Hepatitis B in Dialysis Units
There were outbreaks of blood borne hepatitis in dialysis units from 1965 onwards which had a devastating effect on the emerging programmes treating people with kidney failure.
The first was in Manchester in 1965, and this was followed by outbreaks in nine other units between 1966 and 1971. The most extensive and deadly were in Edinburgh and Guy’s.
Confronted by the hepatitis crisis, an advisory committee chaired by Lord (Max) Rosenheim was established by the Department of Health and its 1972 Report made recommendations which were universally implemented, and remain the basis of the standard precautions mandated in renal units to this day.
There were deaths among both patients and staff, dialysis units were closed temporarily, and in some cases threatened with permanent closure. The development of long term dialysis as a mainstream therapy came under existential threat.
The outbreaks were soon attributed to blood borne transmission of hepatitis B (which was only just being characterised as a discreet entity).
Read more about the Edinburgh outbreak and the outbreaks elsewhere.
The Rosenheim Report (1972)
The hepatitis outbreaks in renal units from 1965 onwards led to the establishment of an advisory group to the Department of Health and Social Security, Scottish Home and Health Department and the Welsh Office. Lord Rosenheim, consultant physician at University College Hospital, London (and future President of the Royal College of Physicians) chaired the committee, which physicians, surgeons, a sister and a matron. They produced a set of recommendations aimed to minimise the spread of hepatitis. Lord Rosenheim wrote: “Anxiety about the infection is understandable, but there are no grounds for a negative or defeatist attitude… I hope that all concerned will accept the recommendations and modify their practice in accordance with the suggested codes and that such positive action may lead to the prevention of further outbreaks and alleviation of anxiety.” (Rosenheim report, 1972)
Some conclusions of the Rosenheim report
Recommendations of the Rosenheim Report
Personal experiences of the hepatitis outbreaks in dialysis units in the 1960s
Anne Lambie (Edinburgh)
(edited from an interview with Neil Turner in 2019)
“ It was really very frightening, because there were a number of staff deaths, and quite a lot of patient deaths. And eventually, the problem was solved because they found traces on the little monitor on the venous return side of the machine through which blood passed during dialysis. And Ralph Tonkin realised that this was the way that it was being spread around. By that time, there had been quite a large number of cases. And of course, it involved the closure of the unit, until all these people had been transferred either to home dialysis or to a small special ward. So the programme effectively ceased for a little over a year.
Two young surgeons died, they had been involved in the operation on the index case. And there were a number of technicians who died who had been handling the blood.
Some people in the rest of the hospital thought that the programme should come to an end; understandably .The unit was marvellous and that was mainly due to our Senior Sister who had a tremendous capacity for keeping cool and keeping the morale of the nurses up. She subsequently got the MBE which was very well deserved. I think we just went on. I remember having to assist stopping nasal bleeding in a patient with hepatitis. There were just the three of us – myself, an ENT surgeon, and one of the nurses. Of course, he was pouring blood. We all had protective suits and whatnot. But that was quite scary. But Sister Harbison was splendid
We were in a way lucky because we were already taking precautions with gowns and gloves before the thing happened. The reason being that a year before one of the senior technicians in clinical chemistry developed jaundice. And we thought that this might possibly be hepatitis, which was already rampant in Manchester. So we went on to precautions at that point. It might have been worse if we hadn’t done that.
It was very nasty…. probably the worst experience I had in nephrology.”
Netar Mallick (Manchester)
(edited from an interview with John Feehally in 2018)
“The first ever hepatitis epidemic occurred in Manchester, just a few months before I came back from Cardiff , it killed several people and nearly killed two of the doctors. Jack Tinker (who became a very well known intensive care doctor in London) was comatose for a while and Peter Ackrill (later nephrologist at Withington Hospital) was very seriously ill. And of course, they lost some of the nurses, and one of the technicians who was regularly carrying specimens back to the lab; he must have spilt something on himself and not cleaned it and he died. And all the patients; there were five patients, they were the only patients on chronic dialysis, and they all died.
Geoffrey Berlyne (nephrologist in charge of the dialysis unit) got terribly hit because they said, ‘Oh, you made a terrible mess of it. Nobody else is having this problem. You obviously don’t know what you’re doing.’’ Of course, after that hepatitis developed in many other units. Edinburgh had a massive outbreak, Woodruff in Edinburgh was a huge figure in medicine, so once his unit got hit, the idea of incompetence went away. But by then Geoffrey had been badly damaged – ours was the first hepatitis outbreak and it happened to be one of the more vicious ones.
So, when we restarted dialysis in the early 1970s I knew that if we had another case we would be finished. So we had to make sure we carefully followed what were then the Rosenheim recommendations. We did and never had another case. And maybe we were lucky, but we were very, very careful.
We did publish one of the first tests for hepatitis B, and then we began to use it. And I remember an occasion, quite early on shortly before Christmas, when one of our two dialysis technicians (they washed the boards of the Kiil dialysers and rebuilt them between dialysis sessions) turned up positive. And I though ‘ that’s curtains for us because if she’s positive everybody is positive’. Now at the time they were doing the hep B test with turkey cells, and she’d been out buying a turkey. We repeated it and it was negative! And so, we managed to keep the unit free of hepatitis.”
Stewart Cameron (Guy’s)
(edited from an interview with John Feehally in 2018)
“1969 was the annus horribilis when the hepatitis came, which stopped our unit taking new patients for a while. I was ill for months with hepatitis and it was Chis (Chisholm Ogg) who was turning the people down at that time. We had to turn down young people because we couldn’t import new people into the dialysis unit until we managed to get everybody who was hepatitis positive either transplanted, or home. We rigged up to begin with a ‘clean’ unit and the hepatitis ‘yellow’ unit. But it didn’t work. I mean, we just didn’t have the space and the knowledge and the skills to make it stop. It continued to spread. But the real problem came when it spread outside and people in theatres and laboratories and on other wards started getting it.
A lot of units, like ours, were operating in totally unsuitable circumstances. We didn’t have a proper purpose-built unit, it was small and grossly overcrowded. And our hygiene had been very poor.
We had to transplant the yellow patients. We pretty well had a complete staff team of people to do the transplant work. We were all full of antibodies.
Some medical and nursing staff were sick at Guy’s, I think I was one of the sickest. We had one other one nurse who was very sick, who was admitted to intensive care at the Royal Free because she lived up in North London. I thought I was going to die. I mean, it’s the only time I felt that, but I was so ill. I was yellow enough that if I staggered out into the street, which I occasionally did, just to get some fresh air, people would cross the road. It took me weeks and weeks to get over it. And then then I found I couldn’t stand up for longer than three or four hours. I returned to work, I could work for the morning but if I tried to push into the afternoon. I’d find myself lying on the floor. I‘d just fallen down – crash. I was so angry but I could do nothing about it.
One of the virologists had a lovely picture of the virus particles in my blood, which went around. It had just been described and called Hepatitis B, and shown to be the same as ‘syringe hepatitis’ , as it had previously been called. I was bled because I had a very high titre of antibody; so, they used me as for passive immunisation of people at risk.
Things looked very bleak, the hepatitis outbreaks were one of the reasons why nephrology stopped expanding in the UK in the 1970s, and we were stuck with 50 nephrologists for 20 years. The hepatitis outbreaks just gave the whole business of dialysis a bad name. Not so much nephrology in general as a specialty, but the actual act of dialysis its. People would have been glad to get rid of it. And as a result, our pleas for expansion of dialysis … we beat our heads flat against various ministers of health. “
Last Updated on October 6, 2022 by John Feehally