Reopening, COVID-19 second wave, and kidney disease

When will the US reopen?

Reopening America requires all of us to move forward together by practicing social distancing and other daily habits to reduce our risk of exposure to the virus that causes COVID-19. Reopening the country also strongly relies on public health strategies, including increased testing of people for the virus, social distancing, isolation, and keeping track of how someone infected might have infected other people.

The White House and CDC guidelines for the Opening Up America Again is 3-phased approach based on the advice of public health experts. Under these guidelines, states will reopen one step at a time, rather than all at once. Governors are empowered to tailor the phased reopening to address the unique needs of their individual states, with phased openings at the statewide or county-by-county level.

Phase 1 and Phase 2

According to the White House and CDC guidelines, vulnerable individuals, such as the elderly and people with CKD, should continue to shelter in place in Phase One and Phase Two. If you must leave your home adhere to CDC guidelines regarding travel.

Phase 3

Vulnerable individuals, such as the elderly and people with CKD, can resume public interactions, but should practice physical distancing, minimizing exposure to social settings where distancing may not be practical, unless precautionary measures are observed.

Employers may be able to make special accommodations for vulnerable individuals, for example continuing to work remotely at home or staggering shifts so fewer people are onsite at a given time.

Many large and small venues will be open, including restaurants, movie theaters, places of worship, schools and camps, gyms, and more. Long-term care facilities and hospitals will also be open to visitors and elective surgeries will be scheduled.

It’s important to remember that you are still at increased risk for severe disease should you become infected with COVID-19, so seek the advice of your healthcare team before engaging in any public interactions.

Continue to practice good hygiene

  • Wash your hands with soap and water or use hand sanitizer, especially after touching frequently used items or surfaces.
  • Avoid touching your face.
  • Sneeze or cough into a tissue, or the inside of your elbow.
  • Disinfect frequently used items and surfaces as much as possible.
  • Strongly consider using face coverings while in public, and particularly when using mass transit.

Continue to adhere to State and local guidance as well as complementary CDC guidance, particularly with respect to face coverings.

What are the 3 phases for reopening the US?

The White House and CDC guidelines for the Opening Up America Again is 3-phased approach based on the advice of public health experts. Under these guidelines, states will reopen one step at a time, rather than all at once. Governors are empowered to tailor the phased reopening to address the unique needs of their individual states, with phased openings at the statewide or county-by-county level.

Phase 1

All vulnerable individuals, such as the elderly and people with chronic kidney disease (CKD), should continue to shelter in place. Members of households with vulnerable residents should be aware that by returning to work or other environments where distancing is not practical, they could carry the virus back home. Precautions should be taken to isolate from vulnerable residents.

All individuals, when in public (eg, parks, outdoor recreation areas, shopping areas), should maximize physical distance from others. Social settings of more than 10 people, where appropriate distancing may not be practical, should be avoided unless precautionary measures are observed.

Avoid socializing in groups of more than 10 people in circumstances that do not readily allow for appropriate physical distancing (eg, receptions, trade shows).

Minimize non-essential travel and adhere to CDC guidelines regarding isolation following travel.

Phase 2

All vulnerable individuals, such as the elderly and people with CKD, should continue to shelter in place. Members of households with vulnerable residents should be aware that by returning to work or other environments where distancing is not practical, they could carry the virus back home. Precautions should be taken to isolate from vulnerable residents.

All individuals, when in public (eg, parks, outdoor recreation areas, shopping areas), should maximize physical distance from others. Social settings of more than 50 people, where appropriate distancing may not be practical, should be avoided unless precautionary measures are observed.

Non-essential travel can resume.

Phase 3

Vulnerable individuals, such as the elderly and people with CKD, can resume public interactions, but should practice physical distancing, minimizing exposure to social settings where distancing may not be practical, unless precautionary measures are observed.

Low risk populations should consider minimizing time spent in crowded environments.

Am I vulnerable for COVID-19?

According to the White House and CDC guidelines for the Opening Up America Again, vulnerable individuals include the elderly and people with serious underlying health conditions, such as chronic kidney disease (CKF), high blood pressure, chronic lung disease, diabetes, obesity, asthma. In addition, people with compromised immune systems due to taking immunosuppression drugs such as kidney transplant recipients and people on dialysis are vulnerable individuals.

