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Vaccinations are available for primary prevention of many infections in adults. Morbidity and mortality from invasive diseases such as influenza and Streptococcus pneumoniae (pneumococcus) remain high and may be largely preventable by vaccination of high-risk adults, including dialysis patients. The current 23-valent vaccine-efficacious, with a low adverse event profile-is widely available. Revaccination is also recommended in patients with immunocompromising conditions, including chronic kidney disease. Despite having many opportunities to be vaccinated, adult hemodialysis and peritoneal dialysis patients are often missed During the recent H1N1 influenza outbreak, we conducted a performance improvement project to increase the vaccination rates for pneumococcal pneumonia, hepatitis B, and influenza, with a special focus on prevention. The project included an education phase, baseline assessment of vaccination rates, intervention, and a follow-up assessment of vaccination rates. The geographic jurisdiction of ESRD Network 13 encompasses the states of Arkansas, Louisiana, and Oklahoma. At the beginning of the network-wide project, the documented state-specific rates for influenza immunization were below the average influenza immunization rates for adults reported by Centers for Disease Control and Prevention and far below its target for adults. Our improvement project incorporated educational interventions to improve patient acceptance of vaccinations, educational interventions to improve staff participation in quality improvement activities, and improved techniques of quality improvement data collection and analysis by participants. During this project, the immunization rates for hepatitis B and pneumococcal pneumonia were also reviewed. At project's conclusion, improvement was demonstrated in all three focus areas, with statistically significant improvements noted in both influenza and pneumococcus vaccination rates. The use of educational interventions to improve staff participation in quality improvement, and the collection and analysis of quality improvement data can be replicated in many practice settings to improve immunization rates for dialysis patients and other patients with chronic illnesses.

Hurricanes Katrina and Rita resulted in massive devastation of the Gulf Coast at Mississippi, Louisiana, and Texas during 2005. Because of those disasters, dialysis providers, nephrologists, and dialysis patients used disaster planning activities to work to mitigate the morbidity and mortality associated with the 2005 hurricane season for future events affecting dialysis patients. As Hurricane Gustav approached, anniversary events for Hurricane Katrina were postponed because of evacuation orders for nearly the entire Louisiana Gulf Coast. As part of the hurricane preparation, dialysis units reviewed the disaster plans of patients, and patients made preparation for evacuation. Upon evacuation, many patients returned to the dialysis units that had provided services during their exile from Hurricane Katrina; other patients went to other locations as part of their evacuation plan. Patients uniformly reported positive experiences with dialysis providers in their temporary evacuation communities, provided that those communities did not experience the effects of Hurricane Gustav. With the exception of evacuees to Baton Rouge, patients continued to receive their treatments uninterrupted. Because of extensive damage in the Baton Rouge area, resulting in widespread power losses and delayed restoration of power to hospitals and other health care facilities, some patients missed one treatment. However, as a result of compliance with disaster fluid and dietary recommendations, no adverse outcomes occurred. In most instances, patients were able to return to their home dialysis unit or a nearby unit to continue dialysis treatments within 4 - 5 days of Hurricane Gustav. Hurricane Ike struck the Texas Gulf Coast near Galveston, resulting in devastation of that area similar to the devastation seen in New Orleans after Katrina. The storm surge along the Louisiana Gulf Coast resulted in flooding that temporarily closed coastal dialysis units. Patients were prepared and experienced minimal interruption of dialysis services. Early planning and evacuation in the face of hurricane landfall--lessons learned from Hurricane Katrina in 2005--prevented disruption of treatment.

