The clinically indistinguishable overlap between pneumonitis caused due to immune checkpoint inhibition (ICI) and pneumonia associated with COVID-19 has posed considerable challenges for patients with cancer and oncologists alike. The cancer community continues to face the challenges that lay at the complex immunological intersection of immune-based cancer therapy and immune dysregulation that results from COVID-19. Is there compounded immune dysregulation that could lead to poor outcomes? Could ICIs, in fact, ameliorate SARS-CoV-2-driven T-cell exhaustion?A little more is known about the kinetics of the viral replication in immunocompromised patients now as compared with earlier during the pandemic. Working knowledge of the diagnostic and therapeutic nuances of SARS-CoV-2 infection in patients with active cancers, issues related to viability and replication potential of the virus, unclear role of corticosteroids among those with diminished or dysfunctional effector T-cell repertoire, and the type of immunotherapy with differential risk of pneumonitis will inform decision making related to immunotherapy choices and decision for ICI continuation in the era of COVID-19. The clinically indistinguishable overlap between pneumonitis caused by immune checkpoint inhibition (ICI) and pneumonia associated with COVID-19 has posed considerable challenges for patients with cancer and oncologists alike. The cancer community continues to face the challenges that lay at the complex immunological intersection of immune-based cancer therapy and immune dysregulation that results from COVID-19.The recent rise in COVID-19 cases globally, referred to as the second wave, along with the associated challenges, also brings in opportunities for improved care for patients undergoing ICIs. A little more is known about the kinetics of the viral replication in immunocompromised patients now as compared with earlier during the pandemic. Working knowledge of the diagnostic and therapeutic nuances of SARS-CoV-2 infection in patients with active cancers, issues related to the viability and replication potential of the virus, unclear role of corticosteroids among those with diminished or dysfunctional effector T-cell repertoire and the type of immunotherapy with differential risk of pneumonitis will inform decision making related to immunotherapy choices and decision for ICI continuation in the era of COVID-19.Cancer cells evade the host’s immunity by inhibiting immune effector cells, particularly cytotoxic (CD8+) T cells, by employing immune checkpoint pathways, such as programmed cell death-1 (PD-1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4). The ligands for PD-1, programmed cell death ligand 1 (PD-L1) and programmed cell death ligand 2‚ as well as the ligands for CTLA-4, B7-1 (CD80), and B7-2 (CD86), are upregulated in both solid tumors and hematological malignancies. Two PD-1 inhibitors (nivolumab and pembrolizumab), three PD-L1 inhibitors , and one CTLA-4 inhibitor (ipilimumab) have been approved by the US Food and Drug Administration (FDA) for a myriad of cancers.Theoretically, ICIs are assumed to have an immunostimulatory effect—unleashing effector T cells from checkpoint-mediated immunosuppressive tumor microenvironment and, hence, potentially leading to autoimmunity. However, the actual directional impact of ICIs on the immune system is unknown. In the real world, while ICIs have been used to treat chronic viral infections , caused by John Cunningham (JC) virus), there have also been reports that ICIs have led to the reactivation of latent tuberculosis and Epstein-Barr Virus (EBV)-driven idiosyncratic irAE.While ICI-related pneumonitis accounts for up to a third of all deaths caused by irAE, its risk and severity are not uniformly distributed. Pulmonary toxicity occurs at varying rates, and incidence and severity depend on the underlying tumor type, pre-existing pulmonary architecture, the type of ICI, the dosage and frequency, and whether the ICIs are used as monotherapy versus in combination .The severity of ICI-related pneumonitis is graded per the Common Terminology Criteria for Adverse Events V.4.03 and the management of respective grades are outlined elsewhere.EGFR mutation, prior receipt of chest radiotherapy, or history of treatment with tyrosine kinase inhibitors in combination with ICIs.MDM family and EGFR, may also be considered prior to the initiation of ICIs. The duration of onset of pneumonitis due to ICIs further varies and, again, depends on the ICI regimen and tumor type. Pneumonitis is more likely to develop earlier with NSCLC than with melanoma and with combination ICIs than with single-agent.Additionally, other clinical factors that ought to be considered when deciding on initiation or continuation of ICIs for patients who have recovered from COVID-19 or who are at risk of exposure or those who reside in areas with moderate to high community spread of COVID-19. Smoking is shown to be associated with an increased risk of ICI-related pneumonitis.ICI-related pneumonitis remains a diagnosis of exclusion and additional diagnostic studies must be considered. Key differential diagnoses, including infections, tumors, and other autoimmune processes, ought to be ruled out in a timely manner in order to allow prompt institution of appropriate management. In addition to the intersecting radiological features of the two disease entities, the overlapping histopathological features predominantly include diffuse alveolar damage and interstitial fibrosis.The delay in diagnosis is further compounded by reports of false-negative upper airway testing  and issues with sampling methods. The data, thus far, underscore a potentially distinctive viral shedding pattern in immunocompromised patients due to both an inability to contain the virus early  and an abundance of viral replication in the lower tract early .Evolving data have shown that patients with cancer undergoing active treatment have poor outcomes due to COVID-19. A recent study evaluating 3920 patients with cancer with COVID-19 showed an 18% 30-day mortality in patients who underwent immunotherapy within 1–3 months prior to COVID-19.‘caution is advised when applying published correlations of Ct values with disease severity or as a predictor of active infection and transmissibility,’ per the joint statement of the Infectious Diseases Society of America (IDSA) and the Association for Molecular Pathology (AMP) on the use of SARS-CoV-2 PCR Ct values for clinical decision-making.Patients with cancer are at risk of prolonged shedding of replication-incompetent virus, for many months in some cases.all cancer patients receiving approved or investigational immunotherapyas part of their treatment regimen, either as standard of care or as part ofclinical trials and without a general contraindication to vaccination, should/could receive an FDA approved and/or authorized SARS-CoV-2 vaccination whenmade available to them’While the optimal dosing and timing for COVID-19 vaccination remain elusive in patients with cancer, all patients undergoing active treatment should be considered as ‘highly prioritized’. While patients who have received B-cell depleting agents in the preceding months may not mount an adequate humoral immune response with standard dosing regimen, patients undergoing immunotherapy are theoretically likely to develop protective immunity with the standard dosing. Longitudinal studies examining antibody and cellular immune responses, as well as randomized trials evaluating safety and efficacy of vaccine in patients undergoing ICIs, are needed. Universally, the risk of nosocomial transmission should be minimized by vaccinating all healthcare workers caring for patients with cancer, and strict mitigation strategies should remain in place across cancer centers. Expert opinion of a committee of the Society for Immunotherapy of Cancer (SITC) recommends that ‘While there are no data, or any hypotheses that may be generated, on the differential efficacy and safety of different types of SARS-CoV-2 vaccines based on the differences in the manufacturing platforms/technology, any vaccine could hypothetically lead to an exaggerated immune response in ICI recipients. A non-randomized prospective study among ICI recipients, with 23 patients with lung cancer and 11 age-matched healthy controls, demonstrated a high rate of irAE (52%) occurring at a median time of 3 months after a trivalent inactivated influenza vaccine.As oncologists continue to face tough decisions while prescribing life-prolonging immunotherapy in an era when the COVID-19 pandemic puts these profoundly immunosuppressed patients at substantial risk of irAEs, it is imperative that an informed and consensus decision is reached between the provider and the patient. Both parties ought to be aware of the risks that the immunotherapy regimen poses and should weigh that against the benefit ICIs will confer in terms of the intent of treatment.


