ACHIEVING A DRAMATIC INCREASE IN HEPATITIS B VACCINATION UPTAKE IN A RESOURCE-LIMITED HAEMODIALYSIS UNIT: A SUCCESSFUL QUALITY IMPROVEMENT INITIATIVE

Hepatitis B virus (HBV) infection remains a significant public health issue, with particularly high risk among patients with End Stage Renal Disease (ESRD). International guidelines, including those from the CDC and major nephrology societies, recommend universal HBV vaccination for all CKD and Haemodialysis (HD) patients. However, prevention remains challenging in low- and middle-income countries like Pakistan, where limited resources, logistical barriers, and low patient awareness contribute to poor vaccination coverage. Local data show that only 20% of haemodialysis patients in Pakistan are vaccinated against HBV, underscoring the need for locally tailored quality improvement (QI) strategies. This project aimed to achieve a 100% vaccination rate in our HD unit through a structured QIP, identifying barriers and implementing targeted interventions.

A QI project was conducted in the maintenance haemodialysis unit from October 2024 to April 2025 using the Plan–Do–Study–Act (PDSA) framework to improve HBV vaccination coverage. The study population included all patients receiving haemodialysis twice or thrice weekly who tested negative for HBsAg by ELISA. Baseline demographic and vaccination data were collected. Four doses of HBV vaccine were considered as full vaccination for HD patients in accordance with KDIGO recommendations. During the first PDSA cycle, barriers were identified through staff discussions and patient interviews. Interventions included education sessions for healthcare providers and patients, establishment of clear vaccination and follow-up pathways, and introduction of standardized documentation and record-keeping systems. Monthly reviews and feedback ensured reinforcement. Vaccination rates were reassessed six months later to evaluate improvement from baseline. 

A total of 100 eligible HD patients were included; 69% (n=69) were male and 31% (n=31) female, with a mean age of 47.9 ± 14.95 years. Most patients (78%) had 5–12 years of education, and 72% had been on dialysis for less than five years. At baseline, only 32% (n=32) were fully vaccinated, 12% had received one or two doses, and 56% (n=56) were unvaccinated (never received any dose).

Key barriers included limited knowledge and awareness among both patients and staff, confusion about vaccination schedules, and misperceptions linking HBV vaccination to COVID-19 vaccines. Financial concerns were reported but mitigated by the availability of free vaccines at nearby canters, indicating that the main issue was educational rather than economic. No vaccine hesitancy was observed.

Following targeted education campaigns, signposting to vaccination canters, and improved record keeping, vaccination uptake increased markedly. By the end of the intervention period, 100% of eligible patients had completed the HBV vaccination schedule.

Through structured QI methodology, clinical inertia was addressed by improving education, awareness, and system processes. Focused interventions and continuous reinforcement enabled full vaccination coverage, sustained through quarterly audits. The next phase will include monitoring seroconversion and providing booster vaccinations as needed. This initiative demonstrates that structured, context-specific QIPs, regular audits, and awareness efforts can mitigate inertia, significantly improve preventive care indicators using existing resources, even in low and middle income countries.