The Impact of a National Surgical Mask Wearing Policy on COVID-19 Transmission in Haemodialysis Units in the Republic of Ireland

Abstract

I n late 2019 a novel betacoronavirus named SARSCoV-2 was reported in China, and subsequently spread rapidly to cause a global pandemic. SARSCoV-2 is primarily spread through respiratory droplets typically released by coughing, sneezing, breathing or speaking and may be aerosolized by singing, ventilation or the use of nebulisers. The most common symptoms of COVID-19 infection include fever, cough, fatigue, anorexia, myalgia and diarrhoea, however severe illness occurs in a subset of individuals and usually begins approximately 1 week after the onset of symptoms. Patients with End Stage Kidney Disease (ESKD) have been identified internationally as one such vulnerable subgroup at risk of severe COVID-19 infection and complications. In Ireland the Health Protection Surveillance Centre (HSPC) confirmed the first case of COVID-19 in the Republic of Ireland on 29 February 2020. The governance of the care of all patients with end stage kidney disease treated with maintenance dialysis in Ireland lies with the Health Services Executive (HSE) of Ireland and specifically the National Renal Office (NRO) in the HSE. The HSPC and the NRO issued a joint guidance document regarding the management of dialysis patients during the COVID-19 pandemic on March 16 2020. This included strategies on how to identify patients at risk, provide isolation facilities and personal protective equipment, guidance on 2-meter social distancing, patient transport provision and a stipend to facilitate self-driving of dialysis patients to and from the dialysis center. At the time of the first wave of the pandemic in the Republic of Ireland, there were 1925 adult haemodialysis patients distributed across 23 haemodialysis units nationally. Asymptomatic and pre-symptomatic spread of the virus represents a significant challenge to the containment of SARS-CoV-2 infection, particularly in environments such as dialysis units. Measures such as physical distancing, limiting public gatherings, largescale stay at home orders, and national lockdowns are now known to curb COVID-19 transmission. However at the time of the pandemic first wave onset in Ireland, good quality evidence endorsing the efficacy of facemasks were lacking. The NRO recognized that dialysis patients were not only vulnerable to COVID19 complications but also could not adequately selfisolate by virtue of the fact that they had to present to the dialysis centers multiple times per week. In addition the NRO was cognizant of suggestions arising from the pandemic in Italy that dialysis units may have been associated with transmission from healthcare settings back into the community. Despite the lack of evidence at the time, since it was considered a low cost intervention associated with empiric logic, the NRO instituted a mandatory surgical mask wearing policy for dialysis patients and dialysis healthcare workers for the duration of dialysis sessions on 7 April 2020. With the support of the HSE Medical Devices Critical Assessment Group and HSE procurement, the NRO distributed digital thermometers and surgical masks to all haemodialysis patients in the Republic of Ireland from 7 April 2020 onwards. Dialysis patients were requested to wear these surgical masks prior to arriving at the dialysis unit and to continue wearing the masks throughout the entire time in the dialysis unit. In addition eating on dialysis was