Pooled specimen screening for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can improve laboratory testing capacity. This study assessed the impact of pooling and retesting individual swabs on the overall detection rate and reduction in the frequency of retesting.® Xpress SARS-CoV-2 test kit. The optimum number of samples per pool was calculated using the application ‘A Shiny App for Pooled Testing’.One hundred respiratory swabs specimens were tested individually and in pools of three or five samples using the Cepheid’s XpertTwenty-five pools were generated from 101 samples. Out of 13 pools that contained five samples each, three pools gave true positive results. While out of the 12 pools that contained three samples each, five pools gave true positive results. Four samples gave a false negative pool result. The overall sensitivity and specificity of the assay in the pools were 66.6% and 100%, respectively. The cycle threshold was reduced in most of the pools compared to individual sample tests.The overall pooled test had a remarkable impact on laboratory resources. Yet, caution is warranted when selecting the cases for pooled testing, since the reduction in sensitivity can significantly impact and increase the risk of exposure to infection. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic instigated a huge impact on clinical microbiology laboratories and contributed to major challenges in the laboratory diagnosis. Considering the high infectivity of SARS-CoV-2, there is an urgent need for a rapid and accurate diagnostic assay for both clinical decisions and infection control purposes. Therefore, reverse-transcription polymerase chain reaction (RT-PCR) is considered the method of choice for diagnosing SARS-CoV-2 infection .Despite the commercial availability of these tests, testing load is unprecedented and remains greater than the laboratory personnel, materials and equipment resources. In order to conserve the resources and overcome their ongoing shortage, several diagnostic laboratories considered pooled testing strategy that was accepted later on by the US Food and Drug Administration (FDA) for diagnostic, screening and surveillance purposes . At the Generally, FDA stated that five is a reasonable specimen number for pooled testing for the initial validation process, given that the prevalence is 5%–6%. For populations with lower prevalence, a larger specimen number can be pooled. Although the pooled testing method appears to be cost-effective, it still has certain limitations. Hence, many important technical and clinical points need to be noted for pooled testing protocol. For example, pooling of different types of samples is not acceptable. Also, initial volume of the collected specimen needs to be sufficient enough for both pooled and individual testing. As pooling of samples is expected to reduce the analytical sensitivity, testing by pooling method needs to be clearly mentioned in the final laboratory report. Lastly, regular follow-up tests should be conducted to monitor the percentage of weak positive samples and the rate of positivity before and after applying the pooled testing strategy, while considering the possible delay in detecting a positive case .® Xpress system.To date, the available evidence for implementing pooled testing strategy is promising and suggests sufficient accuracy –8. To thThis study was conducted prospectively at King Fahd Hospital of the University (KFHU), which is a 550-bed secondary health care institution in Al-Khobar Saudi Arabia, which receives referral of critically ill COVID-19 suspected patients from all the surrounding regions, as well as ambulatory cases.The sample size was calculated as described previously . The fol® Xpress SARS-CoV-2 test kit  was used to test all clinical specimens according to the manufacturer’s instructions. It is a cartridge-based system for the detection of the target sequence E and N2 gene of sarbecovirus and SARS-CoV-2, respectively. Residual sample volumes were stored at 8 °C after initial testing and then used in our pooling study within 24 h after collection.Combined nasopharyngeal (NP)/oropharyngeal (OP) swab specimens were submitted to the diagnostic microbiology laboratory at the hospital by the emergency department (ED) or employee health clinic for SARS-CoV-2 testing by RT-PCR. The swab specimens were transported in viral preservative medium (VPM)  refrigerated and processed within 24 h of collection. The Cepheid’s XpertWe included clinical samples obtained from the COVID-19 low-risk group (score below 5) based on COVID-19 clinical visual triage scoring. Samples were enrolled in the study in the order of their receipt in the laboratory to simulate a real-life scenario. Additionally, we included health care workers following a known and definite but unprotected exposure and patients tested as routine screening upon admission and prior to any surgical or radiological procedure. We excluded the repeated samples obtained from the laboratory-confirmed COVID-19 patients from the study.https://bilder.shinyapps.io/PooledTesting/, assuming that the sensitivity of the assay is 95% and its specificity is 99% . The second group comprised three samples per pool (36 samples into 12 pools). The samples were pooled in the order of their receipt in the microbiology laboratory. One hundred microlitres from each sample were taken for corresponding pool. Finally, 300 μL from the total quantity of the pool were taken for the RT-PCR test. The pools were tested as soon as they were compiled.https://www.medcalc.org/calc/diagnostic_test.php). The κ coefficient was calculated using the κ free calculator website . The PCR results of pooled samples were compared to the initial result of each individual sample. The results of the tested pool were considered true positive when the RT-PCR result of the pool was positive and there were one or more positive individual samples within the same pool. When both pooled samples and all of its compound samples were negative, the pool was considered as true negative. If the result of pooled samples was negative, and there was a positive sample on individual sample testing, the result was considered a false negative. The changes in the cycle threshold (Ct) values of E and N2 genes between the pooled sample and positive individual tests were also evaluated.The results were tabulated in Excel spreadsheets. The sensitivity, specificity, negative likelihood ratio, negative predictive value, and accuracy were calculated using the MedCalc website  for which the Ct value for the pooled samples was lower than that for the corresponding individual samples .Due to the lack of adequate reagent supply for SARS-CoV-2 testing, several studies have suggested implementation of the strategy of pooling samples to scale up testing throughput and efficiency and to overcome the reagent shortage , 10–12. Our data showed that pooling of samples for SARS-CoV-2 testing markedly reduced the number of conducted tests and, therefore, increased the testing capacity of the clinical microbiology laboratory. To avoid obtaining high positivity rate, we carefully selected the cases to have low pre-test probability score based on the visual triage assessment protocol followed at our hospital. A score of four or less indicated that a patient had a contact with confirmed COVID-19 case or worked in a facility or lived in an area known to be undergoing an outbreak of COVID 19 in the 14 days preceding to the onset of symptoms and exhibited only one of the symptoms that are not typical for COVID-19, such as headache, nausea, vomiting or diarrhea. Indeed, several other studies suggested employing pooling strategy for screening of patients who have a low risk of infection , 6, 15.® Xpress SARS-CoV-2 test kit has been reported to be highly sensitive compared to other commercially available and laboratory-based assays (® Xpress SARS-CoV-2 test kit and that pooling will definitely reduce the analytical sensitivity of the assay. The sample with pool ID number 18 (Our data also showed that pooling of samples markedly and negatively affects the sensitivity of the assay. The Cepheid’s Xpertd assays –18. Hencd assays , 19. In d assays  was testumber 18  recordedumber 18 –22.Two of samples in this study exhibited a lower Ct value in the pool than in the single test. Such effect has been previously reported and was attributed to a carrier effect of multiple positive samples in the pool . In our The limitations of our study include the small sample size and the selection of swab specimens. Further, larger studies need to address the potential use and cost-effectiveness of specimen pooling in certain patient populations with low risk and optimise the pool size and sample volume accordingly. Additionally, the clinical team needs to be aware that a pooling strategy is being implemented in the laboratory, which may reduce assay sensitivity, especially with large pool sizes.In this study, we examined the effect of pooled specimen testing for COVID-19 using a fully automated nucleic acid amplification test. The overall pooled test accuracy and diagnostic performance had a remarkable effect on laboratory resources. Yet, caution is warranted while selecting the cases for pooled testing, since the reduction in sensitivity can have significant impact if the misdiagnosed cases result in high-risk infectiousness circumstances, such as in pre-surgical patients.


The pandemic of the coronavirus disease 2019 (COVID-19) represents an unprecedented challenge to identify effective drugs for prevention and treatment. While the world’s attention is focused on news of COVID-19 vaccine updates, clinical management still requires improvement. Due to the similarity of cancer-induced inflammation, immune dysfunction, and coagulopathy to COVID-19, anticancer drugs, such as Interferon, Pembrolizumab or Bicalutamide, are already being tested in clinical trials for repurposing, alone or in combination. Given the rapid pace of scientific discovery and clinical data generated by the large number of people rapidly infected, clinicians need effective medical treatments for this infection. The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has caused catastrophic damage to human life. Since December 2019, the pandemic has spread worldwide and still is ongoing. SARS-CoV-2 primarily infects the upper and lower respiratory tract; however, it can also affect other vital organs. Most people recover from the acute phase of the disease, but some people continue to experience a range of effects for months after recovery. Clinical management is currently focused on supportive care and prevention and control of complications such as acute respiratory distress syndrome (ARDS) [Although the world’s attention is understandably centred on reports of COVID-19 vaccine updates, from supply to administration, the need for treatments cannot be overlooked, as vaccination cannot protect everybody and as infection overwhelms hospitals and nursing homes. When we compare COVID-19 to the common flu, which is routinely targeted and has readily available and effective vaccines, we can see that no vaccine is ideal. Therefore, flu medications are still in high demand to avoid hospitalization and save lives. While the rise of new variants of COVID-19 threatens the efficacy of the available vaccines, it is critical that we must continue researching therapies to minimize hospitalization and cure COVID-19. The world health organization created (WHO) guidelines on using vaccines and antivirals during influenza pandemics to address the shortage of vaccines and antivirals . DemonstThe food and drug administration (FDA) granted emergency use authorization to two monoclonal antibody treatments for non-hospitalized adults and children over the age of 12 who have mild to moderate COVID-19 symptoms, who are at risk for developing severe COVID-19 or being hospitalized for it. Regeneron’s casirivimab and imdevimab combo and Eli Lilly’s bamlanivimab and etesevimab combination are the two treatmentsPrior approval for the single use of bamlanivmab to treat COVID-19 was withdrawn in April 2021 due to new data revealing minimal efficacy . While tConsequently, effective therapies, which are available to anyone who needs them, must work with various populations and ensure that the responses to the pandemic are