BMD was assessed by dual-energy X-ray absorptiometry. Carotid-femoral pulse wave velocity (cf-PWV) was used as an indicator of arterial stiffness. Subjects were divided into two groups by median cf-PWV. Physical activity in free-living conditions was evaluated using a triaxial accelerometer. Nutrient intake was also measured using the brief-type self-administered diet history questionnaire. In the High-PWV group, BMD showed a significant negative correlation with age. Using a partial correlation model, BMD was associated with the number of steps and unsaturated fatty acid intake in the High-PWV group. These results suggest that BMD in middle-aged women with high levels of arterial stiffness may be associated with both the number of steps and nutritional intake. Recommendations of physical activity and nutritional intake for the prevention of osteopenia should include consideration of arterial stiffness.There is little consensus regarding the impacts of physical activity and nutrient intake on bone mineral density (BMD) in subjects with high or low levels of arterial stiffness. This study was performed to investigate whether physical activity and nutrient intake are associated with BMD in middle-aged women with high levels of arterial stiffness. The study population consisted of middle-aged women aged 40–64 years ( Osteoporosis, a chronic disease characterised by reduced bone mineral density (BMD), is one of the most prevalent factors contributing to fractures, mortality and mobility limitation in the elderly , and theArterial stiffness and Atherosclerosis can be focused as one of the factors of these disagreements. Because recent studies also suggested that there is potential for cross-talk between arterial systems and bone metabolism ,11,12. APhysical activity and nutrient intake are modifiable factors that influence arterial stiffness. Habitual physical activity has a positive effect on arterial distensibility ,25,26,27Kahwati et al. reported that neither vitamin D, calcium, nor combined supplementation was associated with reduced fracture incidence in healthy adults without known nutrient deficiency . AvenellThere is limited consensus, however, on the effects of physical activity and nutrient intake on individuals with high or low levels of arterial stiffness. The effects of these types of physical activity and nutrition intake on BMD remain unclear. This pilot study was performed to investigate whether physical activity and nutrient intake are associated with BMD in middle-aged women with high levels of arterial stiffness. Middle-aged women younger than 65 years of age were recruited from local communities for this study. Data related to sociodemographic characteristics (date of birth), medical history , current smoking status and alcohol intake and current medications (name and dosage) were collected during the screening visit. Women with any medical considerations, including taking specific drugs or supplements  that could affect bone metabolism were excluded. The study population included seven subjects with SBP > 140 mmHg, but they had not received medical treatment. Ten women fulfilled the exclusion criteria. All subjects provided written informed consent after being informed of the benefits and risks of the investigation. This study was approved by the Ethics Committee of Ritsumeikan University . All participants reviewed and signed informed consent forms in accordance with the Declaration of Helsinki. 2). Skeletal muscle mass index was calculated by dividing the appendicular fat-free mass (FFM) in kilograms (kg) by height in meters squared (m2). Body composition was assessed by dual-energy X-ray absorptiometry (DXA) using enCORE software . Subjects fasted overnight and did not perform any exercise in the morning before measurements were taken. In this study, BMD values were derived from total-body DXA scans. Total-body BMD is not an appropriate surrogate for diagnosing osteoporosis or assessing fracture risk  because Pulse wave velocity (PWV) is considered to be an indirect indicator of arterial stiffness, reflecting vascular damage. Subjects rested for 15 minutes in the supine position before carotid-femoral PWV (cf-PWV), brachial-ankle PWV (ba-PWV) and blood pressure measurements were taken. The cf-PWV, ba-PWV and blood pressure were measured simultaneously using a vascular testing device ; Omron Colin, Kyoto, Japan). The cf-PWV was measured using applanation tonometry, with an array of 15 transducers (form PWV/ABI), as described previously ,38,39. TBlood was drawn from subjects in the seated position. Fasting (>12 h) blood samples were collected by venipuncture in tubes with or without ethylene diamine tetraacetic acid (for plasma or serum). Blood samples were centrifuged at 1500 rpm for 15 min and were stored at −20 °C. The serum concentration of triglycerides was determined using commercial kits . Serum high-density lipoprotein cholesterol (HDL-C) was measured by an enzymatic method . Fasting plasma glucose (FPG) was measured by the glucose dehydrogenase method. Whole-blood glycohemoglobin A1c (HbA1c) was measured by an enzymatic method .The duration and intensity of physical activity in free-living conditions were evaluated using a triaxial accelerometer  ,41. The n-3 fatty acids and n-6 fatty acids were calculated in grams per day using the food list section of the BDHQ. Total energy was calculated in kilocalories per day from BDHQ responses. Questionnaires indicating an extreme energy intake of greater than two standard deviations were considered to be invalid and were excluded. Nutrient intake was measured using the brief-type self-administered diet history questionnaire (BDHQ), which is a fixed-portion questionnaire that assesses dietary intake during the previous month ,43. The Covariates were measured at the same time as the DXA assessment and included age (years) and height (cm). Height without shoes was measured using a stadiometer.t-test. All measurements and calculated values are expressed as the means ± standard deviation. Correlation analyses of total-body and regional BMD with study variables were performed using Pearson’s correlation analyses. Partial correlations were adjusted for age and BMI and used to examine the relationships between BMD, physical activity and nutritional intake. All analyses were performed using SPSS . Statistical significance was set at α < 0.05.Outcome measures included BMD , physical activity and nutritional intake. Fat intake was defined as SFA, MUFA and PUFA in grams per day. Fat intake was then adjusted for total energy intake with the residual method . In thisWe assessed cf-PWV to evaluate arterial stiffness (median cf-PWV = 1053 cm/s). All subjects were classified into two groups by cf-PWV (Low- and High-PWV groups). Descriptive characteristics for Low- and High-PWV groups, as well as all subjects, are shown in p < 0.05). To exclude the possible effect of age on physical activity, we performed partial correlation analysis.In this study, age was associated with total and non-locomotive MVPA in all subjects  and BMI was associated with locomotive MVPA (r = 0.52). Similar results were observed in the High-PWV group. BMI and body fat were associated with total MVPA . In the Low-PWV group, age was associated with total and non-locomotive MVPA  when adjusted for age and BMI . SignifiThis study was performed to investigate the associations of physical activity and nutrient intake with BMD in middle-aged women with high levels of arterial stiffness. To our knowledge, there have been no previous studies directly comparing physical activity and nutrient intake in middle-aged women with low and high levels of arterial stiffness.The main results of our study were as follows: 1) in the High-PWV group, total-body, arm and leg BMD were negatively associated with age; 2) in the High-PWV group, a positive partial correlation was found between the number of steps and leg BMD after adjusting for age and BMI; 3) in the High-PWV group, partial correlations were observed between MUFA, PUFA, α-tocopherol Eq intake and BMD.In the High-PWV group, BMD was negatively associated with age. Previous studies have demonstrated that early postmenopausal women can be “fast bone losers”  or “slow bone losers”  due to differences in basal bone turnover ,46. SumiSome studies have highlighted a significant association between the severity of atherosclerosis and BMD ,49, withEvans et al. reported that a 9-month walking program with protein supplementation had no effect on BMD in postmenopausal women . SimilarIn the High-PWV group, partial correlations were observed between unsaturated fatty acids  and α-tocopherol eq intake and BMD. These observations can be explained by antioxidant and anti-inflammatory effects.Saturated fatty acids, levels of which were significantly elevated in the PWV-High group, have been suggested to be atherogenic through induction of endothelial dysfunction ,59. Numen-6 polyunsaturated fatty acid, have been shown to produce anti-inflammatory cytokines  [Oleic acid, a typical monounsaturated fatty acid, and linoleic acid, an , IL-13) ,68. More, IL-13) . Zhang et al. investigated whether antioxidant intake was associated with risk of fracture and whether this association was modified by the smoking status that induces excessive oxidative stress. The results indicated that vitamin E (antioxidant) intake was associated with reduced risk of fracture in ever smokers but not in never smokers . SimilarIn addition, Takeshima et al. reported that osteoblast differentiation is inhibited by oxidative stress and rescued by antioxidant treatment with vitamin E . These sThe major limitations of this study were the small sample size, although the nutritional intake and physical activity of this study may reflect mean values for present Japanese middle-aged women ,75,76,77An understanding of vascular-related bone loss may be necessary for effective and efficient prevention and treatment of osteopenia in middle-aged women. The recommendation of physical activity and nutritional intake interventions for the prevention of osteopenia should include consideration of arterial stiffness.