What if my area opens up?

You should still practice the same precautions of staying at home, wearing a facemask, hand washing, and social distancing.

Whether you have kidney disease, have a transplant, or are on dialysis, you are still at increased risk for infection and for worse complications if you catch COVID-19.

Please be in close contact with your healthcare team, including your dialysis center or transplant center for further recommendations or instructions.

Visit the CDC for more information.

Do I still need to wear a mask?

Yes, you should still wear a face mask if you must go out for an essential reason such as a medical appointment or to get food or medicine. Whether you have chronic kidney disease, have a transplant, or are on dialysis, you are still at increased risk for infection and for worse complications if you catch Covid-19.

Therefore, you should still stay at home except for the most essential reasons.

Please be in close contact with your healthcare team, including your dialysis center or transplant center for further recommendations or instructions.

Visit the CDC for more information.

What if I need to go out in public?

Phase One and Phase Two

According to the White House and CDC guidelines, vulnerable individuals, such as the elderly and people with kidney disease, should continue to shelter in place in Phase One and Phase Two. If you must go out in public, you should maximize physical distance from others. Note: a cloth face cover is not a substitute for social distancing.

Phase Three

Vulnerable individuals, such as the elderly and people with kidney disease, can resume public interactions, but should practice physical distancing, minimizing exposure to social settings where distancing may not be practical, unless precautionary measures are observed. Note: a cloth face cover is not a substitute for social distancing.

You can find more information about going out in public during COVID-19 at Opening up America Again Guidelines and Centers for Disease Control (CDC).

Can I go back to work?

" Do not return to work if you have any symptoms of COVID-19 until you are cleared by a medical provider."

If you are concerned about your health and safety, you should share your concerns with your employer or manager. Depending on your job there may be options, such as continuing to work remotely from home; temporarily moving to another department or role; or other accommodations. You may also want talk to your company’s HR department to learn more about your company’s return-to-work policies including accommodations for social distancing, use of protective equipment, temperature checks, and disinfecting the work area.

Dangerous work environments

The CDC recently issued new guidance for reopening buildings [ADD Link: https://www.cdc.gov/coronavirus/2019-ncov/php/building-water-system.html] after they’ve been shut down for a while, such as businesses that closed due to the COVID-19 pandemic. If you are returning to a building that has been closed for some time, you should be aware of 2 microbial hazards – mold and Legionella (the cause of Legionnaire’s disease). People with weakened immune systems, including transplant recipients who take immunosuppressants, are at increased risk of developing Legionnaire’s disease.

According to the Occupational Safety and Health Administration (OSHA), if you believe working conditions are unsafe or unhealthful, you should bring the conditions to your employer’s attention, if possible. You may also file a complaint with OSHA concerning a dangerous work environment at any time.

You can find more information about worker safety and health during COVID-19 at Opening Up America Again Guidelines and Occupational Safety and Health Administration (OSHA).

Can I go out to eat?

Phase One

Restaurants with sit-down dining can operate under strict physical distancing protocols. At risk individuals should heed federal guideline recommendations and shelter at home for Phase 1 , so going out to eat is not advisable.

Phase Two

Restaurants with sit-down dining can operate under moderate physical distancing protocols. However, according to the White House and CDC guidelines, vulnerable individuals, such as the elderly and people with kidney disease, should continue to shelter in place in Phase Two, so going out to eat is not advisable.

Phase Three

Restaurants with sit-down dining can operate under limited physical distancing protocols. However, according to the White House and CDC guidelines, vulnerable individuals, such as the elderly and people with kidney disease, can resume public interactions, but should practice physical distancing, minimizing exposure to social settings where distancing may not be practical, unless precautionary measures are observed. Therefore, going out to eat may not be advisable unless the restaurant is still practicing strict physical distancing protocols. Please note that cloth face covers are not substitutes for social distancing.

Find more information here about going out to eat Opening Up America Again Guidelines 

Can I travel?

Phase One and Phase Two

The Opening Up America Again guidance recommends that people over the age of 65, who have kidney disease, on dialysis, or taking immunosuppression medication should stay home during Phase 1 and Phase 2. If you must travel you should adhere to CDC guidelines regarding travel.