globally successful and inclusive. Having both important tools in our arsenal would ensure that most of the population is shielded from the severe effects of COVID-19. However, the development of novel antiviral drugs needs long-term investigation in clinical trials. Therefore, the benefit of repurposing drugs to justify off-label usage is linked to the established safety profile. However, it may vary depending on the disease and the consolidated data on pharmacodynamics, pharmacokinetics and efficacy in phase I–IV trials ,5. Some Several anticancer compounds were investigated as possible future drugs for COVID-19, among the thousands of coronavirus drugs studied. This article includes anticancer drugs that have already been approved or are being fast-tracked by regulatory authorities, supported by published evidence and used to treat the treatment of cancer patients. In times of crisis, such as COVID-19, drug repurposing is a valuable technique because it provides quick access to agents with not only accessible safety data but also defined manufacturing lines and supply chains, which facilitates the process of discovery. The major limitation of the use of repurposed therapeutics is associated with dosage regimens. Most of the time, effective concentrations needed for antiviral activity are often higher than those clinically attainable under the approved regimens .Drug repurposing is not a reason for designing low-quality clinical trials or emphasizing the bias of early outcomes and uncontrolled cohorts, and it is desirable to use molecules with a specified safety profile. In addition, these therapies have early-and late-phase data on toxicity and complications management, which are especially helpful in the setting of a pandemic versus novel therapies. Several antineoplastic agents have the potential to improve COVID-19 outcomes by using the exact mechanisms and targets used in cancer treatment . These tUsing the OpenData Portal  was possAntiviral therapy and prevention approaches are focused on (a) inhibiting the replication of the viral genome by either preventing the virus from entering the host cells or suppressing one or more phases of replication; (b) boosting the immune system and producing a type of antiviral memory via vaccination; (c) injection of antiviral antibodies generated in the plasma .SARS-CoV-2 replicates similarly to other Coronaviridae viruses. Coronaviruses can infect the host through both endosomal and non-endosomal (cell surface) routes. The viral protein kinases and their associated signaling cascades have now been targeted in order to reduce coronavirus replication, particularly SARS-CoV-2. The virus can enter the cells via endocytosis or plasma membrane fusion through the interaction between the Spike (S) protein of the virus and angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2) at the target cell ,13.After receptor-mediated endocytosis of the virus into the host cells, the virus releases the viral genome (single-stranded positive RNA) and uses the host ribosome to translate into viral polyproteins. Viral proteinases 3CLpro and PLpro cleave viral polyproteins into effector proteins see . RNA-depThe SARS-CoV-2 infection activates both innate and adaptive immune responses in the host. Patients with severe COVID-19 have a lower number of natural killer (NK) cells and a higher level of the C-reactive protein. The early failure of antiviral immunity during SARS-CoV-2 infection is correlated with a significant decrease in total T cells and NK cells .Exploring potential clinical targets for COVID-19 attenuation is critical for long-term COVID-19 treatment.Cancer treatment is still a major challenge, but tremendous progress in anticancer drug discovery and development has occurred in the last few decades. The spent decades developing drugs for cancer-induced inflammation, immune dysfunction, and vascularization provided us with a number of drug options that could be useful in the treatment of other diseases.Patients affected by COVID-19 also display inflammation, immune dysfunction and vascular syndrome dysfunction .Evidence suggests that the immune response to SARS-CoV-2 can play different roles: dysregulated immune responses in critically ill patients with COVID-19 is reflected by lymphopenia, mainly affecting CD4+ T cells, including effector, memory, and regulatory T cells, and decreased IFN-γ expression in CD4+ T cells. Exhaustion of cytotoxic T lymphocytes, activation of macrophages, and a low human leukocyte antigen-DR expression on CD14 monocytes has been noted in patients with COVID-19 . These sFurthermore, the homeostasis maintained by the vascular endothelium in health is affected by COVID-19 infection. In clinical studies, patients with COVID-19 have higher levels of fibrinogen, fibrin degradation products, and D-dimer, which appear to be related to disease severity and thrombotic risk . Since tThe drug repurposing approach puts the drug discovery process on a fast track. COVID-19 researchers’ attention to its potential growth is wider in a range of different scientific fields. Due to the availability of in-vitro and in-vivo screening data, chemical optimization, toxicity studies, bulk manufacturing, formulation development and pharmacokinetic profiles of FDA-approved drugs, drug development cycles are shortened as all these critical steps can be bypassed ,8. In adSeveral drugs that have been approved for cancer indication by the US FDA are now in COVID-19 clinical trials to test their efficiency in reducing mortality and speed up recovery. The following The homeostasis maintained by the vascular endothelium in health is affected by COVID-19 infection. In clinical studies, patients with COVID-19 have higher levels of fibrinogen, fibrin degradation products, and D-dimer, which appear to be related to disease severity and thrombotic risk [SARS-CoV-2 compromises the type 1 interferon antiviral response; therefore, IFN administration seemed a promising approach to stimulate macrophages, which engulf antigens and natural killer cells (NK cells). IFN might be able to strengthen the immune system by activating dormant components . ClinicaRibavirin, lopinavir/ritonavir, remdesivir or hydroxychloroquine are some of the drugs tested in combination with IFNs in clinical trials see . The stuThe problem is that when interferons boost the immune system, COVID-19 are likely to worsen before they improve. Giving anyone an interferon-based drug if they are still on a ventilator and their symptoms are about to overtake them may be fatal. This is why, in the case of viral infections, interferon therapies are usually only used as a last resort . NonetheThe current COVID-19 infection is linked to elevated cytokine levels or hypercytokinemia. Patients who develop cytokine storms quickly experience cardiovascular collapse, multiple organ dysfunction and death . The marThe administration of IL-6 blocking agents, such as tocilizumab and siltuximab, has been shown to be effective . RepurpoThe drug siltuximab is a chimeric monoclonal antibody that binds to interleukin-6 (IL-6), preventing binding to soluble and membrane-bound interleukin-6 receptors. Current evidence showed that siltuximab led to a reduced mortality rate from COVID-19 promising to be a possible therapy; however, more studies are necessary .Immune checkpoints are regulatory molecules that are found on the surface of immune cells. When proteins on the surface of immune cells called T cells recognize and bind to partner proteins on other cells, such as tumor cells, immune checkpoints are activated. The T cells receive an “off” signal which may prevent cancer from being destroyed by the immune system. Therefore, immune checkpoint inhibitors are immunotherapy drugs that work by preventing checkpoint proteins from binding to their partner proteins. As a result, the “off” signal is not sent, allowing T cells to kill cancer cells ,27.The same principle can be applied for COVID-19 as a potential therapeutic approach see . EvidencAndrogen deprivation therapy (ADT), also known as androgen suppression therapy, is an antihormone therapy used to treat prostate cancer. Increasing evidence suggests that androgen has the potential to regulate the cellular TMPRSS2 expression and ACE2 .TMPRSS2 is a membrane protease necessary for COVID pathogenesis, which is regulated by androgens. Blocking TMPRSS2 with bicalutamide can reduce viral replication and improve clinical outcomes. These agents may down-regulate TMPRSS2 mRNA and expression resulting in less entry of SARS-CoV-2 entry into cells and thus could arise as promising therapeutic tools in early SARS-CoV-2 infection and COVID-19 , see TabToremifene used in the treatment of advanced breast cancer in postmenopausal women is a first-generation nonsteroidal-selective estrogen receptor modulator. It displays potential effects in blocking various viral infections, including MERS-CoV, SARS-CoV and Ebola virus. Prevents fusion between the viral and endosomal membrane by interacting with and destabilizing the virus membrane glycoprotein and eventually inhibiting viral replication . MoreoveOther molecules revealed potent pre-clinical efficacy against SARS-CoV-2 by inhibiting replication. In the life cycle of SARS-CoV-2, many host proteins play a role, and some are required for viral replication and translation. Drugs that target viral proteins are usually the focus of research, but a complementary approach is to target the required host proteins .Plitidepsin is an inhibitor of elongation factor 1A (eEF1A) and is an authorized drug in Australia for the treatment of multiple myeloma. Antiviral activity of plitidepsin has been analyzed in a human hepatoma cell line infected with the HCoV-229E-GFP virus, a virus similar to the SARS-CoV-2 virus . ClinicaAnother promising drug being tested in clinical trials is Zotatifin to assess its safety and tolerability. Zotatifin is a selective small-molecule inhibiting the eukaryotic initiation factor 4A (eIF4A), a powerful anti-proliferative target found at the intersection of the RAS and PI3K signaling pathways .To test the hypothesis that PI3K blockade could hamper immune system hyperactivation and thus reduce lung inflammation and interfere with the viral cycle, researchers used one of the most successful targeted strategies in cancer treatment: kinase cascade blockade . In a raOn the other hand, Zanubrutinib is an irreversible Bruton tyrosine kinase inhibitor. The aberrant activation of the Bruton tyrosine kinase has a key role in the tumorigenesis of B-cell lymphoma. For COVID-19 evidence suggesting protective effects, a phase II trial is ongoing, aiming to reduce the disease-related immune dysregulation and hyper-inflammation .Low-dose thoracic irradiation strategies with anti-inflammatory or prophylactic vitamin D have shown antiviral potential. However, there is a lack of direct pre-clinical and clinical evidence for COVID-19 and other therapeutics that may be more accessible, less risky, and less complicated for treatment .Recently, we have acquired an unparalleled knowledge of the molecular processes and immune tolerance mechanisms regulating the occurrence and severity of human neoplasms, contributing to a wide variety of targeted anticancer and immunotherapy treatments . DespiteThe COVID-19 pandemic has swiftly swept through the world, resulting in huge morbidity and significant mortality. While the news of vaccination brings the promise to the end of the pandemic, the importance of medicines must not be forgotten since it helps to limit the spread of disease and allows both prevention and treatment. Either using repurposed drugs, alone or in combination or even new molecules, the pandemic provides an opportunity to create new models for evaluating novel therapeutic approaches quickly. Due to similarities between cancer and COVID-19, anticancer drugs are repurposed in clinical trials to test their efficacy in targeting inflammation, immune dysfunction, and coagulopathy. Finally, the management of the SARS-CoV-2 pandemic includes multidisciplinary collaboration to identify suitable treatment options for everyone, including and especially countries with limited access to vaccines and people already hospitalized. From the evidence reviewed here, several anticancer drugs seem to retain a promising activity to treat patients with COVID-19.


