Background: The Rosenheim report, published in 1972, was aimed at decreasing the transmission of hepatitis B virus (HBV) in the renal unit. A review in 1996, revealed the non-compliance of some centres with the guidance to vaccinate individuals against HBV.
Objectives: To describe two events of acute hepatitis B virus (HBV) infection within 9 weeks in individuals attending the renal unit and the steps taken to prevent further transmission.
Study design: Serological and molecular testing was carried out on the two individuals with acute HBV and other HBV carriers in the unit. Epidemiological information was collected along with information on HBV vaccination and HBsAg screening.
Results: There were 15 known HBV carriers in the unit. HBV genotype E was transmitted from a carrier to patient 1 when they were in the same ward. Transmission to patient 2 occurred when he followed patient 1 on the theatre list. Breaks in infection control were identified and steps were taken to prevent further transmission events.
Conclusions: Breaks in infection control procedures were rectified. No further transmission of HBV was identified. This highlights the need for vigilance regarding infection control practices in the renal unit setting.