Tumor metastasis is one of death causes for patients of prostate carcinoma. PIWI-interacting RNAs (piRNAs) are a subtype of noncoding protein RNAs that are involved in tumorigenesis, but the effect of piRNAs in prostate carcinoma (PCa) remains unclear. This article showed the identification of piRNAs was performed using a piRNA microarray screen in PCa tissues and several piRNAs were identified as dysregulated. The two up-regulated piRNAs (piR-19004 and piR-2878) and one down-regulated piR-19166 have been validated in the tissues and cell lines of PCa using quantitative reverse transcription polymerase chain reaction (qRT-PCR). Further studies showed that piR-19166 is transfected into PCa cells to suppress its migration and metastasis. Mechanistically, cortactin (CTTN) 3' untranslated region (UTR) was complementary combined with piR-19166 by bioinformatic prediction and identified as a direct target of piR-19166 through dual-luciferase reporter assay. Over-expression and knockdown of CTTN could respectively rescue and simulate the effects induced by piR-19166. Finally, piR-19166 suppresses migration and metastasis by the CTTN/matrix metalloproteinases (MMPs) pathway in PCa cells. Thus, these findings suggested that piR-19166 targets the CTTN of prostate cancer cells to inhibit migration and distant metastasis, and may represent a new marker of diagnosis and treatment for PCa patients in early stages. Prostate carcinoma (PCa) is a common form of malignant tumor in older men and is the second leading cause of cancer-associated death in United States , 2. AlthRecently, the functions of noncoding protein RNAs (ncRNAs) in PCa have been widely studied –9. PiRNAIn the current study, piR-19166 was down-regulated by qRT-PCR in PCa tissues and cell lines, and correlated negatively with metastasis. In addition, the function of piR-19166 in migration of PCa cells, the target of piR-19166 and metastasis mechanism of PCa were investigated together. This study may presents piR-19166 served as a novel target for further early therapeutic studies of PCa.A piRNA expression profiling of Arraystar piRNA Microarray was conducted using RNA isolated from five PCa tissues and five normal prostate tissues (NC). The screen and data analysis were performed by Arraystar Inc. The results showed that a box plot  formed aSeveral piRNAs identified by the piRNA screen were up-regulated or down-regulated between PCa group and NC group, their expression folds were listed in To further confirm down-regulated expression of piR-19166, RNA in situ hybridization (ISH) was explored its RNA expression in 42 specimens of PCa and matched normal prostate tissues, and qRT-PCR was detected in PCa cell lines(PC3 and LNCaP) and RWPE-1. As shown in The above data demonstrated piR-19166 was relation closely with LN metastasis in PCa patients, so the role of piR-19166 will be investigated in migration though Transwell Assay. Firstly, lentiviral vector overexpressing or silencing of piR-19166 and corresponding negative control (NC) was transfected and confirmed into PC3 and LNCaP by qRT- PCR analysis P<0.05, , 5B. Thehttps://blast.ncbi.nlm.nih.gov/ Blast.cgi?PAGE_TYPE=BlastSearch). The bioinformatics comparison result also showed there is one complementary binding site between piR-19166 and CTTN 3’UTR region  include MT1-MMP, MMP2 and MMP9, are a direct target of CTTN , the CTTAs a primary prostate tumor, its prognosis is relatively favorable and 5-year survival rate in the worldwide is more than 98 % . By reasPIWI-associated RNAs (piRNAs) belongs to non-coding protein small RNA with the length of 25 to 33nt, playing a biological role by interacting with PIWI protein. There are four kinds of PIWI protein in human, including PIWIL1 / HIWI, PIWIL2 / HIWI, PIWIL3/ HIWI and PIWIL4 / HIWI. Gene alteration in cancer cells are regulated by a series of small molecules, including piRNAs. Previous research results explored that PIWI protein and piRNAs are related to development and progression of cancer. For example, PIWI protein has abnormal expression in a variety of tumors, such as seminoma, gastric cancer, breast cancer, pancreatic cancer, liver cancer, glioma and so on, which may play a role of carcinogen or tumor suppressor –20. PiRNin vitro suggested that piR-19166 could block cell metastasis of PCa cells and decrease the number of metastatic tumors in lung of nude mice. The observations explored piR-19166 was served as a biomarker of metastasis in PCa.In the current study, piR-19166 was obvious down-regulation in PCa tissues and cell lines compared to adjacent normal prostate tissues and normal prostate epithelial cells via ISH and qRT-PCR, and the piR-19166 expression in lymph node metastasis (LNM) group is lower than that of in non lymph node metastasis group by qRT-PCR. These data demonstrated piR-19166 may be a tumor suppressor gene in development of PCa. Besides, close relation between piR-19166 expression and LNM hinted PCa patients with negative expression of piR-19166 were more prone to lymph node metastasis. Similarly, CTTN has been confirmed as an oncogene and positive regulator of metastasis by previous study –27. By bIn summary, low levels of piR-19166 are associated with LN metastasis in PCa; piR-19166 may suppress migration and metastasis by regulating CTTN/ MT1-MMP/MMP2 /MMP9 signaling pathway. The newly identified results suggest that piR-19166 is an important tumor suppressor gene and block- metastatic gene in PCa. The research could provide a new diagnostic and therapeutic target for PCa patients with lymph node metastasis.42 pairs of PCa specimens and matched normal prostate tissues from March 2018 to October 2019 were collected from the Department of Urinary surgery of the Affiliated Hospital of Yangzhou University . PCa were confidently diagnosed by one pathologist. All fresh tissues were obtained during surgery and immediately stored in liquid nitrogen prior to use. Approval for this study was granted by the Institute Research Medical Ethics Committee of Affiliated Hospital of Yangzhou University . Patients provided written informed consent.Human prostate cancer cell lines, PC-3 cells and LNCaP cells, were purchased from the American Type Culture Collection . The cells were maintained in RPMI-1640 medium (Invitrogen Life Technologies), supplemented with 10% fetal bovine serum (FCS). The RWPE-1  cells were kindly provided by Dr X.Y. Dong  and maintained in defined keratinocyte serum free medium with 5 ng / ml epidermal growth factor.Total RNA was isolated from PCa tissues and matched normal prostate tissues as previously described . The extTissue sections (thick 7 um) were dewaxed regularly and digested by pepsin to expose RNA. After RNAs were hybrided in 42°C for the night, the sections were added sealing fluid, biotinylated anti-digoxin, and streptavidin-biotin complex (SABC). Then biotin peroxidase was instilled. 3,3’-Diaminobenzidine tetrahydrochloride (DAB) was used for tissue staining. The sections were dyed hematoxylin, dehydrated and sealed. Morphological changes of tissue were observed under a microscope. Criteria for staining results: the brown and yellow particles in cytoplasm or nucleus were the positive result of piR-19166. Ten high-power fields were randomly selected to count the percentage of positive cells: less than 5% was low expression; more than 5% was high expression. A positive control group was set according to the reagent instruction, and the stained tissue without primary antibody was a negative control group.Total RNAs from PCa cells, PCa tissues and matched normal tissues were isolated using TRIzol reagent (Invitrogen). RNAs were reverse-transcribed to cDNA using the PrimeScript First Strand cDNA synthesis kit (Takara) according to the instructions. qRT-PCR was performed on an Applied Biosystems 7500 Real Time PCR system. The expression of piRNA and mRNAs was normalized to U6 and GAPDH, respectively.The assays were performed as previously described .The 167 nucleotide (nt) full length 3′-UTR of CTTN was amplified by PCR from genomic DNA of PC3 cells and cloned into the EcoRI and XhaI sites of pGL3-BS vector . The primers for CTTN 3′-UTR were as follows: 5′- tcggccaagaatactt -3′ and 5′-tcggtttgaatcatct -3′. The mutant 3′UTR of CTTN was generated using a Quick Change mutagenesis kit  according to the manufacturer’s protocol. Co-transfection of piR-19166 or negative control and reporter vectors was performed using Lipofectamine 2000 . After 48 h, dual luciferase activity was measured using a Dual-Luciferase Reporter Assay System  according to the instructions. Firefly luciferase signal was used for normalization.5 cells were added into the upper wells transwell chamber without matrigel. In both assays, PC3 cells were seeded in culture medium without fetal bovine serum (FBS) in the upper wells, and in medium containing 10% FBS served as chemoattractant in the lower wells. After 14 hour incubation, the PC3 and LNCaP cells of the filters were fixed with methanol for 15 min, stained with 0.1% crystal violet for 20 min and counted in an inverted microscope For the migration assays, 2× 10The assay of western blot was performed as previously described . The pri6) suspended by phosphate puffer solution (PBS) were injected subcutaneously into the backs of null mice  from Animal Center of Yangzhou University. The mice were randomly divided into the piR-19166 mimic group and NC mimic group. The tumor volume (length × width2/2) was used to measure with a slide caliper. For metastasis models, the PC3 cells were inoculated into the tail veins of 20 mice respectively. At the end of the arrays, the mice were scarified and the tumors and their lungs were removed, quantified and frozen for further assay. All nude mouse studies were approved in the animal facility at Ethics Committee on Animal Experimentation of Yangzhou University accordance with institutional guidelines.PC3 cells  was used for staining immune complexes. The results of criterion showed that the tumor cell membrane and / or cytoplasm and / or nucleus appeared brown granules as positive. The percentage of positive cells was number of positive cells / all the cells in 5 random fields (100 cells in each field) under 10 × 40 high power microscope.SPSS V.16 software package for Windows  was used for Statistical analyses and All graphs were created using GraphPad Prism 5 software . The student’s t-test was used to assess difference between groups. Chi-Square was applied for categorical variables. Correlation analysis was performed using the Spearman rank test. Statistical significant difference was considered as P<0.05.