Is the reopening of schools during the COVID-19 pandemic associated with increased COVID-19 incidence and mortality?In this cross-sectional study of 643 Brazilian municipalities including 18 761 schools, on average, there was no systematic association between school reopening and COVID-19 incidence or mortality in São Paulo State up to 12 weeks after reopening, which was also the case for schools in the most vulnerable conditions. Aggregate mobility was already high before the school reopening and did not significantly increase afterwards.The results of this study suggest that reopening schools under appropriate protocols in low- and middle-income countries during the pandemic is unlikely to be associated with higher aggregate COVID-19 cases or deaths when counterfactual mobility is already high. School closures because of COVID-19 have left 1.6 billion students around the world without in-person classes for a prolonged period. To our knowledge, no study has documented whether reopening schools in low- and middle-income countries during the pandemic was associated with increased aggregate COVID-19 incidence and mortality with appropriate counterfactuals.To test whether reopening schools under appropriate protocols during the COVID-19 pandemic was associated with increased municipal-level COVID-19 cases and deaths in São Paulo State, Brazil.This observational study of municipalities in São Paulo State, Brazil, uses a difference-in-differences analysis to examine the association between municipal decisions to reopen schools during the COVID-19 pandemic and municipal-level COVID-19 case and death rates between October and December 2020. The study compared 129 municipalities that reopened schools in 2020 with 514 that did not and excluded data for 2 municipalities that reopened schools and closed then again.New COVID-19 cases and deaths per 10 000 inhabitants up to 12 weeks after school reopenings and municipal-level aggregate mobility for a subset of municipalities.There were 8764 schools in the 129 municipalities that reopened schools compared with 9997 in the control group of 514 municipalities that did not reopen schools. The municipalities that reopened schools had a cumulative COVID-19 incidence of 20 cases per 1000 inhabitants and mortality of 0.5 deaths per 1000 inhabitants in September 2020 (the baseline period) compared with an incidence of 18 cases per 1000 inhabitants and mortality of 0.45 deaths per 1000 inhabitants during the baseline period in the comparison group. The findings indicated that there were no statistically significant differences between municipalities that authorized schools to reopen and those that did not for (1) weekly new cases  and (2) weekly new deaths  before and after October 2020. Reopening schools was not associated with higher disease activity, even in relatively vulnerable municipalities, nor aggregate mobility.The findings from this study suggest that keeping schools open during the COVID-19 pandemic did not contribute to the aggregate disease activity. This cross-sectional study examines whether reopening schools under appropriate protocols during the COVID-19 pandemic was associated with increased municipal-level COVID-19 cases and deaths in São Paulo State, Brazil. First, recent evidence suggests that the likelihood of infection among family members and school staff increases substantially when schools are open.18 To our knowledge, no study has documented the aggregate consequences of keeping schools open in low- and middle-income countries during the COVID-19 pandemic with appropriate counterfactuals. Few studies have examined the association between school reopenings during the pandemic and COVID-19 disease activity in high-income countries,27 and their findings were mixed.Conversely, keeping schools open during the pandemic might not elevate risks of COVID-19 incidence and mortality. In fact, studies suggest that children, particularly those in primary school, are among the safest groups for whom social distancing could be gradually forgone because of their relatively low transmission risk.This article examines a natural experiment in São Paulo State, Brazil. All state schools were closed by the end of March 2020 in response to increasing COVID-19 cases. In-person school activities remained suspended throughout September 2020. Between October and December 2020, 129 municipalities authorized schools to partially reopen for in-person activities. Using public data on the evolution of the pandemic across different municipalities, we tested whether school reopenings under appropriate protocols was associated with increased COVID-19 cases and deaths in São Paulo State, considering the staggered timing of municipal decrees that authorized schools to reopen in the state.28 We focused on the period ranging from August to December 2020 so that we could examine trends for COVID-19 cases and deaths before and (up to 12 weeks) after school reopenings in the state. Third, we collected data for aggregate mobility from Google reports, which were available only for a subset of all municipalities. Fourth, we collected municipality characteristics  from Brazilian Census data. Lastly, we collected school characteristics from the Brazilian school census. We provide more details about data sources in eTables 1 and 2 of the The study was deemed exempt from institutional review board approval because it only used data on publicly available health outcomes that were aggregated at the municipality level. As such, no individual data were analyzed. First, we used data on the timing of municipal decrees that authorized schools to partially reopen for in-person activities in the state that were collected by the São Paulo State Secretariat of Education. Second, we used publicly available data on COVID-19 cases and deaths from municipal health secretariats and the Brazil.io repository.We focused on 2 main outcomes of interest: new weekly per capita COVID-19 cases and deaths (both in logs). The log transformation allowed us to interpret the estimates as percentage differences in the outcomes of interest. We added 1 to all values to prevent dropping weekly observations for which we did not observe any new cases or deaths. As such, the study contained values for both outcomes across all municipalities and periods in the sample.This study contains data on the existence and timing of all municipal decrees that allowed schools to partially reopen in São Paulo State since October 2020. A total of 131 of the 645 municipalities (20.3%) in the state eventually reopened schools in 2020  attended in-person school activities between October and December 2020.Because decisions whether to reopen schools for in-person activities in 2020 were not random, merely comparing trends of COVID-19 cases and deaths across different municipalities after in-person activities were allowed to resume would mistakenly associate school reopenings with disease activity, especially when considering mean reversion.30 Because this estimator includes a matching procedure in the first step , we formally estimated the association between school reopenings and disease activity using the difference-in-differences estimator of Callaway and Sant’Anna.For all regressions, we controlled for municipal characteristics  from the 2010 Brazilian population census and the baseline per capita COVID-19 cases and deaths . School infrastructure was the first principal component from a vector of school characteristics from the 2019 Brazilian school census .We also estimated heterogeneous associations between school reopenings and COVID-19 disease activity regarding the following municipality characteristics: (1) baseline COVID-19 deaths; (2) average quality of school infrastructure; (3) per capita income; and (4) share of the population 65 years or older. In each case, we split municipalities according to the sample median and focused on whether the associations were statistically different from 0 within the highest risk/most vulnerable subsample.31 based on cell phone location. The outcome we had access to is an index that captures changes in mobility compared with the municipal average during the week of February 15, 2020, as measured in percentage points. The index is only available for 412 municipalities in São Paulo State. While these mobility data were not tagged to the school-relevant population, the question was whether authorizing schools to reopen had an association with overall mobility in each municipality greater and beyond that of children and their caregivers in tandem with the main analyses, which concerned municipal-level COVID-19 cases and deaths. Analyses were conducted using Stata (StataCorp) and R (R Foundation).Lastly, we estimated the association between school reopenings and the municipality’s average mobility index during that week using the same difference-in-differences strategy. This outcome is publicly available from Google mobility reportsThis study included 643 municipalities in São Paulo State, of which 129 (20.1%) authorized schools to reopen in 2020 (comprising 8764 schools) and 514  did not. Municipalities that reopened schools had a cumulative COVID-19 incidence of 20 cases per 1000 inhabitants and mortality of 0.5 deaths per 1000 inhabitants during the baseline period. Municipalities that did not authorize schools to reopen had a cumulative COVID-19 incidence of 18 cases per 1000 inhabitants and mortality of 0.45 deaths per 1000 inhabitants during the same period. eTable 8 in the In the The results in eTable 3 in the 27 and the empirical strategies used could only estimate the short-term associations of school reopenings with disease activity (2-3 weeks after in-person classes returned).The results of this cross-sectional study of 643 municipalities in São Paulo State suggest that reopening schools during the pandemic was not systematically associated with higher COVID-19 cases or deaths. The average differences in disease activity after October 2020 across municipalities that authorized schools to reopen and those that did not were small and not statistically significant at any week after reopening regarding new COVID-19 cases or deaths. This is not because the study design lacked statistical precision; effect sizes on cases were nearly 0 during most weeks of the study period, and the average COVID-19 incidence and mortality was higher within municipalities that did not reopen schools in 2020. The results suggest that school reopening was not significantly associated with disease activity even in municipalities with lower-quality school infrastructure, lower per capita income, or a higher senior population share or in those most severely affected by the pandemic. Evidence from the studies conducted in high-income countries about the association of school reopenings and COVID-19 disease activity is mixed,32 and none of them estimated effects under appropriate counterfactuals. Studies that estimate the effects of school reopening by comparing cases within municipalities before and after in-person activities returned are likely to detect false positives. This is because of mean reversion, the statistical tendency for negative (positive) shocks to be followed by positive (negative) ones.31 Locations that allow schools to reopen are statistically more likely to have experienced unusually low COVID-19 cases before in-person classes returned. Analogously, comparing the average COVID-19 incidence and mortality across locations that authorized schools to reopen with those that did not would potentially overestimate the effects of reopening during the pandemic; such locations typically differ in many dimensions, particularly regarding their previous trends for COVID-19 cases, hospitalizations, and deaths. Analyzing a comparison group with similar pretrends for COVID-19 case rates and deaths is a critical element of a study design to assign a clearer interpretation to empirical findings.In low- and middle-income countries, to our knowledge, most studies only analyzed risks within the school community rather than at the aggregate level,Resuming in-person school activities might potentially affect the aggregate evolution of the COVID-19 pandemic through 2 mechanisms. First, students and school staff might get infected at school and subsequently infect their families. Second, school reopenings might increase the mobility of children and their caregivers, leading to infections beyond the school setting. Regarding the first mechanism, schools were authorized to reopen in São Paulo State during the study period only under appropriate protocols, including strict limits to in-person attendance. For the second mechanism, the analysis of mobility data suggests that school reopening was not significantly associated with higher aggregate mobility in a setting where counterfactual mobility was already very high. The mobility index in São Paulo State reached prepandemic levels at the beginning of November, which suggests that families were not safe from contagion in the absence of in-person school activities.There are 3 limitations to the analyses in this study. First, data limitations only allowed for documentation of the association between school reopenings and aggregate disease activity. As such, the null results estimated in this study do not imply that school reopenings during the COVID-19 pandemic pose no risks for school staff or the families of students, especially in settings where robust protocols to prevent infections at the school setting are not in place. Additional research is needed to document the direct effects of school reopenings in low- and middle-income countries on those populations with appropriate counterfactuals. That would require drawing on individual-level data on COVID-19 cases, hospitalizations, and deaths for students, school staff, and their families for schools that reopened and those that did not while parsing out any differences in previous trends in disease activity across them.Second, we were only able to estimate intention-to-treat associations of school reopenings with disease activity. This is because we do not have detailed information on which schools effectively reopened or municipal-level school attendance. As such, this study’s findings are not informative about the association of marginal increases in student attendance with municipal-level COVID-19 cases and deaths.34 to identifying which variants of the virus are circulating in these settings,35 are also needed to further inform risk assessments in each context.Third, these findings might not necessarily replicate in other settings. Brazil is dense and was hit hard by the COVID-19 pandemic, which is likely a relevant benchmark for other low- and middle-income countries. Moreover, the null results documented in this study remain consistent across a wide range of local contexts, such as income levels, school infrastructure, senior population share, and local disease activity. However, in other countries or during periods in which mobility has been more successfully restrained by nonpharmaceutical measures, the study cannot rule out that school reopenings could be associated with increased overall mobility and contagion, contributing to aggregate disease activity, especially if safe reopening protocols are not in place. Complementary approaches, from seroprevalence surveys36 the results suggest that the policy debate in low- and middle-income countries must focus on how to safely keep schools open amidst the pandemic rather than whether or not to do so.The findings in this study suggest that reopening schools in low- and middle-income countries during the pandemic is unlikely to contribute to aggregate risk in the presence of safe reopening protocols, especially where mobility is already high. As such, the results suggest that the aggregate benefits of keeping schools closed are low. Together with recent evidence about the large educational costs of school closures across countries of all income levels,


