How COVID19 will strike vulnerable groups, such as those with chronic disease

During epidemics (eg COVID-19), vulnerable populations (eg elderly, homeless, institutionalized) are at risk of infection & of being reservoirs of infection. On both accounts, they need our care. Let’s talk about a particularly vulnerable group: our fellow citizens on dialysis 1/
In the USA, there are 468,000 people receiving dialysis, and they must go to a dialysis center roughly three times per week. Without dialysis, such patients will simply die, often within 14 days.
There are >7,500 dialysis centers in the USA registered with Medicare @CMSGov (which covers people with end-stage kidney disease). Each center has ~5-40 ‘stations’ where patients must sit for roughly 4 hours, while being dialyzed, three times per week. data.medicare.gov/Dialysis-Facil… 3/

Dialysis patients often get to know each other and the staff at the dialysis centers near their homes. Everyone is in close proximity. It’s cozy.

But dialysis centers can be places where chronically ill people, w immune systems compromised by renal disease, can get & spread respiratory infections (they can also become infected w blood-borne pathogens, but that’s another topic). These are called ’nosocomial infections.’ 5/
Plus, when health care workers get sick with COVID-19 (and must be quarantined), dialysis centers might not have requisite staff. Dialysis centers might be closed. Yet, without dialysis, patients would die. 6/
Overall the pulmonary infectious mortality rate is 14-fold to 16-fold higher in dialysis patients than in the general population at *baseline*, even absent an outbreak like COVID-19.
Studies in China of the COVID-19 pandemic unsurprisingly show that chronically ill patients (such as those with kidney disease) are at heightened risk of death if they become infected with the virus. medrxiv.org/content/10.110… 8/
In a past influenza pandemic (H1N1), dialysis patients’ risk of infection appeared high.
But here is the thing: patients getting dialysis have *no choice* but to go to a facility. They cannot stay at home. And they are vulnerable to precisely the infections that they would wish to avoid. 10/
What kind of preparations should our society be making right now to care for dialysis patients during the COVID-19 pandemic, in case it gets bad? 11/
Most dialysis patients are not prepared for a disaster. For instance, one survey found that only 54% of respondents stored ample food and water and only 49% had a list of requisite items from a checklist for use during a disaster.
The Renal Disaster Relief Task Force was established by the International Society of Nephrology @ISNkidneycare in the 1990’s (super cool organization, btw). But it focuses on providing dialysis in defined areas, such as after earthquakes & hurricanes. cjasn.asnjournals.org/content/2/4/80… 13/
I cannot find information on our state of preparedness for caring for our dialysis patients if the COVID-19 epidemic takes root in dialysis patients or if it compromises function of dialysis facilities. I fear that the @nkf hotline may be overwhelmed.
As usual, our amazing @CDCgov has thought about some aspects of this. For instance, here is a link to useful information cdc.gov/kidneydisease/… and here is a 3-day emergency diet plan for dialysis patients: kcercoalition.com/contentassets/… 15/
Medicare @CMSGov also has a preparedness plan for dialysis *facilities* cms.gov/Medicare/End-S… But this plan doesn’t seem to contemplate coping with a pandemic! 16/
Finally, many of these issues related to the heightened risk of COVID-19 in end-stage renal disease patients, and to our inability to provide for them if the pandemic is severe, apply to other chronically ill patients with other diseases who are dependent on institutions. 17/

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