Phase Three

Vulnerable individuals, such as the elderly and people with kidney disease, can resume public interactions, but should practice physical distancing, minimizing exposure to social settings where distancing may not be practical, unless precautionary measures are observed. If you must travel you should adhere to CDC guidelines regarding travel.

Safety measures for travel:

  • Practice physical distancing whenever possible
  • Wear facemasks or coverings in addition to physical distancing
  • Wash hands frequently and do not touch your face
  • Use a disinfectant wipe on all surfaces you touch (example: seats, seat belts, trays).

You can find more information about travel during COVID-19 at Opening Up America Again Guidelines and Centers for Disease Control (CDC).

Can I visit with friends and family?

Phase One and Phase Two

People who are at high risk for severe illness from COVID-19 infection should refrain from engaging in any public interactions during the first 2 phases. Therefore, visiting with friends and family is not advisable. We also recommend that you seek advice from your healthcare team.

Phase Three

According to the White House and CDC guidelines, vulnerable individuals, such as the elderly and people with kidney disease, can resume public interactions, but should practice physical distancing, minimizing exposure to social settings where distancing may not be practical, unless precautionary measures are observed. Therefore, visiting with friends and family may be possible using these precautions. We also recommend that you seek advice from your healthcare team. Please note that cloth face covers are not substitutes for social distancing.

Read the White House guidelines here: Opening Up America Again Guidelines

What if I feel sick?

If you feel sick, follow these steps:

  • Stay home except to get medical care (including dialysis treatments)
  • Do not go to work or school
  • Contact and follow the advice of your healthcare provider
  • Separate yourself from other people
  • Watch your symptoms

If you have a fever, cough or other symptoms you might have COVID-19. Other COVID-19 symptoms may include chills, muscle pain, headache, sore throat, or new loss of taste or smell. Emergency warning signs include trouble breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face.

You can find more information about what to do if you feel sick on the Centers for Disease Control (CDC) website and the Opening up America Again Guidelines.

Should I get antibody testing for COVID-19?

You can ask your healthcare team, or check with local/state health departments, to help decide if you should receive an antibody test and if it can be done safely for people with kidney disease.

Serological tests detect antibodies in the blood when the body is responding to a specific infection, such as COVID-19. They are also known as antibody tests. These antibodies are produced when someone has been infected, so a positive result from this test indicates that person was previously infected with the virus.

Antibody tests can help clinicians and their patients find out if someone was previously infected with COVID-19. The information can help researchers figure out how much the virus has spread in a community and to see if people can donate convalescent plasma, which might help others sickened by COVID-19. However, research is ongoing to see if antibodies from a CVOID-19 infection can protect someone from reinfection and if this protection lasts.

Also, these tests can have limitations. For example, specificity (doesn’t detect non-target viruses) and sensitivity (true positive rate, meaning antibodies exist) of antibody tests may vary. The CDC is evaluating the performance of antibody tests in collaboration with the FDA and other federal organizations.

CDC page for more information

FDA page for more information

State and Territorial Health Departments

Local Health Departments

What is herd immunity?

The CDC defines herd immunity as “protection from disease in a group, due to a large enough proportion of the population having immunity to prevent the disease from spreading from person to person.”

The idea is that if a large enough portion of a population is immune to a certain infection (either through recovery or vaccination) then transmission would slow and serve as a barrier for others without immunity.

However, a very large portion of the population would need to be immune to an infectious disease, such as COVID-19, in order for this to work. People who have recovered from an infection are usually protected from reinfection, based on what is known about other viruses (research is ongoing). However, many, many more people would need to be infected for this to possibly work, which would mean many more people would get sick and possibly die. This is why general recommendations and strategies have focused on social distancing (such as maintaining a distance of 6 feet from others, washing hands, and wearing facial covering) to reduce transmission as new treatments and vaccines are researched and developed.

What does it mean to build up immunity?

The immune system is the body's defense against infections. Part of this defense involves making antibodies to help keep the body protected from future infections. An antibody is made to protect against a certain virus or other germ.

It’s possible to build up protection or immunity by antibodies produced from an infection, such as with COVID-19, based on what is known about other viruses. However, this is a new virus and research is ongoing to see if antibodies from a COVID-19 infection can protect someone from reinfection and if this protection lasts.

Can I resume routine medical appointments?

