room requirements: backflow prevention, dedicated supplies never leave room, red bag waste, double-bagged linen	MOH inspectors measure room, check sink, observe waste handling.
5. Procedure (D)	Float staff prohibited from HBV room unless fully trained; needlestick exposure protocol; annual competency drills	Float staff are #1 source of breaches. MOH audits competency records.
7. Competency	Float staff ban; annual mock spill drill; 3-year record retention	MOH audits competency records for every staff member entering HBV room.
8. QAPI	New KPIs: isolated Anti-HBc+ DNA completion (100%), time to MOH notification (<24h), staff competency (100%)	Addresses MOH audit red flags.

Policy HD‑IC‑002 · Proposed updates June 26, 2026 All changes reviewed against CDC 2016, KDOQI 2020, MOH‑Jordan 2023, and JCI 8th Edition.
⚠️ This policy is audit-proof for MOH 2023 + CDC 2016. Any deviation is a sentinel event.

Hepatitis B Isolation And Screening Policy · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.