To evaluate patterns of health care utilization for sports-related concussions (SRCs) and non-sports-related concussions (NSRCs) among Medicaid-insured children before and after the enactment of Ohio’s concussion law in April 2013.We analyzed claim data from the Partners For Kids (PFK) Ohio Medicaid database. Concussion diagnoses were identified between April 1, 2008 and June 30, 2017. We compared frequency of concussions by age and sex across the law period. We evaluated type of health care utilization before and after law enactment using multinomial logistic regression.Over the 9 year study period, 6157 concussions were included, most of which (70.4%) were NSRCs. The proportion of SRCs increased with age. Among children younger than 5 years old, the majority (96.1%) of concussions were NSRCs. During the post-law period, greater odds of primary care visits than emergency department (ED) visits were observed for both SRCs  and NSRCs  compared to the pre-law period.We observed higher proportions of health care utilization for NSRCs than SRCs in Medicaid insured children and a shift in health care utilization from the ED to primary care in the post-law period. SRCs and NSRCs are likely to have different patterns of health care utilization before and after the enactment of Ohio’s concussion law. Our results demonstrate that Ohio’s youth concussion law had a quantifiable impact on health care utilization. Accepted for an oral presentation at the American Public Health Association (APHA) Annual Meeting in San Diego, California, USA  and received “2018 Best Paper Award for the Student Paper Competition, APHA, ICEHS”.Poster presentation at the Big Ten – Ivy League TBI Summit Annual Meeting in Philadelphia, Pennsylvania, USA Concussion, a type of mild traumatic brain injury (mTBI), is a common injury among children and adolescents  had enacted a state youth concussion law   pediatric accountable care organization database. PFK provides health care coverage to nearly 330,000 low-income and Medicaid-eligible children in central and southeastern Ohio . For patients with multiple concussion-related visits, at least 90 days without a concussion-related visit was required to denote unique injuries  codes: 850.0, 850.1, 850.11, 850.12, 850.2, 850.3, 850.4, 850.5, and 850.9, and codes beginning with S06.0 . Concussions with first visit dates after January 1st, 2017 were also excluded from analyses to ensure all follow-up visits for each injury were included in our analyses . To be included in the analyses, patients also needed to be enrolled in PFK for at least 30 days before their initial concussion-related medical visit   before April 1, 2008, the start date of our analyses . Injury mechanism was determined by external cause for injury codes . A concussion was defined as a SRC if the injury occurred while an individual was participating in an organized  or non-organized sport (e.g. weight lifting), and NSRCs were classified by E-codes that were not sports-related in nature (e.g. motor vehicle accident).To facilitate comparisons between SRCs and NSRCs, concussions were excluded from our analyses if they were missing an E-code value for mechanism of injury  and age group at time of first concussion-related visit .The final analytic sample included 6157 (38.2% of usable concussion sample) unique concussions that were sustained by 5961 (41.2% of usable patient sample) unique patients. These injuries involved 10,816 visits consisting of 17,598 claims from April 1st 2008 until June 30, 2017.Frequency of health care utilization (injury-level variable) was calculated as the number of unique concussion injuries.Rate of health care utilization (injury-level variable) was calculated per year, as the number of unique concussions each year divided by the total membership months of the PFK population during that year, multiplied by 100,000.Type of health care utilization (claim-level variable) was defined by the provider specialty listed on the medical claim. Provider claims were grouped into five categories: (i) ED, (ii) primary care, (iii) specialty care , (iv) sports medicine, and all (v) other . The number and percentage of claims in each category was calculated by total visits, first visit, and follow-up visit(s).We compared the frequency of concussions in our study population before and after the enactment of Ohio youth concussion law by SRCs and NSRCs, sex, and age group using chi-square tests. The overall concussion rate and concussion rates by sex and age-groups in the pre- and post-law periods were also calculated. Multinomial logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between law effective period (pre-law as the referent) and type of health care utilization stratified by type of concussion (SRCs and NSRCs). Adjusted models included sex  and age group (< 5 as the referent). We could not classify about 62% of concussions into SRCs or NSRCs due to missing E-codes. To study the potential effect of missing E-code, we conducted a multiple imputation based on sex and age using logistic regression (number of imputations is 25) ; 2742 (44.5%) occurred in the pre-law period and 3415 (55.5%) occurred in the post-law period , whereas in the post-law period the highest proportion of claims were for primary care visits . This trend was observed for both SRCs and NSRCs [data not tabled].In the pre-law period, the highest proportion of concussion-related health care claims were from the ED  and SRCs  were more likely to seek care from a primary care provider (PCP) than the ED during the post-law period. Similarly, during the post-law period we observed a significant change in type of health care utilization such that for both SRCs and NSRCs patients were more likely to seek care from a sports medicine provider as compared to the ED  (Table P < 0.05), although proportions of ED visits started to decline after 2013  that may affect patient’s health care utilization patterns were not available. Moreover, we used the law effective date to measure the law effect as opposed to assessing the strength of the law or the implementation of the law. Finally, our cohort of Medicaid-insured children was from one state; thus, our results may not be generalizable to other populations of Medicaid-insured children or children with different types of insurance.Our research demonstrated higher proportions of NSRCs compared to SRCs in our Medicaid population. Overall, ED utilizations were more common for initial care/ first visits. Results also revealed a shift in type of first health care visit from the ED to PCPs and sports medicine providers in the post-law period. Our results demonstrate that Ohio’s youth concussion law had a quantifiable impact on health care utilization. As evident from these findings, concussions pose a major burden on our health care system, partly because of the law requirement that concussed youth must obtain medical clearance before returning to play or practice. Efforts to prevent concussions among children before they occur could help reduce this burden. Future studies should use national databases of pediatric populations to validate these findings.Additional file 1: eTable 1. Odds ratio estimates of health care utilization by provider specialty among Medicaid-insured children after multiple imputation for missing values of injury mechanism (sports- vs. non-sports-related).


The BCG vaccine, widely used in Brazil in new-borns, induces adjuvant protection for several diseases, including childhood virus infections. BCG activates monocytes and innate memory NK cells which are crucial for the antiviral immune response. Therefore, strategies to prevent COVID-19 in health workers (HW) should be carried out to prevent them becoming unwell so that they can continue to work during the pandemic. The hypothesis is that BCG will improve the innate immune response and prevent symptomatic infection or COVID-19 severity.The primary objective is to verify the effectiveness and safety of the BCG vaccine to prevent or reduce incidence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in the city of Goiânia (Brazil) among HW previously vaccinated with BCG and also its severity and mortality during the pandemic of the disease.Secondary objectives are to estimate the incidence of COVID-19 among these professionals and the innate immune response elicited to BCG.This a phase II trial for repositioning BCG as a preventive strategy against COVID-19.The trial is an open-label, parallel-group randomised clinical trial, comparing HW vaccinated with BCG and HW not vaccinated.The trial will recruit 800 HW of Goiânia - Goiás, Brazil to reach a total of 400 HW included after comorbidities questioning and laboratorial evaluation.Eligibility criteria: Any HW presenting BCG vaccination scar with direct contact with suspected COVID-19 patients for at least 8 hours per week, whether in hospital beds, ICU, or in transportation or admission  who have negative IgM and IgG COVID-19 test.Participants with any of the following characteristics will be excluded:- Have had in the last fifteen days any signs or symptoms of virus infection, including COVID-19;- Have had fever in the last fifteen days;- Have been vaccinated fifteen days before the inclusion;- Have a history or confirmation of any immunosuppressive disease such as HIV, presented solid tumour in the last two years or autoimmune diseases;- Are under preventive medication with antibiotics, steroid anti-inflammatories, or chemotherapy;- Have less than 500 neutrophils per mL of blood;- Have previously been diagnosed with tuberculosis;- Are breastfeeding or pregnant;- Are younger than 18 years old;- Are participating as an investigator in this clinical trial.HW will be randomized into the BCG vaccinated group or the BCG unvaccinated control group.5 to 8 x105 CFU of live, freeze-dried, attenuated BCG Moscow 361-I, Bacillus Calmette Guerin vaccine (Serum Institute of India PVT. LTD.).The BCG vaccinated group will receive in the right arm, intradermally, a one off dose of 0.1 mL corresponding to approximately 2 x10The unvaccinated control group will not be vaccinated.The HW allocated in both groups will be followed up at specific times points until 180 days post inclusion.The vaccinated and control groups will be compared according to COVID-19 related outcomes.The primary outcomes are the incidence coefficient of infection by SARS-CoV-2 determined by RT-PCR of naso-oropharyngeal swab specimen or rapid lateral flow IgG and IgM test, and presence of general COVID-19 symptoms, disease severity and admission to hospital during the 180 days of follow up.The secondary outcome is the innate immune response elicited 15-20 days after vaccination.randomization.com [http://www.jerrydallal.com/random/permute.htm].The vaccine vial contains approximately 10 doses. In order to optimize the vaccine use, the randomisation was performed in blocks of 20 participants using the platform The randomization was prepared before any HW inclusion. The results were printed and inserted in sealed envelopes that were numbered with BCG-001 to BCG-400. The printed results as well the envelopes had the same numbers. At the time of the randomisation, each participant that meets the inclusion criteria will receive a consecutive participant number [BCG-001-BCG-400]. The sealed envelope with the assigned number, blinded to the researchers, will be opened in front of the participant and the arm allocation will be known.There is no masking for the participants or for the healthcare providers.The study will be blinded to the laboratory researchers and to those who will be evaluating the outcomes and performing the statistical analyses. In this case, only the participant identification number will be available.Four hundred heath workers will be randomised in two groups. Two hundred participants will be vaccinated, and 200 participants will not be vaccinated.th, 2020. The clinical trial protocol was registered on August 5th, 2020. It is estimated that recruitment will finish by March 2021.The protocol approved by the Brazilian Ethical Committee is the seventh version, number CAAE: 31783720.0.0000.5078. The trial has been recruiting since September 20th, 2020 at REBEC (Registro Brasileiro de Ensaios Clínicos). Register number: RBR-4kjqtg and WHO trial registration number UTN: U1111-1256-3892.The protocol number was registered on August 5The full protocol is attached as an additional file, accessible from the Trials website (Additional file Supplementary information accompanies this paper at 10.1186/s13063-020-04822-0. Additional file 1. Full study protocol


