## 4 Discussion  
In the present study, we have demonstrated that taking aggressive and proactive infection preventive measures could successfully impede secondary transmission of COVID-19 in HD facilities. The nosocomial spreading was greater in HD units than in other settings because of the high susceptibility of HD patients to SARS-CoV-2 infection. This vulnerability was inherent to the particular clinical- and treatment-related characteristics of dialysis patients. The national government has issued a level-3 alert since 17 May and has suspended school classes, limited the number of gatherings, prohibited businesses in entertainment venues, and forbidden meals in restaurants. Our COVID-19 joint rapid response team managed COVID-19 control through collaborative activities and has formulated clinical infection preventive guidelines for our HD center from the very early \begin{table}
\begin{tabular}{c c c c c} \hline \hline  & **Total Patients (_n = 8_) \({}^{*}\) & **Alive (_n = 3_) \({}^{\$}\)** & **Deceased (_n = 5_)** & _p-Value_ \\ \hline Male, \(n\) (\%) & 3 (37.5) & 1 (33.3) & 2 (40) & 0.714 \\ Age, year & 68.9 (60.88–97.00) & 63.1 (60.88–64.30) & 74.9 (61–97) & 0.143 \\ W.B.C. (\(\times\)1000/uL) & 4.20 (1.00–6.80) & 5.30 (3.30–6.80) & 4.20 (1.00–5.00) & 0.250 \\ Hb (g/dL) & 9.55 (7.60–12.40) & 8.20 (7.60–12.40) & 10.5 (8.4–10.8) & 0.571 \\ Platelet (\(\times\)1000/uL) & 125 (39–225) & 155 (76–173) & 103 (39–225) & 0.571 \\ Albumin (gm/dL) & 3.66 (3.06–4.15) & 3.76 (32.37–3.91) & 3.56 (3.06–4.15) & 1.000 \\ AST (IU/L) & 25 (16–67) & 26 (16–61) & 24 (20–67) & 1.000 \\ ALT (IU/L) & 17 (9–34) & 31 (17–34) & 12.5 (9–18) & 0.114 \\ Alkaline-P (IU/L) & 110 (48–154) & 128 (48–154) & 110 (69–110) & 0.700 \\ Total Bilirubin (mg/dL) & 0.35 (0.3–0.6) & 0.3 (0.3–0.4) & 0.4 (0.3–0.6) & 0.393 \\ Cardiac/thoracic ratio & 0.59 (0.48–0.65) & 0.55 (0.48–0.57) & 0.61 (0.58–0.65) & 0.036 \({}^{*}\) \\ Creatinine (mg/dL) & 9.04 (4.00–15.18) & 9.04 (6.39–11.74) & 7.45 (4–15.18) & 0.857 \\ Na (meq/L) & 137.5 (121–141) & 138 (137–139) & 135 (121–141) & 0.393 \\ K (meq/L) & 3.70 (3.2–6.9) & 4.60 (3.20–5.70) & 3.70 (3.4–6.90) & 1.000 \\ Ca (mg/dL) & 8.90 (8.50–11.10) & 9.95 (8.8–11.10) & 8.9 (8.5–10.0) & 0.571 \\ P (mg/dL) & 5.00 (2.00–9.90) & 4.40 (2.8–6.0) & 5.0 (2.0–9.9) & 1.000 \\ Ferritin (ng/mL) & 869.5 (41.9–6954.0) & 877.0 (41.9–1100.0) & 862.0 (82.3–6954.0) & 0.786 \\ Ca \(\times\) P product & 38.54 (20–88.11) & NA (31.08–52.80) & 46.00 (20.00–88.11) & 0.571 \\ C t value & 17.50 (11.75–27.10) & 17.53 (11.75–27.10) & 17.47 (16.75–18.57) & 1.000 \\ CRP (mg/L) & 36.62 (15.17–70.79) & 17.2 (15.17–35.70) & 52.81 (20.60–70.79) & 0.071 \\ LDH (U/L) & 249 (185–355) & 249 (185–355) & 243.5 (219.0–290.0) & 1.000 \\ Lactate (mg/dL) & 46.35 (7.80–116.60) & 11.05 (7.80–14.30) & 97.5 (78.40–116.60) & 0.333 \\ Procalcitonin (ng/mL) & 0.535 (0.16–1.75) & 0.51 (0.16–0.56) & 0.56 (0.48–1.75) & 0.393 \\ \hline \hline \end{tabular}
\end{table} 
Table 4: Characteristics of COVID-19 confirmed HD patients in Keelung City (_n = 8_) \({}^{*}\). stage of the outbreak. In addition to national preventive measures, strict implementation and adherence of four major specific strategies: space segmentation, access control, quarantine operations, and high-quality medical staff protection have shown advantages to fighting against SARS-CoV-2 infection and have ensured the safety of patients and staff during their hemodialysis treatment, even in the presence of confirmed cases. However, COVID-19-associated mortality is high in HD patients, being the high cardiac-thoracic ratio, an important prognostic factor for clinical outcomes of infected HD patients. Coronaviruses, commonly transmitted human-to-human, have caused several disastrous pandemics in human history. The outbreak of severe acute respiratory syndrome (SARS) in 2003 resulted in 346 confirmed SARS cases and 37 deaths in Taiwan.