You can contact your healthcare team to see if or when you can resume routine in-person medical visits. You can also ask if they offer remote visits, either through a smartphone app, Skype or other methods. If you need a certain treatment, vaccine, or test, then you should ask when it might be safer, or if you need to be there in person what precautions you might need to take (such as social distancing or facial covering).

Some states and locals are starting to slowly open up their stay-in-place orders. Other areas continue to maintain stay-in-place orders. These openings will be done slowly and in phases. Even if a certain area is starting to open up, vulnerable individuals are advised to stay at home as much as possible in these early phases, especially there are still new cases of COVID-19 in your area. Vulnerable individuals include the elderly and people with underlying health conditions including, but not limited to, high blood pressure, chronic lung disease, diabetes and kidney disease.

Opening up America Again Guidelines

Can I schedule elective procedures?

According to the White House and CDC Phase One and Phase Two guidelines, “elective surgeries can resume, as clinically appropriate, on an outpatient basis at facilities that adhere to CMS guidelines.” However, the guidelines also state that, vulnerable individuals, such as the elderly and people with kidney disease, should continue to shelter in place in Phase One and Phase Two. Therefore, you might be able to schedule an elective surgery, but you should seek the advice of your healthcare team based on the level of COVID-19 risk in your area.

Some hospitals or clinics might start allowing elective procedures, such as an endoscopy or knee replacement, if COVID cases are at a level where these procedures can be done safely and with a low infection risk. Others still might not allow them based on the level of COVID-19 risk in their area.

Either way, you should stay in touch with your healthcare team, and seek advice and express any questions or concerns.

Opening up America Again

State and Territorial Health Departments

Local Health Departments

What should I consider if I’m on dialysis?

First and foremost, you should know that you are still at increased risk for infection and for worse complications if you catch Covid-19.

You should continue to maintain the same precautions for hand washing, social distancing, staying at home, and wearing a facemask.

Please be in close contact with your dialysis center for any further recommendations or instructions.

Visit the CDC for more information.

What should I consider if I am planning or have undergone kidney transplant?

People who plan to or have already had a kidney transplant are at increased risk of developing severe illness from COVID-19 and preventing your exposure to the virus is the best approach.

You should continue to maintain the same precautions for hand washing, social distancing, staying at home, and wearing a facemask.

Please be in close contact with your transplant center for any further recommendations or instructions

Visit the CDC for more information.

Are young transplant recipients at increased risk from COVID-19?

" The idea that COVID-19 is sparing of young people is just false. Parents need to continue to take the virus seriously."

Lawrence C Kleinman, MD, MPH
Professor and Vice Chair for Academic Development/
Chief, Division of Population Health, Quality, and Implementation Sciences
Department of Pediatrics at Rutgers Robert Wood Johnson Medical School

Recent reports indicate that children, teens, and young adults are at greater risk for severe complications from COVID-19 and most of the children admitted to pediatric intensive care units have underlying conditions, such as kidney transplant recipients who are immunosuppressant medication.

Published findings -
A newly published study followed 48 children and young adults (newborns to 21 years old) who were admitted to pediatric intensive care units (PICUs) in the United States and Canada for COVID-19 in March and April. Over 80% of the patients had chronic underlying conditions.

During the 3-week study period, over 20% of these patients experienced failure of 2 or more organ systems due to COVID-19, and nearly 40% required a breathing tube and ventilator. At the end of the follow-up period, nearly 33% of the children were still hospitalized due to COVID-19, with 3 still needing ventilator support, 1 child on life support, and 2 children died.

New developments -
Even more recently, a growing number of children have been identified who appear to have a different response to COVID-19, which doctors are calling Pediatric Multi-System Inflammatory Syndrome. The symptoms of Pediatric Multi-System Inflammatory Syndrome include a persistent fever, rash, as well as gastrointestinal symptoms such as vomiting and diarrhea. Patients can also suffer from cardiac inflammation. In the coming days, the CDC is expected to issue guidance with information for treatment.

What can parents of young transplant recipients do?

The best way to keep children on immunosuppressant treatment well is to prevent their exposure to the virus. Continue to practice everyday preventive actions to help reduce your risk of getting sick and infecting your child and

  • Avoid close contact with people who are sick
  • Stay home when you are sick, except to get medical care
  • Cover your coughs and sneezes with a tissue and throw the tissue in the trash
  • Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food
  • Use an alcohol-based hand sanitizer with at least 60% alcohol, if you’re unable to wash your hands (eg, using a gas pump)
  • Clean and disinfect frequently touched surfaces and objects (eg, tables, countertops, light switches, doorknobs, and cabinet handles)
  • Wear a cloth mask when around your child

Contact your child’s transplant center for more information.