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a single-stranded, positive-sense, enveloped ribonucleic acid (RNA) virus. SARS-CoV-2 and its associated disease coronavirus disease 2019 (COVID-19) has caused a global pandemic in the year 2019-2020. COVID-19 has caused widespread death, economic burden, and overcrowding of hospitals. As of September 2020, there is no reliable pharmacological treatment for patients affected by COVID-19. Herein we present a case of a 41-year-old Caucasian female who presented to the emergency department with flu-like symptoms for the past five days. The patient was admitted for COVID-19 symptoms and subsequently developed COVID-19 associated thrombotic syndrome and ischemic stroke. Below, we discuss risk factors, pathology, and rare manifestations resulting from COVID-19 infection. COVID-19 primarily affects the lungs, but a review of the current literature shows limited cases of ischemic stroke and diffuse thrombosis induced by infection of the novel COVID-19 in relatively healthy individuals with minimal risk factors. Severe acute respiratory syndrome coronavirus (SARS-CoV-2) and its disease, coronavirus disease 2019 (COVID-19), is a respiratory infection with potential multisystem involvement that has caused a global pandemic. A unique aspect of this virus is the ability to alter the metabolism of clotting factors, resulting in coagulopathy. The lack of knowledge and novelty of COVID-19 has provided a difficult task for physicians to manage. The etiology of COVID-19 is unknown and has caused a significant number of cases worldwide. Mortality rates as high as 2-4% have been reported. SARS-CoV-2 belongs to the family of Coronaviridae and is a positive-sense, enveloped single-stranded, ribonucleic acid (RNA) virus. The etiology of the virus appears to be zoonotic and its origin is uncertain. In humans, SARS-CoV-2 is primarily transmitted via the spread of respiratory droplets due to coughing, sneezing, or talking [The most common symptomology of COVID-19 consists of fever, cough, shortness of breath, myalgias, and loss of taste or smell. Some of the less common presenting signs include pharyngitis, headache, and GI symptoms such as diarrhea ,3. TheseCurrent diagnostics and screening protocols remain largely focused on individuals exhibiting symptoms such as fever, cough, and shortness of breath along with asymptomatic individuals with known or suspected exposure . The maiCurrent complications from COVID-19 are vast and diverse. Some of these include serious neurological complications, acute respiratory distress syndrome, hematological abnormalities, and altered cranial nerve functions such as anosmia . SignifiThe extensive clinical manifestations and their unpredictable outcomes are the most salient concern for COVID-19. By investigating risk factors, commonalities in clinical presentation, and predictors of prognosis, physicians will be able to improve patient management through the development of standard protocols and guidelines for patients who are infected by COVID-19.A 41-year-old Caucasian female presented to the emergency department with a chief complaint of worsening shortness of breath. She tested positive for COVID-19 nine days prior to admission after developing headaches and rhinorrhea. Her symptoms worsened and she was evaluated in the emergency department five days prior to admission with complaints of shortness of breath, cough, fever, nausea, and vomiting. A chest radiograph was taken at this time . A physical exam revealed diffuse rhonchi in the bilateral lungs. The patient was tachycardic and febrile meeting sepsis criteria and was started on intravenous fluids, ceftriaxone, and azithromycin. Neurological examination revealed no focal deficits. She was admitted for COVID-19-positive acute respiratory failure with hypoxemia and sepsis treatment.Upon admission, she received 100mg remdesivir. Due to worsening respiratory status and progressive respiratory failure, the patient was intubated and placed in a RotoProne bed on day 2 of hospitalization. Examination of the patient on hospital day 4 revealed new-onset petechiae covering parts of her upper back and bilateral upper arms with noticeable patchy bruising. A complete blood count (CBC) revealed her platelets dropped to 60 and hemoglobin dropped to 10. Coagulation labs showed D-dimer >5250, fibrinogen 161, activated partial thromboplastin time (aPTT) 41.6, and prothrombin time (PT) 14.6. Peripheral blood smear showed no schistocytes. To manage thromboembolic complications associated with COVID-19, 300mg aspirin suppository was administered starting hospital day 4. Enoxaparin 40mg was later added to this regimen beginning hospital day 7 in addition to the discontinuation of remdesivir due to the completion of therapy.On hospital day 9, due to erratic changes in blood pressure, there was a concern for intracranial pathology. Magnetic resonance imaging (MRI) of the head was performed Figure .Enoxaparin dose was increased to 80mg. Extubation occurred on day 12 of hospitalization. Subsequent neurological examination revealed spontaneous eye-opening, however, she did not follow commands but did withdraw to pain. She had considerable recovery of neurological function in the following days but significant right hemiparesis remained. She was discharged to an acute rehab facility. While current evidence surrounding COVID-19 prognosis is limited, preliminary data have suggested certain clinical biomarkers have been associated with a critical illness. C reactive protein >200, oxygen saturation <88% at admission, and D-dimer level >2,500 were found to have a stronger association with severe illness compared to age or presence of comorbidities . Recent One of the theories that best represents the development of thrombosis can be explained using Virchow's triad which describes three major contributors to clot formation. These include endothelial injury, stasis of blood flow, and alterations in factors involved in the coagulation cascade leading to a hypercoagulable state . CurrentThere have been reports of ischemic stroke occurring in patients with COVID-19. Significantly, some cases have been in adults younger than 50 years old with no associated cardiovascular risk factors . DespiteHypercoagulability is a severe complication that occurs in patients with COVID-19. There is an increasing number of cases reporting a novel thrombotic syndrome associated with COVID-19. This syndrome appears to emulate disseminated intravascular coagulation (DIC)-like clinical picture with mild thrombocytopenia and elevated fibrinogen levels . HoweverThe primary pathogenesis of TMAs is driven by profound complement activation resulting in thrombotic events with very rare associated bleeding episodes . PrelimiOwing to the novelty of the prothrombotic state induced by COVID-19, management can be challenging for clinicians. Anticoagulation recommendations for both prophylaxis and therapy are currently being developed, however, due to limited data, there are no universal guidelines. Thromboprophylaxis with low molecular weight heparin (LMWH) is recommended for intubated COVID-19 patients in the intensive care unit as this has shown evidence of improved survival . FurtherOutcomes and prognosis for COVID-19 infections in rheumatic patients are currently being investigated and are poorly understood. There is a concern for this population of patients due to their immunocompromised status. The American College of Rheumatology has created a task force to follow the rapidly evolving data and will continue to update its guidelines for the management of rheumatic patients as new evidence emerges [Our patient was on chronic hydroxychloroquine therapy for the treatment of rheumatoid arthritis. Notably, hydroxychloroquine therapy was held upon initiation of remdesivir therapy. There has been debate on the use of hydroxychloroquine and its outcomes in COVID-19 infection. In a review of the current literature, there is no conclusive pharmacologic treatment regimen that improves mortality in patients with COVID-19. Clinical trials with hydroxychloroquine have not provided evidence to support its efficacy in prophylaxis in patients with COVID-19 .COVID-19 infection has induced a worldwide pandemic that has affected thousands of individuals of numerous age groups, risk factors, and medical histories. Infection of COVID-19 in young, relativity healthy individuals manifests as a mild and transient respiratory illness. An associated systemic thrombotic syndrome leading to a cerebrovascular accident is a rare and unique COVID-19 manifestation that can potentially lead to severe disability and death.


Others have argued that democraticgovernments have generally failed relative to more autocratic ones, simplybecause autocrats can make the hard choices required for stemming the spreadof viruses. We address this question by asking whether more ‘egalitarian’forms of democracy matter, given that they contain more equitablehealth-care access We use standard regression techniques, including instrumental variablesanalysis addressing endogeneity on COVID-19 testing and deaths data as ofthe end of May and beginning of September. We use novel data from theVarieties of Democracy Project on health-system equity and egalitariandemocracy.Our results suggest that more equitable access to health care increasestesting rates and lowers the death rate from COVID-19. Broader egalitariangovernance, measured as egalitarian democracy, however, shows the oppositeeffect. Thus, factors associated with health-care capacity to reach andtreat matter more than broader societal factors associated with socialcapital and trust. The results are robust to alternative testing procedures,including instrumental variable technique for addressing potentialendogeneity.Despite a great deal of public health focus on how equitable governance helpsfight the adverse effects of so-called neoliberal pandemics, we find thatbroadly egalitarian factors have had the opposite effect on fightingCOVID-19, especially when an equitable health system has been taken intoaccount. Fighting disease, thus, might be more about the capacity of healthsystems rather than societal factors, such as trust in government and socialcapital. High inequality undermines social cohesion, erodes public trust, and deepenspolitical polarization, all of which negatively affect governments’ abilityand readiness to respond to crises. This explains why the United States,Brazil, and Mexico account for nearly half of the world’s reported deathssince the start of the pandemic. The celebrated economic historian, Barry Eichengreen, suggests that the black–whitedisparity in COVID-19-related deaths in the USA can be traced directly todifferences in welfare policies, which in turn can be blamed on racism and societalinjustice ,3. Jeffr1 which contains greater equality in the distribution of political powerresources, has greater inclusivity in political decisions and provides broadbasedaccess to public goods, including health, generates favourable outcomes regardingthe COVID-19 pandemic. Naturally, more egalitarian governance contains moreequitable health systems, with greater capacity for reaching and treating people,thus stemming the spread of the virus. Using data on COVID-19 testing and deathrates, we examine to what extent COVID-19-related outcomes might be explained byhealth-system ‘capacity’ compared to broadly egalitarian social and politicalgovernance. We also assess how an accessible health system conditions specificpandemic-targeting policy, such as testing policy and the stringency of lockdown, onCOVID-related deaths.Indeed, a number of celebrated public-health scholars argue that the lack ofinclusive, pro-poor governance is at the