Hurricanes Katrina and Rita alerted the world to North America's Gulf Coast's vulnerability to natural disasters. This vulnerability was most evident in poor, minority and elderly populations, and patients with chronic diseases requiring treatment such as dialysis. These hurricanes resulted in massive devastation of the healthcare infrastructure, including dialysis units, across the Gulf Coast region, and often resulted in temporary or permanent closure of dialysis units, predominantly in the New Orleans metropolitan area; however, Hurricane Rita primarily affected Lake Charles. Most notable was the population shift of dialysis patients in Louisiana due to hurricanes Katrina and Rita. Before the 2005 hurricane season, there were 2011 and 362 dialysis patients residing in the parishes (the Louisiana equivalent to counties) most affected by hurricanes Katrina and Rita, respectively. Each of these parishes had experienced increases in dialysis patient populations over the past 5 years. However, following the storms, there were 1014 and 316 dialysis patients residing in the affected parishes. Reasons for the population shifts were multifactorial in nature and included individual, provider, and healthcare system factors. As patients and physicians return to these affected areas, dialysis services will need to be reallocated based on new demographics and distribution of services in Louisiana communities. In planning for future dialysis services, adaptations will need to occur to prevent future interruption of services and loss of patient access to dialysis services.

Hurricane Katrina resulted in massive destruction of the gulf coast of the United States in 2005. In the immediate aftermath, displaced dialysis patients required urgent hemodialysis or additional peritoneal dialysis (PD) supplies. Massive damage to the health care infrastructure in these communities disrupted dialysis services for several months. As a result of this event and subsequent storms during the 2005 Atlantic hurricane season, many decisions regarding future services to dialysis patients in hurricane prone communities (HPCs) need to occur. Nephrologists, dialysis nurses, dialysis providers, and patients need to discuss the ramifications of and types of continued dialysis services in HPC. Nephrologists should encourage PD, and efforts to educate on other renal replacement therapies including PD and transplant should occur. With the potential for interruption of electrical, sewerage, and water services, more patients should consider PD. Recovery from future events begins with appropriate disaster planning. Many questions are considered and need answering in planning for dialysis services in HPC and other communities subject to natural disasters. This summary provides the basis to begin discussions when planning for dialysis services in communities prone to natural disasters.

Background: Hurricane Katrina resulted in partial or complete devastation of dialysis services throughout the Gulf Coast, including the New Orleans metropolitan area. In the immediate aftermath, dialysis had to be provided to patients by surrounding communities in Louisiana, and ultimately by dialysis programs throughout the nation. Peritoneal dialysis patients, though typically more independent, also endured challenges in continuing dialysis following Hurricane Katrina. Hurricane Rita caused similar damage to the western Gulf Coast at Lake Charles, Louisiana and Beaumont, Texas and further delayed recovery of dialysis services in the New Orleans metropolitan area., Setting: A review of the problems created by the disaster provided many opportunities to improve healthcare delivery and to prepare for recovery from the event. Understanding what happened to the delivery of dialysis and chronic kidney disease services allows the opportunity to develop better systems to support this particularly vulnerable population of patients., Conclusion: Many lessons can be learned from these events to minimize future interruption of dialysis services in the face of natural disasters such as hurricanes.

Infectious complications are the leading cause of morbidity and mortality in peritoneal dialysis (PD) patients. Infectious diseases play a role in the morbidity and mortality of hemodialysis (HD) patients as well. Prevention of transmission of infectious diseases is of paramount importance in any program concentrating on renal replacement therapy, including HD, PD and kidney transplantation. Despite effective means to eradicate infections, increased usage of antimicrobial agents has resulted in antimicrobial resistance. The focus of this paper will be infections in dialysis. Some of the infectious complications discussed here may be applicable to patients with end-stage renal disease who have received a kidney transplant. Prevention of infections in dialysis includes development of infection control strategies by dialysis units with appropriate surveillance strategies. Dialysis staff education, patient education and physician participation is essential for successful infection control in dialysis units. Patients with other chronic infections, such as hepatitis B and human immunodeficiency virus (HIV) infection on dialysis may require additional infection control strategies for dialysis units to prevent infection of other patients and dialysis unit staff. Surveillance and prevention of tuberculosis is part of the comprehensive infection control plan for patients and staff and special considerations may occur for treatment of tuberculosis in other epidemiologic and economic areas of the world. Immunizations, a cornerstone to prevent many infections, have led to decreased morbidity and mortality for many diseases and many immunizations play a role in prevention of disease in dialysis patients.