{'fraction_non_alphanumeric': 0.03765954757993176, 'fraction_numerical': 0.030835334260078354, 'mean_word_length': 5.134883720930232, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Review of the present features and the infection control challenges of COVID‐19 pandemic in dialysis facilities

Abstract The COVID‐19 has swept the world causing suffering, death, loss, and massive economy damage. The dialysis population is vulnerable and the dialysis facility is critical in maintaining operations and avoiding disease transmission. The present information regarding the clinical features of COVID‐19 infection in the dialysis population was collected, and the useful measures of COVID‐19 infection prevention and infection control in the dialysis facilities were summarized. Leadership, education, preparedness, management, and recovery phase were determined to be the critical procedures. It is hoped this updated interim review might provide information for medical professionals to take proactive action to best prepare and mitigate damage when facing the COVID‐19 pandemic challenge.


| INTRODUCTION
The world is now in the middle of the COVID-19 pandemic. Since a cluster of severe pneumonia cases was first noted in Wuhan, Hubei transmission. 1,2 Today, on 28 April 2020, there were 3 004 956 COVID-19-infected cases globally, causing 205 901 deaths, and affecting 184 countries. Taiwan has 429 COVID-19 confirmed cases with clinical presentation including 298 (69.6%) cases of mild disease, 95 (22.2%) cases of pneumonia, 35 (8.2%) cases of acute respiratory distress syndrome, and six deaths (1.4%). 3 The first mortality case in Taiwan was a case of end-stage renal disease (ESRD) with peritoneal dialysis. The first two mortality cases in the United States were ESRD cases under regular hemodialysis (HD). 4 A recent article and news also suggested increasing dialysis indication in severe COVID-19 patients. [4][5][6] At this moment, physicians and scientists continue fighting at the front lines, swiftly collecting data, studying, and constantly learning about this novel contagious disease. Accordingly, this interim summary is not a comprehensive review but aims to update present clinical information and infection control strategies currently focusing on COVID-19 control in dialysis facilities. Till mid-April, most of the other published articles have not focused on dialysis populations, and only some related information can therefore be highlighted. In the first case series reported in the United States, in the presentation and outcome of 21 critically ill patients, the majority was linked to exposure at a skilled nursing facility. Fifteen of the 21 cases (71%) needed mechanical ventilation, 11 deaths occurred (52.4%), and eight cases (38.1%) remained critically ill with ventilator support at the time of reporting. Among the patients, two (9.5%) cases had baseline ESRD and four cases developed acute kidney injury (AKI) (19.2%). 10 Moreover, seven cases (33.3%) showed cardiomyopathy and one case developed seizure.
Whether these acute multiple organ injuries reflected a direct organ complication induced by the virus or resulted from overwhelming critical illness remains to be determined. 10 One large, retrospective case series of 1591 COVID-19-positive cases who were admitted to the intensive care unit (ICU) in the Lombardy Region of Italy showed similar presentation and patient outcomes. 11 In total, 1300 of the 1591 cases needed respiratory support, and among these, 1150 (88%) needed invasive mechanical ventilation, and five cases needed extracorporeal membrane oxygenation (ECMO) support, with 405 (26%) dying in the ICU and 920 (58%) still in ICU care at the time of report. The most common comorbidity was hypertension (509, 49%) and the second was cardiovascular disease (223, 21%). Thirty-six cases (3%) were identified as having chronic kidney disease (CKD). 11 An early case series of critically ill COVID-19 patients of the Seattle region included 24 cases from nine hospitals. 12 Sixteen cases (67%) came from home and six (25%) cases were from skilled nursing homes, with a mean age of 64 years; five cases (21%) had history of CKD, but there were no ESRD cases; 18 cases needed invasive mechanical ventilation (75%), no case needed ECMO; and 12 cases (50%) died in the hospital. 12 On the other hand, reports from China showed more diverse information. One large case series including 1099 cases from China had the median age of 47 years, where 261 cases (23.7%) had coexisting disease including 81 (7.4%) with diabetes mellitus, 165 (15%) with hypertension, and only eight cases (0.7%) had CKD.

| Education
Professor Ikizler has emphasized the importance of patient and health care worker education. 1

| Screening and triage
Professor Ikizler has also suggested advising patients to call ahead and report any fever or respiratory symptoms. 1 In general, early recognition of symptomatic patient signs including fever, cough, upper airway involvement, or conjunctivitis and avoiding entrance to the waiting and treatment area is suggested. 16 In Taiwan, all clinics and hospitals perform at-the-gate body temperature measurement and infectious risk assessment recording any recent travel, occupation, contact, and clustering (TOCC) history. 15,18 The TOCC at present concerns every traveler from abroad who must abide by home quarantine for 14 days, health-care workers and staff related to transportation or travel business, those ever attending large-scale public or private activities, and recent health problems simultaneously occurring in family members, friends, or coworkers, while also considering any alerting symptoms including fever, respiratory symptoms, newly noticed loss of taste and smell, and diarrhea. Any symptomatic patient will be triaged and examined for COVID-19 at a separate area. 23

| Patient allocation and PPE
We allocate patients according to their COVID-19 infection status and the risk status. [15][16][17]21 Symptom-free, TOCC free Patients with no symptoms and no exposure history or cluster history receive regular dialysis at the clean zone. Caring medical staff comply with dialysis standard precautions, while the patient and health-care workers wear facemasks in the treatment area. 19 In the updated CDC guidelines, to address asymptomatic and presymptomatic transmission, implementation of source control for everyone entering the health facilities is suggested. 19 Symptom-free, with TOCC risk Patients having history of exposure are closely monitored for their health condition for 14 days after exposure. They may dialyze in the transition zone and the caring team is equipped with higher-level PPE, including shields or goggles for eye protection, N95 masks, waterproof isolation gowns, hair caps, and gloves. 16,17,21 The confirmed case Patients are allocated to the patient zone, ideally, the negative pressure isolation room. If the medical capacity is exceeded, the COVID-

| Environment disinfection
The air conditioner should be operated full-time to maintain good indoor ventilation, while stringent cleaning and disinfecting of surfaces of the environment and equipment are mandatory as is the terminal station. The cleaning worker should be equipped with adequate PPE. 17,23

| Recovery phase
Before the herd immunity and promising therapies available in the longer future, we may plan for a step-down strategy step-by-step.
Source control with adequate masking, keeping social distance, cleaning, and disinfecting surfaces of the regular environment, and hand hygiene could become a normal part of life.

| THE CHALLENGES AND THE CHANCES
The early report from China showed that COVID-19 was not associated with AKI or had relatively low incidence around 3% to 9% of AKI. 24,25 Updated and accumulated data have now shown the incidence of AKI is higher, up to 15% of the severe COVID-19 cases and is associated with high mortality. 26 (Table 1).

ACKNOWLEDGMENTS
The authors thank the teamwork of the contingency team and the dialysis committee of the Taiwan Society of Nephrology.