heart of the spread of many epidemics, suchas obesity, drug abuse and even homicide –7. TheseFor illustrative purposes, consider the examples of Taiwan and Sweden. Taiwan ishardly a Scandinavian-style democracy but has a capable health system where allcitizens, and foreign residents (for at least six months), are entitled to agovernment insurance plan. Thus, an equitable and capable health system perhapsexplains the country’s success in containing the virus, not necessarily broad-basedequity. Similarly, Australia has a relatively equitable health-care system, even ifa Scandinavian-style welfare state is absent . AustralIn the case of Sweden, it was argued that broad societal trust and social capitalwould be a critical factor in controlling the virus without much need forextraordinary measures . Sweden’2 The equality of access to health care, however, is very similar across thesecountries, as are broad welfare policies and democratic inclusivity, whichsupposedly lead to high social capital and political trust. This comparison mightindicate that health-care equity matters for fighting disease not because of thebroader societal implications of societal trust in an egalitarian democracy, butrather because access to health care simply captures organisational capacities ofhealth-care systems3 to deal more effectively with a pandemic. The governments of Vietnam, NewZealand and South Korea invested heavily in critical health-care facilities, andperhaps, as a result, had the capability to respond effectively to the COVID-19crisis purely from the perspective of health-system capacity rather than the broadsocietal equity associated with strong welfare states [The Swedish expectation, however, has not been met. When taken as a proportion ofeach country’s population, the numbers show that Sweden had 10.3% infections and0.06% deaths compared to 0.023% infections and 0.002% deaths from COVID-19 inNorway. Thus, Sweden shows a death rate 30 times greater than Norway’s. Similarly,Finland, Iceland and Denmark also show much smaller death rates compared to Sweden.e states . CompareEquality and justice are goods in their own right, and they are usually identifiedwith democracies. However, not all democracies are the same ,14. How Hypothesis 1: Equality in access to health care reduces the societalimpact of health pandemics.4Hypothesis 2: Health-care equity should matter more than broadegalitarian governance for reducing the harm from healthpandemics.Supplemental Table A1 for the list of countries). COVID-19testing and death rates were measured on 25 May 2020. The correlation betweenthe May data and data for 25 June is almost identical atr=0.96, suggesting that the cross-sectional variation remainedsteady over a month of measurement. We also tested the data accumulated up tothe month of September. We estimated the following equation: We utilised a cross-section of data for 210 countries (see COVID)c captures COVID-19 tests per million (log) and COVID-19 deaths per million(log) in country c as of 25 May 2020.5 The Worldometers data are real-time data that are also the main sourcefor the Coronavirus Government Response Tracker maintained by Oxford Universityand utilised by several others [6cHCE measures the extent of equity in health care incountry c. The Varieties of Democracy (V-Dem) project measuresthe degree to which any given country at any given point in time provides accessto adequate health care for the poor that is comparable to the health careaccessed by the rich. The V-Dem egalitarian democracy index includes severalaspects of equity that measure the equality in distribution of political powerin any given society in terms of gaining access to government and to resourcesthat empower people politically and enable all people to participatemeaningfully [where ln and ameasure of government health-care expenditure as a share of gross domesticproduct (r=0.69), as well as with the Global Burden of Diseaseproject’s indicator of health access and quality index (r=0.84).7The expert codings are subject to rigorous scrutiny and testing using itemresponse theory that reduces uncertainty and assigns a single value to eachcountry for each year. The ordinal coding is then transformed to be an intervalscale indicator suitable for analysis across countries. Equality of access tohealth shows a strong correspondence with the World Bank’s World DevelopmentIndicators (WDI) data on infant mortality rate . Equalprotection implies that the state grants and protects rights and freedoms evenlyacross social groups . They arAdditionally, we tested the conditional effects of two government policy stancestowards fighting the COVID-19 pandemic with our two main variables of intereston the outcome measured as deaths per million. The first of these two broadpolicy stances, government testing policy, is an index developed by OxfordUniversity researchers . The indcZ) included other potential determinants of COVID-19 outcomes that mightbe related with our main variables of interest. We included the level ofdevelopment measured as per capita income in 2010 US dollar constant pricesobtained from the World Bank (2019). Income level has a bearing on COVID-19tests and deaths via its impact on health-care equity, as richer countriesshould have greater demand for social equity and have higher infrastructuralcapacity. Next, we included a measure of urbanisation (percentage share of urbanpopulation), as studies show that the transmission of COVID-19 is higher inurban centres because of the ease of transmission and contraction due to travel,connection to outside world and so on, and urbanisation relates to the nature ofegalitarian processes associated with modernisation [c sourced from the WDI data platform because research shows that thefatality rate from COVID-19 rises sharply with age due to co-morbidities [Supplemental Table A3, and the details on definitions and datasources are provided in Supplemental Table A4. We limited the controls in order to avoidover-fitting the data. We estimated ordinary least square (OLS) specificationsthat include Huber–White corrected standard errors robust to heteroskedasticity.We added geographic regional dummies (rλ) to account for regional heterogeneity which may hide timeinvariant local-level factors, such as climate, geographic distances andcultural practices that influence the spread of disease.The vector of control variables =0. Itshould not have any direct effect on the outcome variable of interest – COVID-19tests and deaths – except through the institutional channel. Our instrumentsatisfies these conditions, as noted by the F-test andKleibergen–Paap F-statistic.It is plausible that health-care equity is an outcome rather than cause of poorhealth, or if both outcome and the independent variable were explained by someunmeasured higher-order variable. This issue is not trivial, since those whoargue that health-care equity affects how the system responds to healthpandemics also make causal claims ,21. To atatistic . The secAs seen there, equal access to health care has a positive impact on COVID-19 tests,which is significantly different from zero at the 1% level. Furthermore, column 2shows that equity in health-care access has a negative effect on COVID-19 deaths,which is statistically significant at the 5% level. Interestingly, egalitariandemocracy is negative on tests and positive on deaths at conventional levels ofstatistical significance. These results are robust across the columns in The substantive effects are large. A standard deviation increase above the mean valueof health-care access yields a 1.31% increase in COVID-19 tests per million (log),which is roughly two-thirds the standard deviation of our dependent variable. Astandard deviation increase above the mean value of the health-care equity index isassociated with a 0.38% decrease in COVID-19 deaths per million (log), which isroughly 20% of the standard deviation of the dependent variable. Similarly, astandard deviation increase of egalitarian democracy above the mean reduces COVID-19tests by 15% of a standard deviation of COVID-19 testing and 26% of a standarddeviation of the death rate. These results are substantively quite large.With respect to controls, both per capita income and urban population share showpositive effects on tests. Interestingly, while the effect of income on COVID-19deaths is positive, the effect of urbanisation, especially on deaths, remainsstatistically not significant. These results are intuitive, as richer countries havehad higher exposure. It seems that the greater egalitarian values and processescontained within egalitarian democracies do not distinguish them from otherdemocracies, since some studies have found that higher democracy measured instandard ways is also associated with higher COVID-19 deaths . Notice F-statistic from the firststage rejects the null that the instrument selected is not relevant. In fact, weobtained a higher joint F-statistic and a Kleibergen–Paap statisticon both estimation models reported in column 3, which remains significantlydifferent from zero at the 1% level. Taken together, our results on the impact ofequity in health-care access remain robust to alternative estimation techniques andendogeneity concerns. The results of the control variables are roughly the same asthose reported in columns 1 and 2.In columns 3–6, we present the results with instrumental variable (IV) estimations.Notice that the results in columns 5 and 6 are estimated with the newly released 7September data on COVID-19 tests (column 5) and deaths (column 6). While columns 3and 5 report the results of COVID-19 tests, columns 4–6 capture COVID-19 deaths.There are three observations to be drawn from these results. First, the IVestimation results of health-care equity on COVID-19 tests per million in columns3–5 and deaths per million in columns 4–6 are similar to those reported in ourbaseline estimates in columns 1 and 2. Second, as seen from columns 3–6, not onlyare the effects of health equity statistically significant, but the impact is large.Third, notice that the additional statistics provided in columns 3–6 in In t-test on the coefficient of the interaction term is notsufficient to examine whether the interaction term is statistically significant[As seen in column 1, our interaction term is positive but statistically not differentfrom zero. The health-care equity index on its own (i.e. when the testing policy is0) has a positive and statistically significant effect on COVID-19 tests permillion. However, it is important to note that the interpretation of the interactionterms even in linear models is not so simple. Consequently, a simplenificant. In FiguThe graph on the left of y-axis of the graph on the right (The conditional effect of health-care equity and the stringency index presented incolumn 2 of he right  shows thy-axis of x-axis. In column 3 of There seems to be a large body of literature in public health blaming neoliberalepidemics for damaging health outcomes – arguments that have resurfaced followingthe COVID-19 outbreak ,9.MortaOur results support others that suggest that building an equitable health systemincreases capacity for fighting disease. In a study of the USA, Williams and Cooper argue thClick here for additional data file.Supplemental material, sj-pdf-1-sjp-10.1177_1403494820982106 for Health-systemequity, egalitarian democracy and COVID-19 outcomes: An empirical analysis byKrishna Chaitanya Vadlamannati, Arusha Cooray and Indra de Soysa in ScandinavianJournal of Public HealthClick here for additional data file.Supplemental material, sj-xlsx-1-sjp-10.1177_1403494820982106 for Health-systemequity, egalitarian democracy and COVID-19 outcomes: An empirical analysis byKrishna Chaitanya Vadlamannati, Arusha Cooray and Indra de Soysa in ScandinavianJournal of Public Health