Although COVID-19 vaccines have recently become available, efforts in global mass vaccination can be hampered by the widespread issue of vaccine hesitancy.The aim of this study was to use social media data to capture close-to-real-time public perspectives and sentiments regarding COVID-19 vaccines, with the intention to understand the key issues that have captured public attention, as well as the barriers and facilitators to successful COVID-19 vaccination.Twitter was searched for tweets related to “COVID-19” and “vaccine” over an 11-week period after November 18, 2020, following a press release regarding the first effective vaccine. An unsupervised machine learning approach  was used to identify topics from tweets, with each topic further grouped into themes using manually conducted thematic analysis as well as guided by the theoretical framework of the COM-B  model. Sentiment analysis of the tweets was also performed using the rule-based machine learning model VADER .Tweets related to COVID-19 vaccines were posted by individuals around the world . Six overarching themes were identified: (1) emotional reactions related to COVID-19 vaccines (19.3%), (2) public concerns related to COVID-19 vaccines (19.6%), (3) discussions about news items related to COVID-19 vaccines (13.3%), (4) public health communications about COVID-19 vaccines (10.3%), (5) discussions about approaches to COVID-19 vaccination drives (17.1%), and (6) discussions about the distribution of COVID-19 vaccines (20.3%). Tweets with negative sentiments largely fell within the themes of emotional reactions and public concerns related to COVID-19 vaccines. Tweets related to facilitators of vaccination showed temporal variations over time, while tweets related to barriers remained largely constant throughout the study period.The findings from this study may facilitate the formulation of comprehensive strategies to improve COVID-19 vaccine uptake; they highlight the key processes that require attention in the planning of COVID-19 vaccination and provide feedback on evolving barriers and facilitators in ongoing vaccination drives to allow for further policy tweaks. The findings also illustrate three key roles of social media in COVID-19 vaccination, as follows: surveillance and monitoring, a communication platform, and evaluation of government responses. COVID-19 first presented as an atypical pneumonia of unknown cause in Wuhan, China, in late December 2019. Within a short time frame, the virus spread to multiple countries despite international efforts to contain it, resulting in significant death, psychological impact, and economic disruption around the world . After mMoving on, the next phase of the challenge was to ramp up public health efforts to increase vaccine uptake in the population, possibly through well-thought-out and coordinated vaccination drives. Yet, it is well known that vaccination drives are often hampered by the issue of “vaccine hesitancy,” whereby a large majority of population may have conflicting motivation or opposition to receive vaccines -10. HistTraditionally, research on attitude, perception, and behavior has often relied on methodologies such as surveys, interviews, or focus group discussions. However, such traditional approaches can often be time-consuming in their data collection processes , hence, findings from the traditional approaches may not sufficiently reflect real-time public sentiments on time-sensitive matters, such as those related to COVID-19 vaccination. An alternative would be using data from social media platforms such as Twitter, where researchers can collect near–real-time information that reflects prevailing perspectives and sentiments in the community ,16. SuchIn this infodemiology study, we sought to examine public conversations about COVID-19 vaccines as posted on Twitter—specifically after the press release about the first effective vaccine by Pfizer-BioNTech on November 18, 2020—with the intention to shed light on the potential utility of social media in the context of the COVID-19 vaccination drive, as well as to identify useful strategies that may address COVID-19 vaccine hesitancy and improve vaccine uptake. Specifically, we intended to address the following two research questions:What are the key issues that have captured public attention following the press release of the first effective COVID-19 vaccine?How may social media data inform the barriers and facilitators that can influence individuals’ behaviors regarding receiving COVID-19 vaccines?Twitter was selected as the social media platform for data collection in this study, due to accessibility to researchers of its large quantity of global data . TwitterA publicly available COVID-19 Twitter data set  was searAs the tweets comprised large volumes of free-text data, the unsupervised machine learning approach of topic modeling was used to analyze these data . Topic mBefore conducting topic modeling, the following steps were performed to preprocess the free-text data based on currently recommended best practices ,24. FirsIn our topic modeling approach, the preprocessed words were presented to an unsupervised machine learning algorithm to identify clusters of words that tended to co-occur together. Words with a high probability of co-occurring in tweets were then considered to belong to the same “topic.” Three covariates were included in topic modeling  to improve the accuracy of the model in identifying topics. The optimal number of topics was identified using the algorithm proposed by Lee and Mimno . Topic mOutput from topic modeling was examined by the two authors (TML and CSL) to ensure coherence of the identified topics. A descriptive label for each topic was manually crafted by the two authors based on sample tweets of each topic. Thereafter, the topics were further grouped into themes by the two authors using the inductive and iterative processes of thematic analysis as introduced by Braun and Clarke .In addition to the inductive thematic analysis, we also adopted the COM-B  model  to guideIssues related to capability can often be modified through education and training .Issues related to opportunity may possibly be modified through environmental restructuring , enablement , and restriction  .Issues related to motivation may potentially be modified, for example, through communication, modeling , and incentivization  .To further enrich the main findings, we conducted an exploratory analysis to identify the underlying emotions of each tweet using the VADER  package  in R. VAAlthough many sentiment analysis tools are currently available ,42-45, VSecond, it is based on a human-curated lexicon of 7500 emotion-related words as well as five human-interpretable rules that identify sentiment intensity . As such, unlike other sophisticated machine learning models, VADER’s classification rules are interpretable by humans and not hidden within a machine-access-only black box ,43.Third, as VADER uses a simple rule-based machine learning model, it is computationally efficient and only takes a fraction of computational time to analyze free-text data compared to other sophisticated machine learning techniques. Using an example from a previous study , a set oFourth, as VADER is based on a human-validated lexicon, it does not require any form of training data. This is in contrast to other sophisticated machine learning models that often require extensive sets of training data before they can produce accurate results in sentiment analysis ,43.Fifth, despite its simplicity, VADER has been shown in several comparative studies  to outpeLastly, VADER is available as an open-source package that is easily accessible from widely used data science platforms, such as R and Python.A total of 2,524,982 tweets were initially identified over the 11-week study from November 18, 2020, to February 3, 2021. After removing duplicate tweets and tweets from news media or organizations, a total of 672,133 tweets were eventually included. A flow diagram showing tweet selection is presented in Using the unsupervised machine learning algorithm of topic modeling, 60 topics could initially be identified from the tweets. Coherence of the 60 topics was manually examined by the two authors; during this process, one topic that had the lowest prevalence (~0.4%) was found to bear much similarity with another topic and, hence, the two topics were combined. As such, a total of 59 topics were eventually included. Following thematic analysis by the two authors, the 59 topics could be further grouped into six themes. Word clouds for the six themes are shown in Theme 1 describes “emotional reactions related to COVID-19 vaccines,” and involved 19.3% of the tweets. Tweets in this theme had a mixture of negative emotions, including those toward politicians, over inequitable access of vaccine, and over the antivaccine movement, as well as positive emotions, including those regarding receiving the vaccines and availability of the vaccines. Theme 2 describes “public concerns related to COVID-19 vaccines,” and involved 19.6% of the tweets. Common concerns included vaccine-related death, impact of the vaccines on fertility, and widespread misinformation related to the vaccines. Meanwhile, concerns with a negative tone included those related to insufficient supply of vaccine, delays in vaccine rollout, reported statistics on adverse events related to the vaccines, fitness to receive the vaccines among individuals with medical conditions or allergies, short development phases regarding the vaccines, effectiveness of the vaccines against new strains of the COVID-19 virus, and short-term and long-term side effects of the vaccines.Theme 3 describes “discussions about news related to COVID-19 vaccines,” and involved 13.3% of the tweets. Commonly discussed news items included those related to vaccine development and approval as well as effectiveness of the vaccines against new strains of the COVID-19 virus. Theme 4 describes “public health communications about COVID-19 vaccines,” and involved 10.3% of the tweets. Tweets in this theme included efforts to provide simple explanations on vaccine-related issues, such as those related to the vaccines’ efficacies and mechanisms of action, as well as the use of various media in providing public education .Theme 5 describes “discussions about the approach to COVID-19 vaccination drives,” and involved 17.1% of the tweets. Within this theme, several approaches to vaccination drives have commonly been highlighted, including engaging relevant stakeholders in vaccination drives  and defining priority groups for vaccination . Theme 6 describes “discussions about the distribution of COVID-19 vaccines,” and involved 20.3% of the tweets. Commonly described topics in this theme included discussions about equitable access to vaccines, such as ethical principles of vaccine allocation and equitable access across various subpopulations, as well as rollout efforts of COVID-19 vaccination .We further examined the barriers and facilitators related to COVID-19 vaccination by matching our initial 59 topics to the three components in the COM-B model . Detailed results on the barriers and facilitators are presented in This study used social media data to capture real-time public conversations about COVID-19 vaccines after November 18, 2020, following a press release regarding the first effective vaccine. Six main themes could be identified from the tweets: (1) emotional reactions related to COVID-19 vaccines, (2) public concerns related to COVID-19 vaccines, (3) discussions about news related to COVID-19 vaccines, (4) public health communications about COVID-19 vaccines, (5) discussions about the approach to COVID-19 vaccination drives, and (6) discussions about the distribution of COVID-19 vaccines. Tweets with negative sentiments largely fell within the themes of emotional reactions and public concerns related to COVID-19 vaccines. The tweets could be further classified using the COM-B model to examine the barriers and facilitators related to COVID-19 vaccines. Tweets that focused on barriers remained largely constant throughout the study period, with those related to motivation  being more prevalent than those related to capability  or opportunity . In contrast, tweets that focused on facilitators showed temporal variations over the 11-week study period: those related to capability  peaked initially, while those related to motivation  peaked around the sixth week and those related to opportunity  rose drastically over time.Our findings on the six themes  are consOur findings on the barriers and facilitators to COVID-19 vaccination  present From a broader perspective, findings from this study demonstrated the potential roles of social media in ongoing COVID-19 vaccination drives. Social media has been increasingly recognized in recent literature as a useful source of data to inform issues of public health interest  given thSome limitations should be considered in this study. First, Twitter posts were used to exemplify social media data. Although Twitter is among the most widely used social media platforms ,21, it mThird, most of Twitter’s users were from North America and Europe. Keeping this in mind, our findings may not be as generalizable to other countries. Fourth, the findings may not fully represent the perspectives of the wider population, given that social media is largely used by individuals who have internet access and are technology savvy .Fifth, previous research has found that nonhuman Twitter users  may artificially manipulate public opinion on social media . Most ofSixth, insofar as unsupervised machine learning is well suited to analyses of large volumes of free-text data , such anSeventh, the sentiment analysis in this study was conducted to supplement the main findings from topic modeling. Although the results from our sentiment analysis have face validity (ie, consistently highlighting topics with negative sentiments, as seen in In conclusion, this study used unsupervised machine learning to identify six overarching themes related to COVID-19 vaccines on social media, of which some themes contained tweets with more negative sentiments. The findings may facilitate the formulation of comprehensive strategies to improve COVID-19 vaccine uptake in the community; they highlight the key processes that require attention by policy makers in the planning of COVID-19 vaccination and provide feedback on the evolving barriers and facilitators in ongoing vaccination drives to allow further policy tweaks. From a broader perspective, the findings may also be consolidated into a framework to illustrate three key roles of social media in COVID-19 vaccination, as follows: surveillance and monitoring, a communication platform, and evaluation of government responses.