Reference: Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units. JAMA Pediatr. Published online May 11, 2020. doi:10.1001/jamapediatrics.2020.1948.

Am I eligible for disability benefits if I can’t work?

It is possible that you are eligible for disability benefits if you can't work due to COVID-19. Your social worker can give you information about financial programs, what the qualifications are, and how to apply.

The federal government runs 2 of the best-known programs.

  • Social Security Disability Insurance (SSDI) is a program of the Social Security Administration (SSA). It pays a monthly cash benefit to people who are unable to work for a year or more because of a disability.
  • Supplemental Security Income (SSI) is another SSA program. Benefits are calculated based on an individual’s financial needs, not the amount of tax that they paid. SSI pays its benefits monthly. This amount may be supplemented by state or local benefits.

What are my rights as a kidney patient if my employer wants me to return to work?

There are laws to protect people with chronic conditions and illnesses from discrimination in the workplace. Your legal rights may be protected by one of the following federal acts.

Americans with Disabilities Act (ADA)

If you work for a company with 15 or more employees, the Americans with Disabilities Act (ADA) requires your employer to make any “reasonable accommodations” that you might need in order to perform your work duties.

Examples include:

  • Making parking lots, bathrooms, and work areas handicapped accessible
  • Allowing you to work from home if possible, in your current role
  • Having flexible work schedules (to schedule around dialysis treatments for example)
  • Designating a sterile area to exchange cleansing fluid bags for PD
  • Reassigning you to a less strenuous job if you request one and one is available
  • Assigning any of your non-essential tasks to other employees, at your request

The Equal Employment Opportunity Commission (EEOC) handles complaints under the ADA.

Family and Medical Leave Act (FMLA)

If you work at least 20 weeks of the year for an employer with 50 or more employees, you may qualify for the Family and Medical Leave Act (FMLA). The FMLA allows for 12 weeks of unpaid, job-protected leave for medical reasons.

If you had group health insurance coverage before taking leave, it will continue under the same terms or conditions.

Your employer can ask for medical certification stating that you have a serious illness but cannot punish you for taking leave to have surgery or begin treatment. Your spouse, children, or parents may also be eligible for FMLA leave if you need them to provide you with care or transportation.

The Department of Labor (DOL) handles complaints under FMLA.

Families First Coronavirus Response Act

You may also have protected rights under the new Families First Coronavirus Response Act – which includes the Emergency Family Medical Leave Expansion Act (EFMLEA) and the Emergency Paid Sick Leave Act (EPSLA) – or other state and local laws.

The FMLA Expansion Act provides 12 weeks of leave. If you are a full-time employee, the Emergency Paid Sick Leave Act provides 80 hours of leave. If you are a part-time employee, the law provides leave for the average number of hours you work in a two-week period. Currently these provisions expire December 31, 2020.

For more information, including suggestions for writing a letter to your employer requesting work accommodations because you are at high risk for severe disease from COVID-19, click here.

Is “avoiding COVID-19” a reason to request leave or work from home?

Possibly. Employees with kidney disease may be able to take leave to avoid contracting coronavirus under the Emergency Paid Sick Leave Act (EPSLA).

The CDC recommendations state that people with kidney disease should continue to stay home because they are considered a high risk group for more serious COVID-19 illness; therefore, employees with kidney disease (or those caring for someone with kidney disease) would be eligible for 2 weeks of paid sick leave under the EPSLA on these grounds.

In addition, employees can also take leave under the EPSLA if their physician has advised them to self-quarantine on the belief that the employee is particularly vulnerable to COVID-19.

For more information, including suggestions for writing a letter to your employer requesting work accommodations because you are at high risk for severe disease from COVID-19, click here.

Am I eligible for unemployment benefits due to COVID-19?

You may be eligible for unemployment benefits if you have lost your job due to COVID-19.

  • Apply for federal unemployment benefits at USA.gov and contact your state's unemployment insurance program as soon as possible after becoming unemployed.

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