During the COVID-19 pandemic, gay and other men who have sex with men (MSM) in the United States (US) report similar or fewer sexual partners and reduced HIV testing and care access. Pre-exposure prophylaxis (PrEP) use has declined. We estimated the potential impact of COVID-19 on HIV incidence and mortality among US MSM.We used a calibrated HIV transmission model for MSM in Baltimore, Maryland, and available data on COVID-19-related disruptions to predict impacts of data-driven reductions in sexual partners, condom use(5%), HIV testing(20%), viral suppression(10%), PrEP initiations(72%), PrEP use(9%) and ART initiations(50%), exploring different disruption durations and magnitudes. We estimated the median  change in cumulative new HIV infections and deaths among MSM over one and five years, compared with a scenario without COVID-19-related disruptions.A six-month 25% reduction in sexual partners among Baltimore MSM, without HIV service changes, could reduce new HIV infections by 12·2% and 3·0% over one and five years, respectively. In the absence of changes in sexual behaviour, the six-month data-driven disruptions to condom use, testing, viral suppression, PrEP initiations, PrEP use and ART initiations combined were predicted to increase new HIV infections by 10·5% over one year, and by 3·5% over five years. A 25% reduction in partnerships offsets the negative impact of these combined service disruptions on new HIV infections , 0·0% over one, five years, respectively), but not on HIV deaths , 2·6%). The predicted impacts of reductions in partnerships or viral suppression doubled if they lasted 12 months or if disruptions were twice as large.Maintaining access to ART and adherence support is of the utmost importance to minimise excess HIV-related mortality due to COVID-19 restrictions in the US, even if accompanied by reductions in sexual partnerships.NIH In late April, reduced HIV and STI testing were reported in Baltimore, with many health department staff focussing on the COVID-19 response.11 MSM in the US – among whom 70% of new HIV infections occur nationally – reported fewer sexual partners because of COVID-19 in two national surveys10, but slightly increased or stable partner numbers in two other surveys,18 all conducted in April-May 2020. In these surveys, MSM also reported reduced access to HIV testing,17 care2 and PrEP17 due to COVID-19. Although HIV and bacterial STI screening at a Boston community health centre decreased by 81% early in the pandemic, gonorrhoea and chlamydia test positivity rate increased, suggesting ongoing risk-taking behaviour by a subset of the population.12In the US, COVID-19 prevention and mitigation programs have included stay-at-home orders and venue closures that may limit access to in-person medical care and opportunities to meet sexual partners in other households.19 Modelling for the US suggests that offering HIV testing alongside SARS-CoV-2 testing could reduce HIV incidence.8In the United Kingdom, an HIV testing campaign was launched encouraging MSM and other groups at risk of HIV acquisition to test for HIV during lockdown using home-testing kits, to take advantage of temporary reductions in sexual risk behaviour and hoping to break chains of HIV transmission.We used mathematical modelling together with MSM-specific survey and clinic data to estimate the potential impact of the COVID-19 pandemic and responses to it on new HIV infections and HIV-related deaths among MSM in Baltimore, and to identify where HIV prevention and treatment efforts should be focussed during the COVID-19 epidemic to most effectively mitigate negative impacts of COVID-19 on HIV transmission and survival for this population. We assessed the extent to which reductions in sexual risk behaviour might offset the impacts of reduced access to HIV care and prevention. We also estimated the potential impact of a hypothetical HIV testing campaign during lockdown in this setting.20 to include PrEP use. Briefly, the modelled population is divided into mutually exclusive compartments, stratified by age, race, PrEP use, HIV infection stage, setpoint viral load, and HIV care engagement. In the model, HIV transmission occurs through main, casual and commercial sexual partnerships, as a function of numbers of sexual partners, sex acts per partnership, condom and PrEP use, and HIV infection and ART status of sexual partners. Model equations, schematics, and detailed descriptions are given in the We adapted a previously-published deterministic, compartmental model of sexual HIV transmission and treatment among US MSM,20 Briefly, the model was parameterised with demographic, sexual risk behaviour and HIV testing data from National HIV Behavioral Surveillance (NHBS) data for MSM in Baltimore (2004–2014), and fitted to demographic, HIV prevalence and ART coverage data from Baltimore MSM NHBS and Maryland Department of Health data on HIV care access and viral suppression for Baltimore MSM, using a Bayesian approach. From this we obtained 169 unique parameter combinations (‘fits’) giving outputs consistent with HIV prevalence, demography and ART coverage/viral suppression data trends. For the current analysis, we parameterised age- and race-specific PrEP adherence and dropout using US PrEP Demo Project data21 and calibrated the existing 169 model fits to NHBS PrEP coverage estimates, by adjusting PrEP uptake rates. Key parameters and care continuum levels in the model fits are given in The model has previously been calibrated to data for MSM in Baltimore.The base case scenario – to which COVID-19 disruption scenarios are compared – represented the expected course of the HIV epidemic over time if the COVID-19 pandemic and related disruptions had not occurred. Rates of HIV testing, ART and PrEP initiation, adherence and dropout, sexual partner change and condom use were all assumed to be maintained at their 2019 level from 2020 onwards. Levels of viral suppression and PrEP use increase over 2020–2025 in the base case scenario  due to d10 conducted while stay-at-home orders were in place (in April/May 2020) and asking about COVID-19-related changes to sexual health, sexual risk behaviour and HIV prevention and care , but the studies did not ask how many fewer partners they had. As those reporting fewer partners may still have sexual partners, we explored overall reductions in numbers of all types of sexual partners of 25% and 50% . As two other online surveys of US MSM found no change in numbers of casual sexual partners18 or slight increases in total but no change in unprotected sexual partner numbers,17 we also considered scenarios with no change in partner numbers. We modelled observed reductions in PrEP initiations, PrEP use and HIV testing among those on PrEP, based upon a study at a Boston PrEP clinic.12 Where possible, we used any age- and/or race-stratified estimates from these studies to inform age- and race-specific estimates for these disruptions .These changes were represented in the model by reducing rates of HIV testing, ART and PrEP initiation, and levels of condom use and partner numbers by the estimated amount. Reductions in PrEP use were based upon data on PrEP refills at a Boston PrEP clinic,In our main analysis, we modelled the impact of a six-month disruption due to COVID-19, assuming all disruptions were reversed at the end of the period, with parameters reset instantaneously to their pre-disruption levels.We assessed the impact of each disruption separately and in combination.We tested the sensitivity of our findings to the magnitude of the different disruptions, comparing the individual impacts of 10%, 25% and 50% reductions in partner numbers, condom use, PrEP use and viral suppression, and 50%, 75% and 100% reductions in ART and PrEP initiation rates and HIV testing on and off PrEP. We also explored the impact of three- and 12-month disruptions.19 which aimed to capitalise on temporary declines in sexual activity and HIV transmission to identify those with undiagnosed HIV and prevent further HIV transmission. We modelled this testing campaign alongside plausible COVID-related disruptions to (a) sexual partner numbers only or (b) sexual partner numbers, ART initiation, viral suppression, PrEP initiation, PrEP use and condom use, for a six-month period. We simulated HIV testing campaigns in which 90% of MSM tested at least once during the six-month disruption period, after which HIV testing rates returned to pre-disruption levels.We assessed the expected impact of an HIV testing campaign during lockdown, based on the UK Test Now, Stop HIV campaign,We estimated short-term (one year) and long-term (five year) impacts of COVID-19 on cumulative new HIV infections and HIV-related deaths measured from the start of COVID-related disruptions. Impacts were calculated relative to the base case scenario and expressed as absolute or percentage change.The transmission model was coded and run in C++ and calculations were conducted using R version 3.6.2.We first assessed the impact of data-driven six-month COVID-related disruptions on the number of new infections  and HIV-Without any change in sexual behaviour, the six-month disruptions to testing, ART initiations, viral suppression, PrEP initiations, PrEP use and condom use combined were predicted to increase new HIV infections by 10·5%  over one year, and by 3·5%  over five years. The impact of these combined disruptions could be outweighed by a concurrent six-month 25% reduction in partner numbers  and 9·5%  more HIV-related deaths over one year, respectively, with substantial uncertainty . The othFor individual disruptions, we found each of the following: a 10% reduction in partner numbers, 25% less condom use, or a 10% reduction in viral suppression, could alter the number of new HIV infections over one year by more than 5% . In contPredicted impacts on infections and deaths were proportional to the magnitude of reduction in sexual partnerships, condom use, viral suppression, and PrEP initiation –d. ImpacThe predicted impact of disruptions affecting partner numbers, condom use, viral suppression and PrEP use on new HIV infections also varied proportionately with disruption duration, measured over both one and five years –d. ImpacIf COVID-19 restrictions only reduced sexual activity, by 25%, without impacting HIV care and prevention services, then successfully testing 90% of MSM at least once during the six-month COVID-related disruption may avert 3·7pp  and 2.9pp  additional new infections over one or five years in addition to the infections averted by reduced partner numbers ,b. HowevOur modelling results predict that modest reported COVID-19-related disruptions to HIV testing, PrEP use, condom use and viral suppression, and larger disruptions to PrEP and ART initiations, without any change in sexual risk behaviour (as suggested by some surveys), could lead to substantial short-term increases (11% over one year for a six-month disruption) in new HIV infections and HIV-related deaths among Baltimore MSM. Our results suggest a 25% or 50% reduction in sexual partner numbers (consistent with other survey data) could offset increases in new HIV infections arising from COVID-19-related disruptions to HIV services, but would not offset additional HIV-related deaths caused by these service disruptions. Together, these six-month service disruptions alongside a 25% reduction in partner numbers are predicted to give little change in new HIV infections (−4% over one year and 0% over five years). However, even with a 50% reduction in partner numbers, these same disruptions may still give rise to substantial short-term increases in HIV-related deaths .Our sensitivity analysis suggests disruptions to viral suppression and condom use would have the greatest adverse effects on new HIV infections, while reductions in viral suppression and new ART initiations could lead to the most HIV-related deaths. Even a 10% reduction in viral suppression among those on ART, lasting six months, would lead to ≥5% increases in both new HIV infections and deaths over the following year. Condom use would need to be reduced by 25% to cause a 5% increase in new HIV infections. ART initiations would need to cease completely for six months to bring about a 5% increase in annual HIV-related deaths. Increasing the duration of disruptions to viral suppression and condom use from six to 12 months could double their impact on both HIV infections and deaths, as could doubling the size of each disruption. Finally, we find a widespread HIV testing