In 2016 the World Health Organization set the goal of eliminating hepatitis B globally by 2030. Horizontal transmission has been greatly reduced in most countries by scaling up coverage of the infant HBV vaccine series, and vertical transmission is therefore becoming increasingly dominant. Here we show that scaling up timely hepatitis B birth dose vaccination to 90% of new-borns in 110 low- and middle-income countries by 2030 could prevent 710,000  deaths in the 2020 to 2030 birth cohorts compared to status quo, with the greatest benefits in Africa. Maintaining this could lead to elimination by 2030 in the Americas, but not before 2059 in Africa. Drops in coverage due to disruptions in 2020 may lead to 15,000 additional deaths, mostly in South-East Asia and the Western Pacific. Delays in planned scale-up could lead to an additional 580,000 deaths globally in the 2020 to 2030 birth cohorts. The timely hepatitis B birth dose vaccination is recommended for all new-borns by the WHO, but coverage is inconsistent. Here, the authors model the impact of scaling-up coverage in 110 low and middle income countries and assess how it may be affected by delays for example caused by the COVID-19 pandemic. Nearly 250 million people are estimated to be living with chronic HBV infection globally and the virus causes nearly 900,000 deaths a year due to hepatocellular carcinoma (HCC) and cirrhosis3, measured by the reduction of HBV surface antigen (HBsAg) prevalence in five-year-olds to 0.1% by 2030. Accordingly, targets were established that included scaling up coverage of the infant HBV vaccine series (HepB3), which reduces horizontal transmission, and the timely birth dose , which primarily reduces mother-to-child transmission (MTCT)10, each to 90% by 2030.In 2016, the World Health Assembly endorsed a World Health Organization (WHO) strategy to eliminate HBV as a public health threat by 2030https://www.gavi.org/programmes-impact/our-impact/countries-approved-support, accessed in March 2021): globally, coverage was 85% of infants in 2019, although it was only 73% in the same year in the WHO’s Africa region . However, despite the targets and although the WHO has recommended since 2009 that all new-borns receive the timely HepB-BD vaccine, irrespective of the mother’s serological status, scale-up of the timely HepB-BD has been slow, coverage heterogenous, and there has not been the same funding support from GAVI. By 2019, only an estimated 43% of new-borns had received timely HepB-BD vaccine  and only 110 countries were administering the universal HepB-BD vaccine to new-borns as part of their national policy . There are concerns that the timely HepB-BD is difficult to implement and not necessary for reducing the hepatitis burden to very low levels in some settings12.This is close to being achieved for HepB3, which is usually integrated within the Expanded Programme on Immunization schedule and is funded by Gavi, the Vaccine Alliance (GAVI), in many low-income settings . However, the COVID-19 pandemic and the response to it have created additional barriers to scaling up timely HepB-BD coverage, both due to disruptions in healthcare facilities16, which have affected routine immunization and facility-based births18, and indirectly due to changes in priorities and funding.In 2019, GAVI re-evaluated extending their funding to provide catalytic support for introducing the timely HepB-BD vaccine . Since current timely HepB-BD coverage tends to be low in African countries, these countries will benefit most from scale-up in timely HepB-BD. Elimination of HBV cannot be achieved by 2030 in most geographical regions in the vaccination scenarios analysed in this study . Disruptions in vaccination efforts in 2020 due to COVID-19 will not delay HBV elimination, but will result in an increase in HBV-related deaths in the 2020 birth cohort. Delays in the scale-up of timely HepB-BD coverage will result in both delays in the elimination of HBV and in substantial increases in HBV-related deaths in the following decades.We use a set of models representing the HBV epidemic in each of 110 LMICs, which together represent all six WHO regions and include all current GAVI-eligible countries , or both. PAHO has the best chance of reaching the 2030 target—here moderate timely HepB-BD coverage is combined with low overall HBV, so that an accelerated scale-up of timely HepB-BD could have an effect quickly.Figure Figure Figure Our results are sensitive to the assumptions made about other aspects of the HBV programme—HepB3 and treatment. Firstly, in the foregoing analyses it was assumed that HepB3 coverage levels will be maintained at the levels recorded in each country for 2019 as our primary aim was to explore the impact that timely HepB-BD scale-up alone could have. However, increasing HepB3 coverage levels to 100% in every country leads to fewer infections  and deaths  being averted between 2020 and 2100 as a result of scaling up timely HepB-BD to ≥ 90% by 2030  and an earlier year of elimination being reached overall  of scaling up of the timely HepB-BD to ≥ 90% by 2030 is greatly reduced . Similarly, the impact (on deaths averted) of drops in timely HepB-BD coverage relative to the status quo HepB3 & HepB-BD scenario is reduced  of a 20% drop in timely HepB-BD is reduced by 31% or 70%, respectively), as is the impact (on deaths averted) of delays in timely HepB-BD coverage relative to scaling up the timely HepB-BD to ≥ 90% by 2030  of scaling up timely HepB-BD to ≥ 90% between 2025 and 2040 is reduced by 41% or 76%, respectively). This is because, with treatment, the risk of death following infection is reduced substantially.HepB3 coverage is already very high, having a global coverage of over 80%, protecting large numbers of infants in most countries from horizontal transmission of HBV. However, timely HepB-BD coverage is still low in many places, especially in low and lower-middle income countries where the burden is concentrated, and this is the major impediment to eliminating HBV. Scaling up timely HepB-BD is an effective way of reducing HBV burden in countries, and our results confirm the WHO’s emphasis on the importance of scaling up the timely HepB-BD. The scale-up consistent with the WHO target (≥90% timely HepB-BD coverage by 2030) could reduce HBV-related deaths amongst the 2020 to 2030 birth cohorts globally by 710,000 . This impact is especially great in the AFRO region, which has the highest HBsAg prevalence and the lowest timely HepB-BD coverage. However, timely HepB-BD coverage is currently very low in countries in AFRO, and it may be a more realistic goal to scale up timely HepB-BD to ≥25% by 2030, which would avert 150,000  deaths in AFRO in the 2020 to 2030 birth cohorts compared to the status quo HepB3 & HepB-BD scenario (Supplementary Table 19) followed by the scale-up of antiviral treatment and the expansion of programmes to provide peripartum antiviral prophylaxis to HBsAg+ pregnant women with high viral loads20, which are highly effective in reducing the risk of HBV MTCT24, could speed up elimination even further in particular countries25 or even some WHO regions26.The analyses show it will not be possible to achieve HBV elimination by 2030 (the WHO’s stated ambition for HBV elimination) under the scenarios presented in this paper in any region except for PAHO. Instead, 2040 is now a more realistic goal for the countries modelled in EURO and WPRO, 2050 for EMRO and SEARO, and 2060 for AFRO. However, elimination might be achieved faster if HepB3 coverage were scaled up beyond its level in 2019 and/or if timely HepB-BD coverage were scaled up faster than in the scenarios in these analyses. Additional interventions such as increased testing . However, we note that such an expansion has been delayed due, in part, to the circumstances created by the COVID-19 pandemic27. This is deeply unfortunate, as delays in the scale-up lead to large numbers of additional avoidable deaths especially in Africa .Our findings are consistent with GAVI’s conclusion on the favourability of expanding funding to provide catalytic support for introducing the HBV timely HepB-BD vaccine  are non-specific out of necessity, although they are principled on reports that are available17. Drops in timely HepB-BD coverage in a country could occur for a number of reasons: temporary disruptions to vaccine supplies, less availability of healthcare staff due to sickness or redeployment to provide COVID-19 relief or a reduction in the proportion of facility-births as a result of transport restrictions during lockdown or patients being fearful of catching COVID-19 in healthcare settings. Delays in the scale-up of the timely HepB-BD vaccine in a country could be the result of prolonged transport disruptions  or funds being diverted away from routine vaccines and towards fighting the COVID-19 pandemic. It will be important to determine the impact of the COVID-19 pandemic once more data on the disruptions in different countries are available. Another limitation of these analyses is that we did not model high-income countries . Moreover, vaccine coverage tends to be higher in high-income countries (HICs) than in LMICs. Hence, our analysis is likely to only yield a slight underestimate of global HBV-related deaths. Since HICs tend to have lower HBsAg prevalences than do LMICs, including all of the EURO and PAHO countries in the analyses would probably result in EURO and PAHO each reaching elimination sooner than was found in these analyses.Limitations of this current analysis include the paucity of historical and current prevalence and treatment data, which compromises the certainty with which projections can be made. Prevalence in sub-Saharan Africa, particularly amongst children, is especially uncertainOverall, the scale-up of the timely HepB-BD could lead to major gains in health and is a necessary requirement for achieving HBV elimination. Even though the WHO recommends the scale-up and GAVI has indicated willingness to help fund it, delays in the scale-up of timely HepB-BD are leading to future preventable deaths being accumulated, especially in Africa.We focus on 110 LMIC GAVI-eligible countries that together contain 92% of global HBsAg prevalent cases . Country-specific historical vaccination coverage (1980 to 2019) of HepB3 and timely HepB-BD vaccines were sourced from WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) released in July 2020   and from Cui et al.45 in the case of China. Razavi-Shearer et al.32 and the WHO HBsAg dashboard have been found to give similar HBsAg prevalences in many countries33. In addition to HBsAg prevalence, the model was also fit to country-specific HBeAg prevalence in HBsAg+ women of childbearing age from Razavi-Shearer et al.32 or region-specific HBeAg prevalence in HBsAg+ women of childbearing age from Ott et al.47, as well as country-specific, age-specific HBV-related death rates  from cirrhosis and HCC sourced from the Global Burden of Disease (GBD) Results Tool website in December 2018 . Disability weights for calculating DALYs were obtained from Vos et al.48.The model was populated with country-specific demographic data  from the United Nations’ 2019 World Population Prospects  is administered to new-borns, and the administration of HepB3 (efficacy of 95%) is completed at six months of age.We used a population-level, deterministic, dynamic transmission model50, and 200 particles were sampled from the posterior distribution of each country  using a shape file from the R package rnaturalearth version 0.1.060.Four scenarios were run in the countries Table , all of Further information on research design is available in the Supplementary InformationReporting Summary


