Recommendations from the Brazilian Society of Nephrology regarding the use of cloth face coverings, by chronic kidney patients in dialysis, during the new coronavirus pandemic (Covid-19)

ABSTRACT

These recommendations were created after the publication of informative note 3/2020- CGGAP/DESF/SAPS/MS, of April 4, 2020, in which the Brazilian Ministry of Health recommended the use of a cloth mask by the population, in public places. Taking into account the necessary prioritization of the provision of Personal Protective Equipment (PPE) for patients with suspected or confirmed disease, as well as for healthcare professionals, the SBN is favorable concerning the wear of cloth masks by chronic kidney patients in dialysis, in public settings, except in the dialysis setting. The present recommendations have eleven items, related to this rationale, the procedures, indications, contraindications, as well as appropriate fabrics for the mask, and hygiene care to be adopted. These recommendations may change, at any time, in the light of new evidence.

RECOMMENDATIONS FOR CHRONIC KIDNEY PATIENTS WEARING MASKS DURING THE PANDEMIC

1. Considering the scarcity of Personal Protective Equipment (PPE), the SBN recommends that all asymptomatic chronic renal patients, as well as the general population, should wear protection masks, based on recommendations from the Ministry of Health (MH), through Informative Note 3/2020-CGGAP/DESF/SAPS/MS1.

2. The cloth mask can prevent the spread of droplets expelled from the nose or mouth of people in the environment, acting as a mechanical barrier, thus reducing spread of the disease by asymptomatic or pre-symptomatic infected people, who can transmit the virus, especially in places of community transmission, and where measures of social distance are difficult to follow. Nonetheless, these masks do not protect healthy individuals from contracting the virus^{1 , 2} .

3. We recommend that all chronic kidney patients on dialysis wear a cloth mask when going out for essential activities and during transportation to the dialysis clinic. The use of the mask aims to reduce the spread of the virus by asymptomatic patients in these environments.

4. Patients with Covid-19 infection suspicion or confirmation should wear a surgical mask, as well as adopt other precautionary measures already described in the SBN Good Practice Recommendations³ .

5. Even though there is a shortage of PPE, there is no evidence to support the recommendation for the use of cloth masks within dialysis centers. There is a possibility of contamination at the site, favoring the spread of the virus; concurrently, we know understood that recommending the use of surgical masks by all asymptomatic patients while on dialysis may worsen the current situation of PPE scarcity. Healthcare professionals, employees and patients with suspected or confirmed infection must have priority on having masks. This recommendation may change, depending on the effective supply of these materials in the country.

6. The fabrics recommended for making a mask are, in decreasing order of their ability to filter viral particles: a) vacuum cleaner bag fabrics; b) cotton (composed of 55% polyester and 45% cotton); c) cotton fabric (such as 100% cotton T-shirts); and d) pillowcases of antimicrobial tissue¹ .

7. According to guidelines from the MH, some precautions need to be taken regarding the use of the fabric masks. The instructions for making them and hygiene measures are included in the technical note from the MH, available at: <https: // www. saude.gov.br/images/pdf/2020/April/04/1586014047102-Nota-Informativa.pdf>.

8. Hereby, we stress some recommendations provided by the MH link (item 6) regarding the use of cloth masks:

8.1 The mask should be changed whenever there is dirt or moisture. Chronic kidney patients on hemodialysis should calculate the number of masks required, depending on the time spent traveling to the clinic, and the return home. It is estimated that each mask can be used for a period of two hours.

8.2 The use of the mask is for one individual only, so the patient should not share it, even if it is sanitized.

8.3 Upon leaving the dialysis clinic, the patient must be able to put on the mask without assistance. Healthcare professionals should not assist the patients in this, due to the risk of contamination.

8.4 When arriving at the clinic, the used mask must be removed and packed in a plastic bag exclusively for that purpose, and should not be kept in the same compartment (bag, backpack) as the plastic bag that houses the clean mask that will be used on the return home.

8.5 When arriving home, the patient must clean the masks according to the guidelines contained in the MH technical note: immerse the mask in a container with drinking water and bleach (2.0 to 2.5%) for 30 minutes. The dilution ratio is 1 part of bleach to 50 parts of water (for instance: 10 ml of bleach to 500 ml of drinking water). After the immersion time, rinse the mask under running water and wash it with soap and water. After washing the mask, wash your hands with soap and water. The mask must be dry for reuse. After drying the mask, iron it with a hot iron and put it in a plastic bag¹ .

9. It is important to maintain the other preventive measures already recommended, such as social distance on days when hemodialysis is not performed, avoid touching the eyes, nose and mouth, in addition to hand hygiene with water and soap or 70% alcohol gel.^{1 , 3}

10. Cloth masks should not be worn by people who have difficulty breathing, are unconscious and unable to remove the mask without assistance. Based on clinical criteria, the nephrologist will be able to evaluate other possible contraindications.

11. These recommendations may change at any time, in the light of new evidence. In this sense, one should look for possible updates.