campaign during lockdowns in this setting is likely to have only a small incremental impact on HIV incidence, due to concurrent disruptions to ART, PrEP and condom use.23 particularly for homeless individuals.15 Although US MSM report only minimal reductions in condom use due to COVID-19,2 our sensitivity analysis suggests maintaining condom use will be important to prevent extra HIV transmission.Our results suggest that, during COVID-19-related restrictions, HIV prevention and treatment efforts should be focussed upon maintaining access to ART and ART adherence support for both new and existing users, to minimize negative impacts of COVID-19 on new HIV infections and, especially, HIV-related mortality. Multi-month ART dispensing and tele-health services may be sufficient to help ART users who are already stably virally suppressed maintain suppression during lockdown. Triaging to prioritise in-person care and viral load tests to new or less stably-suppressed ART patients will also be needed,23 Conversely, HIV service access could be hampered by loss of employer-provided health insurance as COVID-19 leads to increased unemployment.2 Loss of health insurance may be particularly detrimental in states which have not passed the Affordable Care Act. However, ART should be available through the Ryan White Care Program or AIDS Drug Assistance Programs.There is uncertainty about the magnitude and durations of disruptions to HIV prevention and treatment services, and how these may change during the COVID-19 pandemic. Going forwards, service provision could improve as services adapt.24 Modelling for Atlanta MSM suggests substantial increases in HIV incidence will occur if service disruptions last longer than sexual behaviour changes.7There is also uncertainty about how long any reductions in sexual risk behaviour may last. A study among Southern PrEP-using MSM found sexual risk-taking increasing in June 2020 following earlier reductions.We find smaller but more persistent impacts (still sizeable after five years) following disruptions to rates of HIV testing, ART and PrEP initiation compared with disruptions to partner numbers and viral suppression. Changes to HIV testing or ART/PrEP initiations rates lead to smaller but longer-lasting changes in diagnosis and ART/PrEP coverage levels, while changes to partner numbers or viral suppression lead to larger direct changes, which we assume rapidly reverse after the disruption period. Post-disruption catch-up campaigns could reduce the longer-term impacts of COVID-19-related disruptions to HIV testing, ART and PrEP initiations.27 In agreement with our results, these studies all suggest the largest detrimental impact will be due to ART disruptions , with disruptions to condom use, HIV testing and ART initiations having smaller impacts.27 In an analysis using five different African models, a six-month interruption to ART for 50% of the population was predicted to give a median 9% (range 6–126%) more new HIV infections and 63% (39–87%) more HIV-related deaths over the following year.6 Our US estimates for a 50% reduction in viral suppression  fall within these ranges. A recent modelling study estimated the impact of COVID-19-related disruptions on HIV incidence among MSM in Atlanta.7 Like us, they found reductions in sexual partnerships could offset the impact of service disruptions on new HIV infections, and PrEP reductions had less effect than ART reductions, partly due to low PrEP coverage (15% in Atlanta).7 Another modelling study assessing impacts on HIV incidence in six US cities including Baltimore similarly found that reductions in sexual partnerships could offset health service reductions.8 However, in contrast to our findings, they projected substantial reductions in HIV incidence would result from expanded HIV testing in Baltimore during COVID-19-related disruptions – this larger impact may arise from testing among heterosexual populations, who have lower HIV testing rates than MSM, and/or because lower levels of awareness of HIV-positive status were assumed (e.g. 78% among MSM vs. 74–95% in our study).8Several modelling studies have estimated the impact of COVID-19-related disruptions on HIV in sub-Saharan Africa.10 and a Boston study;12 disruptions may differ between states due to different levels of COVID-19, COVID-19 response measures, and health funding. Therefore, we may not have captured the true impact of COVID-19 among Baltimore MSM. Our impact estimates may not be directly applicable to other US locations with different HIV epidemics and services although we expect qualitative insights from our model to still be useful. Our predicted small impact of an HIV testing campaign during lockdown may partly be due to high HIV testing rates already occurring in many of our model fits ; we predict larger impacts for populations with lower HIV testing rates. Our small predicted impacts of disruptions to PrEP use may be partly due to low PrEP use among Baltimore MSM (12% in 2017) – larger impacts may be seen in places with greater PrEP use, such as Boston, Chicago, or San Francisco.28 We assume reductions in PrEP use and partner numbers occur independently, whereas MSM may be ceasing PrEP use while abstaining from sex or those apparently lapsing may be switching to non-daily use.29 In this case, our analysis may overestimate negative impacts of PrEP disruptions. Finally, we do not account for mortality directly caused by COVID-19; we may underestimate mortality impacts as COVID-19 outcomes are worse among patients with co-morbidities or low CD4 counts.30While our analysis maximised the use of currently available data on the impacts of COVID-19 on HIV prevention and care and sexual risk behaviour for US MSM, including age- and race-specific data, it has some limitations, chiefly due to uncertainty about the exact magnitude and duration of these disruptions. Many of the data informing disruption sizes were collected at a single time-point, and do not capture changes as the COVID-19 pandemic progressed, as discussed above. Some estimates were only semi-quantitative, for example, 50% of MSM reporting fewer partners does not tell us how many fewer partners they had overall. We found no data on reductions in ART initiations. However, our sensitivity analysis explored the impact of different disruption levels and durations. Our HIV transmission model was calibrated to Baltimore, but estimates of disruption magnitude were based on national surveysIn conclusion, maintaining access to ART and adherence support for those on treatment and those newly diagnosed is crucial to minimise excess HIV-related mortality due to COVID-19-related restrictions in the US. Reductions in viral suppression of 10% could have negative consequences for both HIV incidence and mortality and any declines in sexual risk behaviour would only offset incidence, but not mortality increases. It will be important to collect quantitative data on COVID-19-related effects from multiple time-points and settings, to improve modelling estimates and inform public health decisions. Modelling assessing the impacts of post-COVID ‘catch-up’ campaigns is needed to inform healthcare priorities as restrictions are lifted.Supplement 1


The coronavirus disease 2019 (COVID-19) pandemic is a major threat to the public. However, the comprehensive profile of suicidal ideation among the general population has not been systematically investigated in a large sample in the age of COVID-19.A national online cross-sectional survey was conducted between February 28, 2020 and March 11, 2020 in a representative sample of Chinese adults aged 18 years and older. Suicidal ideation was assessed using item 9 of the Patient Health Questionnaire-9. The prevalence of suicidal ideation and its risk factors was evaluated.A total of 56,679 participants  were included. The overall prevalence of suicidal ideation was 16.4%, including 10.9% seldom, 4.1% often, and 1.4% always suicidal ideation. The prevalence of suicidal ideation was higher in males (19.1%) and individuals aged 18–24 years (24.7%) than in females (14.0%) and those aged 45 years and older (11.9%). Suicidal ideation was more prevalent in individuals with suspected or confirmed infection (63.0%), frontline workers (19.2%), and people with pre-existing mental disorders (41.6%). Experience of quarantine, unemployed, and increased psychological stress during the pandemic were associated with an increased risk of suicidal ideation and its severity. However, paying more attention to and gaining a better understanding of COVID-19-related knowledge, especially information about psychological interventions, could reduce the risk.The estimated prevalence of suicidal ideation among the general population in China during COVID-19 was significant. The findings will be important for improving suicide prevention strategies during COVID-19. Suicide is a significant global public health problem that occurs across lifespans. According to the World Health Organization, one person dies of suicide every 40 s . In addiSuicidal behaviors are multifactorial and involve complex interactions between biological and environmental determinants . Among tThe epidemic of communicable disease, as a major life stressor in both cases and surrounding people, can have profound impacts on mental health . HoweverIn December 2019, coronavirus disease 2019 (COVID-19) characterized by high contagiousness and rapid transmission occurred . The WorThe objectives of this study with a large nationwide sample were to explore the prevalence of suicidal ideation and its risk factors among the general population in China during the COVID-19 pandemic, and further provide evidence for suicide prevention under a public health emergency.An anonymous national cross-sectional online survey with convenience sampling was conducted from February 28, 2020 to March 11, 2020, during which time the cumulative cases of COVID-19 reached a peak in China. Users aged over 18 years of the Chinese website Joybuy, a large e-commerce and information service company that provides online health products and services, were invited to participate in this self-administered survey voluntarily until the convenience sample covered all 34 provincial-level regions in China. The detailed procedure was described in our previous publication . In brieInformation on demographic characteristics, COVID-19-related factors, psychological health literacy, and suicidal ideation were collected in this survey. Demographic characteristics included age, gender, location, marital status, educational level, and monthly family income. Questions pertaining to past history and family history of mental disorders, and history of sleep problems were also asked. The survey questions included inquiries into COVID-19 specific factors that may contribute to suicidal ideation, whether infected with COVID-19 or not, exposed to the most severely affected region recently, experiences of quarantine and unemployment, and participation in frontline work. Frontline work referred to work that had direct contact with confirmed cases of COVID-19 . In addiThe psychological information were evaluated in three domains: (a) perceived psychological stress before and after the COVID-19 pandemic using a visual analog scale, (b) seeking psychological knowledge following the COVID-19 outbreak, and (c) degree of access to information about psychological interventions during the pandemic. Item 9 of the Patient Health Questionnaire-9 was used to assess the presence of suicidal ideation as follows: “Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?” The response options were “not at all,” “several days,” “more than half the days,” and “nearly every day.” Suicidal ideation was defined as positive if respondents answered, “several days,” “more than half the days,” and “nearly every day,” or negative if answered “not at all” ,31. In aχ2 were used to assess statistical differences in categorical variables. The associations between suicidal ideation and relevant covariates were analyzed using the multivariable logistic regression model, and factors associated with the severity of suicidal ideation were examined using