The usual accelerometry-based measures of physical activity (PA) are dependent on physical performance. We investigated the associations between PA relative to walking performance and the prevalence and incidence of early and advanced walking difficulties compared to generally used measures of PA.rel). Self-reported PA was assessed using questionnaires.Perceived walking difficulty was evaluated in 994 community-dwelling participants at baseline  and 2 years later over 2 km (early difficulty) and 500 m (advanced difficulty). We used a thigh-mounted accelerometer to assess moderate-to-vigorous PA, daily mean acceleration, and relative PA as movement beyond the intensity of preferred walking speed in a 6-minute walking test  but not incident early walking difficulty  compared to those without difficulty. The associations between absolute measures of PA and incident walking difficulty were attenuated when adjusted for preferred walking speed.The prevalence and incidence were 36.2% and 18.9% for early and 22.4% and 14.9% for advanced walking difficulty, respectively. PAThe variation in habitual PA may not explain the differences in the development of new walking difficulty. Differences in physical performance explain a meaningful part of the association of PA with incident walking difficulty. Scaling of accelerometry to preferred walking speed demonstrated independence on physical performance and warrants future study as a promising indicator of PA in observational studies among older adults. Walking performance is the key element of mobility that enables continuation of independent living in aging . WalkingIn older adults, walking forms a large portion of daily aerobic PA, which can be assessed in large-scale studies using accelerometry technology. Previous studies have shown that persons with walking difficulty accumulate less accelerometry-based PA compared to people without walking difficulty ,7. This rel) that takes individual variation in walking performance into account   . Preferrt (6MWT) . PArel i, or sex . Thereforel) that is independent of the prevailing walking performance. The aim of the study was to investigate the associations between PArel and the prevalence and incidence of early and advanced walking difficulties compared to the associations of several other accelerometry-based and self-reported measures of PA with the prevalence and incidence of walking difficulties. We hypothesize that the associations are weaker when the effect of physical performance is controlled for.Recently, we demonstrated an association between prevalent walking difficulty and accelerometer-based measures of PA such as intensity and amount of walking in free-living . This stWe present cross-sectional and longitudinal results of the observational “Active aging—resilience and external support as modifiers of the disablement outcome” (AGNES) study. The baseline data were collected between September 2017 and December 2018, and the baseline study protocol has been previously reported in detail (The AGNES-coronavirus disease 2019 (COVID-19) survey, which we conducted in May–June 2020 during the COVID-19 pandemic, provided us an opportunity to collect follow-up data on walking difficulty for the current prospective analyses. A series of restrictions and recommendations were issued in Finland in March 2020. Special attention was paid to the safety of older people, who were considered to be at the highest risk for developing a serious form of the disease. Thus, social distancing, that is, limiting close contact and avoiding places with other people, was recommended especially for people older than 70 years old. Activity destinations such as restaurants, activity centers, and gyms were closed . Althougn = 802) or in case of difficulty or unwillingness to fill in the questionnaire, by interviews over the phone (n = 7). At baseline, 27 participants had missing data on self-reported early and 27 participants on advanced walking difficulty. There were 634 (and 771) participants without early (and advanced) walking difficulty at baseline, respectively, of which 12 (17) were deceased by the follow-up, 86 (110) did not respond, 6 (7) were unable to respond, and 1 (1) had moved to a care home. In addition, there were 4 participants without data on perceived walking difficulty in both 2 km and 500 m during the follow-up. The remaining 525 participants without early or advanced difficulties at baseline and 632 participants without advanced difficulties were included in the incidence analysis of early and advanced walking difficulties, respectively.A flow chart of the follow-up study has been previously published . Of the n = 895). Self-reported PA measures were available for 994 participants. Approximately half of the original sample participated in the accelerometry surveillance. Those who participated in the surveillance did not differ from the people who only participated in the research center assessments in terms of sex, self-rated health, or advanced walking difficulty, but had higher self-reported PA and higher walking speed  and in a postal questionnaire (follow-up): “Do you have difficulty in walking 2 km/500 m?”  for older adults  hardly any activity, mostly sitting, (b) light PA, such as light household tasks, (c) moderate PA about 3 hours a week: walking longer distances, cycling, and domestic work, (d) moderate PA at least 4 hours a week or heavier PA 1–2 hours a week, (e) heavier PA or moderate exercise for at least 3 hours a week, and (f) competitive sports ,23.The accelerometry data collection and numerical analyses have been described in detail previously . BrieflyFor the analysis of the relative intensity cut-point, a modified 6MWT was performed in the research center while wearing the accelerometer. The test was performed in an indoor 20-m corridor at a preferred pace. The mean HPFVM of the 5-second epochs of the 6MWT was recorded as the outcome. Continuous walking throughout the test was required for the analysis of mean 6MWT acceleration .For PA analyses, the whole series of 5-second epochs were split into full 24-hour days from midnight to midnight. Three values were produced as outcomes for each day:(1) Daily average acceleration: the mean HPFVM (in mg) of all of the recorded 5-second epochs ,(2) Absolute MVPA: the number of epochs at or above the acceleration that corresponds to 3 METs based on White et al.’s linear equation for thigh-measured HPFVM . For thi(3) Relative PA: the number of epochs above or equal to the mean acceleration calculated during the 6MWT .We only included days with complete data without any nonwear, which was visually verified from the data. Only participants with at least 3 successfully recorded days were included in the subsequent analyses. The mean of the days scaled for a full week was used as the outcome for each participant.2). As previously mentioned, 6MWT was performed at a preferred pace. Total distance walked by the participants was measured, and average speed was calculated representing preferred walking speed  . The batAs the follow-up was conducted during the COVID-19 pandemic, we additionally evaluated self-reported change in PA due to the restrictions and social-distancing recommendations. For this purpose, a single question was adapted from the seasonal adjustment score of the YPAS : “Have yt-tests, or Mann–Whitney U tests. Correlations between PA and preferred walking speed were tested with Pearson’s correlation coefficient. Logistic regression with actual PA units and z-scores  in terms of advanced difficulty .The incidence of early walking difficulty was 18.9% in 2 years. Altogether 14.9% of participants developed new advanced walking difficulty of which 50.0% had early walking difficulty at baseline. The incidence of early  and advarel, that is, PA above the intensity corresponding to preferred walking speed, which was not significantly different between the groups, either in terms of early or advanced difficulty.Participants with prevalent early  or advann = 38). The analysis showed that lower self-reported PA and accelerometry-based absolute PA but not PArel were associated with incident early walking difficulty  except for YPAS walking time  and PArel, where the association was negative . Preferred walking speed × PA interaction was not significant for any of the PA measures studied (p = .30–.95). Therefore, we included preferred walking speed as a confounder in Model 3. After the adjustment with preferred walking speed, the associations of accelerometry-based PA with the incidence of walking difficulty were attenuated. For all self-reported measures of PA except for vigorous PA, the associations remained statistically significant . The associations regarding accelerometry did not change materially. The associations of self-reported PA with incident walking difficulty were attenuated but were similar in participants with both high and low SPPB scores.To test the robustness of our findings, we stratified the logistic regression analyses based on SPPB scores  was not exceptionally high compared to previous studies on similar populations and the same follow-up duration: 31% in 2 km  and 16% There are both strengths and limitations in this study. We were able to use the baseline data of a relatively large population-based sample of older adults from 3 age cohorts. We used an exceptionally large selection of different PA assessment methods including a novel relative PA index which enabled the investigation of the independent role of PA but without the obvious limitation of PA recollection as in the self-report. During the follow-up, there was a high response rate and few missing responses. As for the limitations, we had to rely on postal questionnaires during the follow-up data collection as all research requiring physical contact with participants was discontinued in our university due to the COVID-19 pandemic. Therefore, we cannot rule out a potential bias due to the difference in the data collection method between the baseline (home interview) and the COVID-19 survey . We were also not able to repeat the accelerometry surveillance, which might have revealed changes in activity behavior more objectively than the questionnaire. The present participants formed a population-based sample, but the sample size was smaller and slightly better functioning in the accelerometry-based compared to self-reported metrics , which cTo conclude, this study showed that differences in physical performance explain a meaningful part of the association of PA with incident walking difficulty. Therefore, the variation in habitual PA assessed relative to physical performance did not explain the differences in the development of new walking difficulty. The use of absolute accelerometry-based measures of PA may overestimate the association between PA and the incidence of walking difficulty as these were not independent of the baseline physical performance level. Self-reported measures of PA seem more robust to the effect of physical performance in older adults compared to absolute accelerometry-based PA, potentially due to the subjectively rated intensity of activity instead of a universal absolute cut-point. Scaling of accelerometry to preferred walking speed demonstrated independence on physical performance and warrants future study as a novel indicator of PA in observational studies among older adults.glab277_suppl_Supplementary_MaterialsClick here for additional data file.