ordinal logistic regression analysis. In addition, the participants were divided into three groups based on their changes in psychological stress after the COVID-19 pandemic, and potential factors associated with suicidal ideation in each group were explored using multivariable logistic regression analysis. Multivariable adjusted odds ratios (ORs) with 95% CIs were reported. Data analyses were conducted using the SPSS 20 software. All tests were two-sided, with p-value less than 0.05, considered significant.Descriptive statistics were used to present demographic, COVID-19-related, and psychological data. Means with standard deviations were used to describe continuous variables, and numbers with percentages were used to describe categorical variables. The prevalence with 95% confidence interval (CI) of suicidal ideation in different demographic characteristics and COVID-19-related factors was reported by gender. Tests of In this national cross-sectional online survey, 56,679 participants  from 34 province-level regions were included in the final analysis. p < 0.001), and the prevalence significantly decreased from the 18 to 24 years group  compared to those aged 45 years or older  in participants with 12,000 RMB or higher monthly family income. Furthermore, people from areas with relatively low-income levels  reported a higher prevalence of suicidal ideation compared to those from high economic development areas. Individuals with a history of mental disorders  and sleep problems  had a higher prevalence of suicidal ideation than those without a history of mental disorders  or sleep problems . During the COVID-19 pandemic, individuals with confirmed or suspected infection by COVID-19  reported higher rates of suicidal ideation compared to uninfected individuals . Participants who were quarantined for more than 14 days  had a significantly higher prevalence of suicidal ideation than those without quarantine . Surprisingly, the prevalence of suicidal ideation was found to be higher in those who were partially quarantined than in those who completed it. Individuals with unemployment also showed increased suicidal ideation  compared to those without experience of unemployment . The prevalence of suicidal ideation in frontline workers  was significantly higher than those who were not in the frontline . However, individuals who had more access to psychological information after the COVID-19 outbreak  had a lower rate of suicidal ideation than those with less access .The overall prevalence of suicidal ideation was 16.4%  among the population surveyed during the pandemic. Males had a higher prevalence of various degrees of suicidal ideation  than females , living in the most severely affected region , experience of quarantine , unemployment , participating in frontline works , higher perceived psychological stress during the COVID-19 pandemic , and more difficulty in access to information about psychological interventions  were significantly associated with the increased risk of suicidal ideation, whereas paying more attention to information about COVID-19 pandemic , better understanding of COVID-19-related knowledge , and getting more access to knowledge about psychological interventions during the COVID-19 pandemic  were associated with lower odds of suicidal ideation.The ordinal logistic regression analysis identified several demographic and clinical characteristics and COVID-19-related factors that were associated with the various degrees of suicidal ideation, which were consistent with the variables related to the overall suicidal ideation (see Supplementary Table 2). In addition, some factors  were independently associated with the risk of suicidal ideation across different groups of distinct changes in psychological stress (see Supplementary Table 3), further validating the relationship of COVID-19 experiences and suicidal ideation.This study of a large nationwide sample from China found a relatively high prevalence of suicidal ideation among the general population during the COVID-19 pandemic. Several factors have been shown to be independently associated with increased risk for suicidal ideation and its various severities, including basic demographic and clinical characteristics , epidemic-related experience , and current psychological state . These findings provide a comprehensive profile of suicidal ideation in the general population during the COVID-19 pandemic, and suggest the importance of relevant mental health policy-making and suicide prevention in a public health emergency.Compared to previous infectious disease outbreaks, such as SARS and Middle East respiratory syndrome, COVID-19 is associated with faster contagion and affects more people . Fear ofThe results of this study showed that young adults and males are more vulnerable to experiencing various degrees of suicidal ideation compared to older populations and females. This is consistent with our previous findings that young people are more prone to depression, anxiety, insomnia, and acute stress, and males were vulnerable to depression, insomnia, and acute stress during the COVID-19 pandemic . It has In this survey, the experience of quarantine and unemployment was found to be associated with suicidal ideation across populations with different changes in psychological stress during the pandemic. To mitigate the rapid transmission of COVID-19 ,44, quarIn addition to quarantine, unemployment was also found in this study to increase the risk of suicidal ideation. Published suicide literature unrelated to pandemics has confirmed a direct relationship between unemployment and suicidal ideation , such thAttention to and knowledge of COVID-19-related information is another important factor in suicidal ideation. People who were more attentive to information on the pandemic and had a better understanding of its consequences had a lower prevalence of suicidal ideation. However, other researchers have reported a positive link between information exposure to COVID-19 and emotional distress . This diThis study, with a relatively large sample, systematically researched the profile of suicidal ideation in China during the COVID-19 pandemic. However, this study had several limitations. First, it was a cross-sectional study, and the causal relationship between multiple risk factors, such as quarantine and unemployment, and suicidal ideation could not be determined. Second, although item 9 of the Patient Health Questionnaire-9 is widely used to assess suicidal ideation ,59, a siIn conclusion, the prevalence of suicidal ideation in China during the COVID-19 pandemic was relatively high, particularly in cases of COVID-19, frontline workers, individuals with a history of mental health problems, those experiencing quarantine and unemployment, and those with poor health-related information. Provision of health information on infection as well as mental wellness is crucial to reduce the risk of suicidal ideation. These findings contribute to a greater understanding of suicidal behaviors during pandemics, help to identify at-risk populations, and lead to targeted prevention strategies. Longitudinal studies with a broader measurement of suicidal behaviors, as well as systematic evaluation of long-term outcomes are needed.


Despite the widespread application of activated carbon fiber (ACF) filters in air cleaning owing to their high surface area and low price, they have certain limitations in that they facilitate bacterial growth upon prolonged use as ACF filters can provide favorable conditions for bacterial survival. The deposition of cupric oxide (CuO) on ACFs can be an effective way of resolving this problem because CuO can inhibit the proliferation of bacteria owing to its antimicrobial properties. However, finding a new method that allows the simple and uniform coating of CuO on ACF filters is challenging. Here, we demonstrate one-pot CuO deposition mediated by polydopamine (PD) to realize an ACF filter with antimicrobial activity. Scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDS), and X-ray photoelectron spectroscopy (XPS) analyses reveal that CuO and PD are uniformly deposited on the ACF surface. The amount of CuO formed on the ACFs is measured by thermogravimetric analysis (TGA). Finally, the changes in surface area, pressure drop, and antimicrobial activity after coating PD-CuO on the ACFs are evaluated. The use of PD-CuO on the ACFs effectively suppresses the growth of bacteria and enhances the mechanical properties without significantly sacrificing the original characteristics of the ACF filter. Activated carbon fibers (ACFs) are an activated carbon-based porous fibrous material with high adsorption properties. ACFs are made of various raw materials such as cellulose, phenolic resin, polyacrylonitrile, and coal tar pitch fibers ,2. Many Cupric oxide (CuO) is one of the metal oxides that show antimicrobial activity owing to the release of Cu ions which disrupt the local living environment of bacteria ,10. AlthMany different approaches have been adopted to deposit metals or metal oxides on fibrous surfaces . Electro2O nanoparticles prepared using thermal plasma technology . U. U1s peaps in PD d 34]. A. A1s peauO phase e 35,36],361s peauO phase . The foruO phase . The peathe ACFs ,38,39. A2/g) decreased with increasing deposition time due to the blockage of the micropores in the ACFs by PD and CuO. However, this blockage does not seem to be perfect considering the fact that once micropores are completely covered by PD and CuO, the surface area of ACF should be in the order of ~1 m2/g from the given fiber diameter (~2 μm) and density (~2000 kg/m3) of ACF. Thus, it is possible that the micropores could be partially covered by PD and CuO or some cracks in PD-CuO could have been generated during the drying process which allowed N2 to penetrate through the free surfaces during the BET measurements. Nevertheless, the degree of surface area decrease reduced after 2 h of deposition and almost no significant change was observed in the surface area after 6 h. This reflects the initial coating of PD-CuO mostly covered the micropores, and subsequent deposition only increased the thickness of the PD-CuO layer, which does not significantly affect the surface area of the ACF. The decrease in surface area from 2 h to 12 h was only 19.35%, for example. This is due to two reasons: i) the thickness increase is insignificant  for both kinds of bacteria. However, in the case of ACF@PD-CuO-12h, 99.9% of antimicrobial activities against both Gram-positive and Gram-negative bacteria were obtained. The antimicrobial activity was maintained as ~100% after a coating time of 4 h. We also confirmed the absence of any viable bacteria on ACF@PD-CuO after the antimicrobial test via ex-situ SEM measurements  for application as a filter with antimicrobial activity. PD and CuO were deposited simultaneously via the polymerization of dopamine and reduction of Cu ions without involving any toxic chemical processes. Compared with previous approaches to prepare the antibacterial filters which involved environmentally toxic Ag nanoparticles or difficult deposition processes, our method is much simpler, cost-effective, and environmentally friendly. The morphology and chemical properties of ACF@PD-CuO analyzed by scanning electron microscopy (SEM), transmission electron microscopy (TEM), energy dispersive spectroscopy (EDS), X-ray photoelectron spectroscopy (XPS), thermogravimetric analysis (TGA), and Fourier transform infrared (FTIR) spectroscopy revealed that a PD-CuO layer was successfully deposited on the ACFs. The prepared ACF@PD-CuO exhibited perfect antimicrobial activities against both Gram-positive and Gram-negative bacteria. After the introduction of PD-CuO, although the surface area  slightly decreased, the level of pressure drop remained almost unchanged. Moreover, the mechanical properties of the ACF were significantly enhanced after coating with PD-CuO, which served as reinforcements for the pristine ACFs. Overall, ACF@PD-CuO prepared by the simple one-pot coating method is a promising filter that can effectively inhibit bacterial growth without losing its various original merits.