The potential for large-scale tip integration and the advantage of a simple probe array suggest substantial promise for our approach to high-throughput imaging far beyond what is currently possible.Scanning probe microscopy techniques, such as atomic force microscopy and scanning tunnelling microscopy, are harnessed to image nanoscale structures with an exquisite resolution, which has been of significant value in a variety of areas of nanotechnology. These scanning probe techniques, however, are not generally suitable for high-throughput imaging, which has, from the outset, been a primary challenge. Traditional approaches to increasing the scalability have involved developing multiple probes for imaging, but complex probe design and electronics are required to carry out the detection method. Here, we report a probe-based imaging method that utilizes scalable cantilever-free elastomeric probe design and hierarchical measurement architecture, which readily reconstructs high-resolution and high-throughput topography images. In a single scan, we demonstrate imaging with a 100-tip array to obtain 100 images over a 1-mm High-throughput imaging has generally been challenging for scanning probe microscopy techniques. Here, the authors introduce binary-state scanning probe microscopy, which uses a cantilever-free elastomeric probes and a hierarchical measurement architecture for parallel topography imaging. The unprecedented resolution of this methodology is attributed to the highly confined apex of the physical probe that traces the topography of the surface through the tip-sample interaction4. This working principle enables high resolving power over other microscopy techniques but at the same time gives rise to a trade-off in throughput owing to the serial nature of the single probe scanning process.From the invention of the topografiner8, the single probe measurement still compels a narrow field of view, which can be useful in specific cases such as the investigation of biomolecules10 and hardly fulfils the general demand for high-throughput topography measurement.Fundamentally, the maximum rate of the topographic change that a single probe can record is limited by the bandwidth of the system, and thus, achieving high resolution inevitably entails deterioration in the throughput. Currently, SPM systems usually have a maximum field of view of up to a hundred micrometres, which is insufficient for high-throughput metrology and restricts the potential range of applications. Despite the previous progress in increasing the imaging speed18. Parallel AFM usually adopts an integrated probe design in which the individual probe contains an on-chip deflection detector to read the tip-sample interaction19. These approaches, however, were challenged by their complicated fabrication processes, which could involve high-cost and complex manufacturing of the multiple probe array. Optical detection methods such as interferometry14 and dispersive beam deflection16 allow off-chip deflection detection with a simple tip array structure but still require complex external instruments, which makes performing highly parallel measurements practically infeasible. Recently, cantilever-free AFM18 impressively demonstrated the massively parallel imaging capability through its scalable probe design, which eliminates the fabrication bottleneck associated with cantilever-based AFM.To overcome this throughput issue, parallelized SPM harnessing a multiple probe array has been proposed mainly for AFMFrom a methodological viewpoint, the imaging architecture of parallel SPM assumes that individual probes in the array function independently. This architecture causes high complexity to construct a parallel detecting system and process high-precision feedback signals of massive probe array, which eventually curtailed the merit of parallel SPM in throughput and resolution. In this regard, the fundamental challenge to be addressed for scalable SPM is efficient measurement architecture fitted into multiple probe operation. Ideally, parallel imaging architecture that enables to reconstruct high-resolution topography through a highly simplified feedback mechanism of a probe array is desirable for high-throughput measurement preserving the imaging capability comparable to conventional single probe SPM.z-scanner and a parallel probe array. The parallel tip array is attached to the same z-scanner, and thus the tips share the vertical movement, which we refer to as the shared z-distance. In this architecture, the parallel probe array detects contact with the surface only in binary states. These binary contact signals are then reconstructed into high-resolution topography images based on the shared z-distance information. This measurement architecture eliminates the need for high-precision detection of the individual probes and thereby dramatically reduces the complexity to fabricate and operate a multiple probe array. Using the BSPM imaging mechanism, we engaged as many as 100 probes and demonstrated high-resolution topography of the surface over an area of one square millimetre. With the potential to achieve both high resolution and high scalability, BSPM can offer a practical alternative for performing multiple topography measurements.In this work, we present an efficient parallel imaging mechanism utilizing binary electrical feedback combined with a scalable cantilever-free elastomeric probe array. The topography measurement method, which we term binary-state probe microscopy (BSPM), has the hierarchical architecture divided into a shared 20. To address this challenge, the BSPM method adopts a shared measurement architecture, in which the entire array of tips shares identical scanning distances for reconstructing the topography, and the function of each tip is simplified to detect contact with the surface in a binary fashion. The BSPM system consists of a shared piezo scanner and a parallel tip array  into a pyramid-shaped silicon mould28. In BSPM mechanism, each tip functions as a switch that detects the electrical signal  to the temporal resolution , as indicated by vpiezo/fsampling. When we scanned, for example, the point at a speed of 100 μm/s with a sampling rate of 100 kHz, the height resolution was at most 1 nm. In practice, however, we note that the noise level of the detector also limits the precision of the acquired scanning distance. After signal amplification and band-pass filtering to minimize the noise  simulation to conduct a stress analysis of the metal-coated elastomer composite. Figure 30. We experimentally found that a tip with a 10:1 base/curing agent ratio and a 50-nm-thick gold film was optimal for measurement.In this sense, to minimize the irreversible deformation, we controlled the stress by modulating the elastomer stiffness and the volume of the metal film. Thus, we varied the base/curing agent ratios and Au film thickness of the tips. We compressed 14-μm-high metal-coated elastomer tips to half their height (7 μm) and measured the height of the recovered tips  with a height of 32 nm  and cantilever-free fashion, which dramatically reduces the complexity of the sensing mechanism and array fabrication. In this context, we evaluated the scalability of BSPM by implementing topography measurements using a 100-tip array. We fabricated an array of 100 metal-coated tips with a tip-to-tip distance of 100 μm . To perform the measurement, we first aligned the one-hundred-tip array with the surface by tilting the sample stage32. We then set a proper vertical scanning range (~2.5 μm) of the tip array to ensure that all tips came in contact with the surface during the measurement. Note that the vertical scanning range of the tip array was slightly larger than that of the single tip because the height of the tip at the centre of the array was shorter than that of the others owing to the curvature of the glass substrate supporting the tip array  of the pre-patterned element  establishing electronics to collect and post-process the contact signals from massively parallel tip array, (ii) studying the detailed mechanical contact phenomena of tip arrays that could induce artifacts, and (iii) finding a non-electrical contact sensing mechanism that is capable of imaging an insulating surface. BSPM offers significant advances in terms of scalability and decreased complexity compared to many previous parallel SPM designs and could be implemented with common conventional SPM equipment.BSPM is a scanning-probe-based imaging method that uses cantilever-free tip arrays with the shared measurement architecture, which is multiplexed for large-scale implementation. BSPM can be readily integrated with the conventional piezo actuator and allows resolutions on nanometre-length scales because of the high sampling rate of the contact signal. The feasibility and functionality of BSPM were demonstrated with 100 images over a 1-mm2 plasma and placed on a vacuum chamber with heptadecafluoro-1,1,2,2-tetrahydrodecyltrichlorosilane (JSI Silicone) diluted in toluene  to form the anti-adhesion layer.A silicon substrate with a 5000 Å oxide layer was sonicated with acetone and isopropyl alcohol. The circular patterns were exposed on the cleaned wafer by photolithography or e-beam lithography. The oxide layer on the silicon substrate was etched with the pre-defined pattern by a 6:1 buffered oxide etchant (J. T. Baker), and then the silicon substrate was etched in 30 wt% potassium hydroxide solution . After the silicon substrate was etched, the circular patterns resulted in pyramid-shaped holes whose width was equal to the diameter of the circular patterns. The remaining oxide layer was then removed by a 6:1 buffered oxide etchant. The etched silicon wafer was exposed to O2 plasma and then patterned by photolithography using a negative photoresist . Gold film  was deposited onto the patterned PDMS tip by thermal evaporation and then lifted off with acetone. In the fabrication of the multiple tip array, unintended gold lines between the adjacent signal lines could be formed through cracks in the photoresist pattern, which occur during thermal evaporation due to thermal expansion of the PDMS layer. This crosstalk line was burned by applying voltage (approximately 5–10 V) between the adjacent signal lines.PDMS  with various base/cross-linker ratios was mixed and degassed in a vacuum. PDMS was poured onto the pyramid-shaped silicon mould and cured at 60 °C overnight, with the supporting glass substrate placed on the PDMS. The cured PDMS tip was separated from the silicon mould. To define the signal line on the PDMS tip, it was exposed to OSupplementary InformationDescription of Additional Supplementary FilesSupplementary Video 1Supplementary Video 2Supplementary Video 3Supplementary Video 4